Healthcare resource utilization after medium-term residential assessment for epilepsy and psychogenic nonepileptic seizures
Introduction
Epilepsy has an estimated prevalence of 1% in the United Kingdom and a heterogeneous presentation [1]. Diagnosis is based upon consideration of the history, collateral information, and eye-witness accounts [2], [3].
A common cause of misdiagnosis is PNES, which are behavioral events with a presumed psychological cause [6]. Approximately, 25% of those with supposed refractory epilepsy who are referred to specialist epilepsy clinics have PNES [1], [2], [4], [5]. Video-EEG, the concurrent recording of video of the patient and EEG during an event, is considered the gold standard for diagnosis of PNES [6], [7].
In individuals with confirmed epilepsy, treatment may be suboptimal with estimates of between 5 and 15% of individuals being on insufficient or incorrect treatment [1], [2]. In such individuals, inpatient EEG monitoring may help optimize epilepsy classification and treatment [7], [8].
In a small subgroup of patients with complex presentations (with infrequent or multiple event types, safety considerations that limit reduction of medications in the community, intolerance of hospital environments, or comorbid conditions, [2]), conventional outpatient and short inpatient assessments (typically 5- to 7-day hospital video-EEG telemetry assessments) may be inadequate to provide diagnostic certainty and optimize treatment. For such individuals, medium-term residential assessment (MTRA) may be considered [2], [8], [9].
Providing epilepsy care can be resource-intensive [10], [11], [12]. Jacoby et al. [10] identified a subgroup of 168 people with more than one seizure a month and defined them as having high HRU. In the year prior to their survey, 16% had an inpatient admission, 27% an Accident & Emergency (A&E) visit, and 49% an outpatient appointment. There is evidence that optimizing treatment [2], [7], in addition to reducing seizures and lowering risk, reduces the side-effect burden and reduces the impact that poorly controlled seizures can have on hospital admissions.
Those with PNES (who are misdiagnosed as having epilepsy) can have high HRU as they often present multiple times for evaluation and are therefore investigated repeatedly [10], [11], [13], [14]. Research in a variety of settings [6], [13], [14], [15], [16] has established that clarifying the diagnosis of PNES and clearly communicating that to patients (including stopping medication [17]) and their families have considerable benefit in terms of reduction in HRU. Additionally, there is a considerable individual benefit in the reduction of iatrogenic risk [2], [17].
Therefore, correct diagnosis and treatment optimization can have significant patient benefit and allow the improved utilization of scarce health resources. Given the complex group admitted to the Scottish Epilepsy Centre, we wished to measure whether the MTRA intervention had a similar impact on health resource use.
The SEC is an independent hospital run by a charitable organization, Quarriers, in partnership with NHS Scotland. The SEC provides a novel model of assessment and treatment for people with complex presentations. There is continuous video monitoring (CCTV) of patient spaces. There is a multi-disciplinary team (nursing, neurology, clinical neurophysiology, neuropsychiatry, and neuropsychology). Referrals are received from NHS consultants across Scotland. Individuals are admitted for diagnostic clarification and review of medication, with an average stay of 28 days. We wished to evaluate the impact of our intervention by comparing HRU use pre- and postadmission.
In the period following this study, the SEC moved to new premises, with increased bed numbers (from 10 to 12), and improved technological provision.
Epilepsy is a clinical diagnosis supported by review of video of events, EEG, scans, and patient history. Diagnosis was made according to normal clinical practice by medical consultants with extensive experience with epilepsy. This diagnosis was facilitated by the environment of the SEC. Continuous CCTV recording in communal areas and some bedrooms allowed the review of events (when staff may have not witnessed the beginning of an event). Nursing and support staff carried and recorded all attended events with handheld devices. Nursing staff (by means of CCTV, patient report, and direct observation) noted all seizures and events. Ambulatory EEG was available and reviewed alongside CCTV as required. An extended admission permitted the diagnostic withdrawal of medication. Most events or seizures that were of diagnostic interest were able to be reviewed or recorded. Electroencephalogram (EEG) was reviewed by a senior clinical neurophysiologist with experience in epilepsy.
Intervention for those with epilepsy involved medication changes as clinically indicated. Diagnosis of PNES was delivered as previously described by Duncan [6]. Antiepileptic drugs (AED)s were discontinued. When medical or nursing assessment indicated psychiatric, cognitive, or adjustment difficulties, regardless of diagnosis, a review was carried out by neuropsychiatry and/or psychology. Interventions varied by clinical need but included the following: medical treatment with psychotropic medication, identifying formal psychiatric follow-up, arranging community support from epilepsy charities or social services, advice to families, neuropsychological assessment and advice to individuals and their families, and direct therapeutic intervention for adjustment or mood difficulties. For those with PNES, psychological treatment was offered.
Section snippets
Methods
The majority of healthcare in Scotland is provided within an integrated public (national) health service, the NHS, free to patients. Provision is organized by geographical area (boards). A retrospective audit of neurological HRU was performed with individuals from the NHS Greater Glasgow and Clyde Health Board Area (NHSGGC) admitted to the SEC over a three-year period (1st April 2010 to 31st March 2013).
A comparison was made with people referred and eligible for admission but not admitted to
Study period and sample
Two hundred forty-eight inpatient assessments to the SEC were identified during a three-year period (1st April 2010 to 31st March 2013). One hundred five NHSGGC patients were identified. Twenty-five had insufficient follow-up or baseline data available (at least one full year of data prior to admission and 2 years postdischarge), 1 person had died (non-neurological), 3 records were inaccessible, and 3 people had proceeded to epilepsy surgery. The 73 individuals included for the analysis had an
Main effects
This study demonstrates an average drop across all patients of 68.27% in health resource utilization (HRU) after admission for residential assessment and treatment (MTRA) at the Scottish Epilepsy Centre (SEC). There was no corresponding change in the comparison group (who were referred but not admitted because of personal preference). To our knowledge, this is the first attempt to quantify the impact of this type of extended intervention with a complex patient group.
Within the overall
Considerations and limitations
The results from this study represent assessment and treatment of a patient group with highly complex diagnostic and treatment needs. From a health system perspective, this is a group of patients who have been unable to have a diagnosis secured through standard NHS neurology services, and/or the complexity of their epilepsy requires longer assessment.
The concordance between admission and change in HRU is statistically significant and, given the complexity of those admitted, suggests that the
Summary and conclusions
This study is the first to quantify the benefit of MTRA in a diagnostically challenging group of patients. We have been able to show that, following MTRA, there is a statistically significant reduction in HRU which is sustained over time for those with epilepsy, PNES, or both conditions. This potentially represents a significant patient impact and reduction of risk in those with PNES. Further examination of MTRA using longer baselines, more direct clinical measures, and longer follow-up periods
Ethical statement
This project did not require ethical review as it drew on data held within existing NHS and SEC records. Access to NHS systems for the purpose of audit was approved within local NHSGGC procedures.
Conflict of interest
The authors have no conflict of interest to disclose.
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Cited by (6)
Dual diagnosis of epilepsy and psychogenic nonepileptic seizures: Systematic review and meta-analysis of frequency, correlates, and outcomes
2018, Epilepsy and BehaviorCitation Excerpt :Included papers contained data obtained from 17,478 people. Two studies were population-based [8,9] while the rest were hospital-based [1,3,4,10–126]. In the latter, patients were recruited mostly from highly specialized epilepsy centers (tertiary hospitals, academic departments, comprehensive epilepsy programs — 112 of 118 studies).
Safety at The William Quarrier Scottish Epilepsy Centre
2017, SeizureCitation Excerpt :Any one of these cameras can be linked to an ambulatory EEG signal – allowing the SEC to offer wireless video telemetry and complete patient mobility within the SEC. Patients are referred from epilepsy specialists when outpatient (or brief inpatient assessment; usually 3–5 days of video-telemetry (VT) has been insufficient to establish a diagnosis or optimise medical treatment [1]. An extended stay and extensive observation is required when there are multiple types of, or infrequent, events, a mixture of epileptic and psychogenic non-epileptic attack (PNES) or co-morbid conditions that complicate presentation (e.g. learning disability or psychiatric illness).
Outcome of psychogenic non-epileptic seizures following diagnosis in the epilepsy monitoring unit
2024, Frontiers in Neurology