Study Spotlights Disparities in Specialized Epilepsy Care

SAN DIEGO – People with epilepsy who lacked health insurance were less likely to receive specialized epilepsy care in the form of video EEG monitoring and surgery, as were those on Medicaid or who were elderly, black, Hispanic, or had comorbidities, a study of nearly 200,000 adults in California demonstrated.

"Specialized epilepsy care can provide proper diagnosis and therapeutic interventions to control seizures and improve quality of life," Nicholas K. Schiltz said in an interview in advance of the annual meeting of the American Epilepsy Society, where the work was presented. "Previous studies have found evidence of disparities in access to epilepsy specialists among persons with low socioeconomic status and among racial and ethnic minorities. Other studies have found patients with Medicaid have difficulty accessing specialty care. This is the first report that explores the impact of both individual and community characteristics on disparities in access to specialized epilepsy care in persons with epilepsy."

For the study, Mr. Schiltz, a PhD candidate in the department of epidemiology and biostatistics at Case Western Reserve University, Cleveland, and his associates performed a cross-sectional analysis using data between 2005 and 2009 from the California State Inpatient Sample, the State Ambulatory Surgery Database, and the State Emergency Department Database, which provided information on all hospital discharges, ambulatory surgeries, and emergency department visits. The researchers linked these datasets to a 2009 Area Resource File, which provided health resource information and socioeconomic characteristics at the county level, and used a two-level hierarchical logistic regression model to determine the probability that an individual would receive video EEG monitoring or surgery. Individual-level predictors included insurance status, age, race/ethnicity, gender, and comorbidities, while county level predictors included proximity to a comprehensive epilepsy center and social and economic characteristics.

Of the 195,166 adults with epilepsy who were included in the study, 4,707 had video EEG monitoring and 779 underwent surgery during the study period. Mr. Schiltz reported that uninsured individuals were less likely to have video EEG monitoring (adjusted odds ratio [AOR] 0.16) or surgery (AOR 0.05). Similarly, those on Medicaid had significantly lower odds of receiving video EEG monitoring (AOR 0.65) and surgery (AOR 0.38), compared with individuals who had private insurance.

Other individual characteristics significantly associated with a low likelihood of having video EEG monitoring including being black (AOR 0.56), Hispanic (AOR 0.81), older (AOR 0.51), and having comorbid conditions (AOR 0.62).

Other individual characteristics associated with a low likelihood of having surgery including being black (AOR 0.22), older (AOR 0.44), and having comorbid conditions (AOR 0.47).

The researchers also found that adults who routinely received their services in an area where epilepsy centers are located were more likely to undergo video EEG monitoring (AOR 1.61) and surgery (AOR 2.64) than were those who had a regular source of care elsewhere.

This effect size "was surprising to us as it shows that receiving care in the area proximate to an epilepsy center is as important a factor as individual factors in determining access to specialty care," Mr. Schiltz said. "It is possible that neurologists or physicians who are in the area close to epilepsy centers are more aware and therefore refer patients to the epilepsy centers. We were also surprised that other community-level characteristics such as the poverty and employment rate were not significant predictors of access, as studies in other areas of clinical and health services research have found this to be the case."

The study’s overall findings, he added, make continued emphasis on highlighting awareness of epilepsy management among general neurologists and primary care physicians "as important as ever, as they serve as the main gatekeepers for patients to access specialized epilepsy care."

Mr. Schiltz acknowledged certain limitations of the study, including the fact that it relied on hospital billing records, which "do not contain detailed clinical information," he said. "In addition, we only identify specialized epilepsy centers based on the data from the National Association of Epilepsy Centers (NAEC). Some of the hospitals that provide specialized epilepsy care might not be a member of the NAEC. We looked at geographic factors at the county level, which may be somewhat crude in a state like California with diverse populations within counties."

Support for the study was provided by the Epilepsy Foundation, a training grant from the Agency for Healthcare Research and Quality, and a grant from the National Center for Research Resources. Mr. Schiltz received support for travel to the meeting from his receipt of an American Epilepsy Society Young Investigator Award.

Mr. Schiltz said that he had no relevant financial conflicts to disclose.

SAN DIEGO – People with epilepsy who lacked health insurance were less likely to receive specialized epilepsy care in the form of video EEG monitoring and surgery, as were those on Medicaid or who were elderly, black, Hispanic, or had comorbidities, a study of nearly 200,000 adults in California demonstrated.

"Specialized epilepsy care can provide proper diagnosis and therapeutic interventions to control seizures and improve quality of life," Nicholas K. Schiltz said in an interview in advance of the annual meeting of the American Epilepsy Society, where the work was presented. "Previous studies have found evidence of disparities in access to epilepsy specialists among persons with low socioeconomic status and among racial and ethnic minorities. Other studies have found patients with Medicaid have difficulty accessing specialty care. This is the first report that explores the impact of both individual and community characteristics on disparities in access to specialized epilepsy care in persons with epilepsy."

For the study, Mr. Schiltz, a PhD candidate in the department of epidemiology and biostatistics at Case Western Reserve University, Cleveland, and his associates performed a cross-sectional analysis using data between 2005 and 2009 from the California State Inpatient Sample, the State Ambulatory Surgery Database, and the State Emergency Department Database, which provided information on all hospital discharges, ambulatory surgeries, and emergency department visits. The researchers linked these datasets to a 2009 Area Resource File, which provided health resource information and socioeconomic characteristics at the county level, and used a two-level hierarchical logistic regression model to determine the probability that an individual would receive video EEG monitoring or surgery. Individual-level predictors included insurance status, age, race/ethnicity, gender, and comorbidities, while county level predictors included proximity to a comprehensive epilepsy center and social and economic characteristics.

Of the 195,166 adults with epilepsy who were included in the study, 4,707 had video EEG monitoring and 779 underwent surgery during the study period. Mr. Schiltz reported that uninsured individuals were less likely to have video EEG monitoring (adjusted odds ratio [AOR] 0.16) or surgery (AOR 0.05). Similarly, those on Medicaid had significantly lower odds of receiving video EEG monitoring (AOR 0.65) and surgery (AOR 0.38), compared with individuals who had private insurance.

Other individual characteristics significantly associated with a low likelihood of having video EEG monitoring including being black (AOR 0.56), Hispanic (AOR 0.81), older (AOR 0.51), and having comorbid conditions (AOR 0.62).

Other individual characteristics associated with a low likelihood of having surgery including being black (AOR 0.22), older (AOR 0.44), and having comorbid conditions (AOR 0.47).

The researchers also found that adults who routinely received their services in an area where epilepsy centers are located were more likely to undergo video EEG monitoring (AOR 1.61) and surgery (AOR 2.64) than were those who had a regular source of care elsewhere.

This effect size "was surprising to us as it shows that receiving care in the area proximate to an epilepsy center is as important a factor as individual factors in determining access to specialty care," Mr. Schiltz said. "It is possible that neurologists or physicians who are in the area close to epilepsy centers are more aware and therefore refer patients to the epilepsy centers. We were also surprised that other community-level characteristics such as the poverty and employment rate were not significant predictors of access, as studies in other areas of clinical and health services research have found this to be the case."

The study’s overall findings, he added, make continued emphasis on highlighting awareness of epilepsy management among general neurologists and primary care physicians "as important as ever, as they serve as the main gatekeepers for patients to access specialized epilepsy care."

Mr. Schiltz acknowledged certain limitations of the study, including the fact that it relied on hospital billing records, which "do not contain detailed clinical information," he said. "In addition, we only identify specialized epilepsy centers based on the data from the National Association of Epilepsy Centers (NAEC). Some of the hospitals that provide specialized epilepsy care might not be a member of the NAEC. We looked at geographic factors at the county level, which may be somewhat crude in a state like California with diverse populations within counties."

Support for the study was provided by the Epilepsy Foundation, a training grant from the Agency for Healthcare Research and Quality, and a grant from the National Center for Research Resources. Mr. Schiltz received support for travel to the meeting from his receipt of an American Epilepsy Society Young Investigator Award.

Mr. Schiltz said that he had no relevant financial conflicts to disclose.

SAN DIEGO – People with epilepsy who lacked health insurance were less likely to receive specialized epilepsy care in the form of video EEG monitoring and surgery, as were those on Medicaid or who were elderly, black, Hispanic, or had comorbidities, a study of nearly 200,000 adults in California demonstrated.

"Specialized epilepsy care can provide proper diagnosis and therapeutic interventions to control seizures and improve quality of life," Nicholas K. Schiltz said in an interview in advance of the annual meeting of the American Epilepsy Society, where the work was presented. "Previous studies have found evidence of disparities in access to epilepsy specialists among persons with low socioeconomic status and among racial and ethnic minorities. Other studies have found patients with Medicaid have difficulty accessing specialty care. This is the first report that explores the impact of both individual and community characteristics on disparities in access to specialized epilepsy care in persons with epilepsy."

For the study, Mr. Schiltz, a PhD candidate in the department of epidemiology and biostatistics at Case Western Reserve University, Cleveland, and his associates performed a cross-sectional analysis using data between 2005 and 2009 from the California State Inpatient Sample, the State Ambulatory Surgery Database, and the State Emergency Department Database, which provided information on all hospital discharges, ambulatory surgeries, and emergency department visits. The researchers linked these datasets to a 2009 Area Resource File, which provided health resource information and socioeconomic characteristics at the county level, and used a two-level hierarchical logistic regression model to determine the probability that an individual would receive video EEG monitoring or surgery. Individual-level predictors included insurance status, age, race/ethnicity, gender, and comorbidities, while county level predictors included proximity to a comprehensive epilepsy center and social and economic characteristics.

Of the 195,166 adults with epilepsy who were included in the study, 4,707 had video EEG monitoring and 779 underwent surgery during the study period. Mr. Schiltz reported that uninsured individuals were less likely to have video EEG monitoring (adjusted odds ratio [AOR] 0.16) or surgery (AOR 0.05). Similarly, those on Medicaid had significantly lower odds of receiving video EEG monitoring (AOR 0.65) and surgery (AOR 0.38), compared with individuals who had private insurance.

Other individual characteristics significantly associated with a low likelihood of having video EEG monitoring including being black (AOR 0.56), Hispanic (AOR 0.81), older (AOR 0.51), and having comorbid conditions (AOR 0.62).

Other individual characteristics associated with a low likelihood of having surgery including being black (AOR 0.22), older (AOR 0.44), and having comorbid conditions (AOR 0.47).

The researchers also found that adults who routinely received their services in an area where epilepsy centers are located were more likely to undergo video EEG monitoring (AOR 1.61) and surgery (AOR 2.64) than were those who had a regular source of care elsewhere.

This effect size "was surprising to us as it shows that receiving care in the area proximate to an epilepsy center is as important a factor as individual factors in determining access to specialty care," Mr. Schiltz said. "It is possible that neurologists or physicians who are in the area close to epilepsy centers are more aware and therefore refer patients to the epilepsy centers. We were also surprised that other community-level characteristics such as the poverty and employment rate were not significant predictors of access, as studies in other areas of clinical and health services research have found this to be the case."

The study’s overall findings, he added, make continued emphasis on highlighting awareness of epilepsy management among general neurologists and primary care physicians "as important as ever, as they serve as the main gatekeepers for patients to access specialized epilepsy care."

Mr. Schiltz acknowledged certain limitations of the study, including the fact that it relied on hospital billing records, which "do not contain detailed clinical information," he said. "In addition, we only identify specialized epilepsy centers based on the data from the National Association of Epilepsy Centers (NAEC). Some of the hospitals that provide specialized epilepsy care might not be a member of the NAEC. We looked at geographic factors at the county level, which may be somewhat crude in a state like California with diverse populations within counties."

Support for the study was provided by the Epilepsy Foundation, a training grant from the Agency for Healthcare Research and Quality, and a grant from the National Center for Research Resources. Mr. Schiltz received support for travel to the meeting from his receipt of an American Epilepsy Society Young Investigator Award.

Mr. Schiltz said that he had no relevant financial conflicts to disclose.