Quality Indicator for Epilepsy Treatment 15 (QUIET-15): Intervening after recurrent seizures in the elderly

Abstract

In this study, we examined the provision of care to older adults with epilepsy and compliance with the “Quality Indicator for Epilepsy Treatment 15” (QUIET-15) measure. We analyzed 2008–2010, 5% random sample of Medicare beneficiaries augmented with data from all beneficiaries who identified as a minority with claims related to seizures (780.3x) or epilepsy (345.xx). Of 36,912 identified epilepsy cases, 12.6% had ≥1 emergency room (ER) visit for seizure(s). For those who presented to ER, among those taking anti-epileptic drugs (AEDs), AED was changed in 15.4%, dose adjusted in 19.7%, and stopped in 14.9%; among those not taking AED, therapy was initiated in 68.5%. In adjusted logistic regressions, African-Americans were more likely to have recurrent seizures than Whites (OR 1.41, 95%CI 1.27–1.56), while Asians were less likely to have recurrent seizures (OR 0.71, 95%CI 0.57–0.89). There were no significant racial/ethnic differences in the likelihood of a post-seizure intervention. The chance of seizure recurrence leading to ER visit decreased with age and increased with the number of comorbidities. Patients with seizure recurrence were more likely to be taking an enzyme-inducing AED (OR 1.69, 95%CI 1.57–1.82) and receiving Part D Low Income Subsidy (OR 1.36, 95%CI 1.22–1.51). The probability of AED change after a seizure was higher for patients with ≥4 comorbidities (OR 1.69, 95%CI 1.25–2.27), patients who saw a neurologist (OR 1.49, 95%CI 1.30–1.70), and patients who were taking an enzyme-inducing AED (OR 1.47, 95%CI 1.27–1.71). Overall, a minority of Medicare beneficiaries experienced seizure recurrence that resulted in an ER visit. However, only half of them received treatment concordant with QUIET-15. Though racial differences were observed in occurrence of seizures, none were noted in the provision of care.

High health care costs in minority groups of older US Medicare beneficiaries with epilepsy

“…Because race/ethnicity differences were not observed in the random sample of Medicare beneficiaries, closer scrutiny of the health care utilization of African Americans and other demographic groups with epilepsy is warranted. Given that African Americans may have lower adherence to AED treatment and be more likely to have ER‐related claims for seizures, it is plausible to hypothesize that their higher costs were driven by ER visits and hospitalizations. In other studies, cost differences for adherent and nonadherent patients were due mainly to these events .…”

“…About 32% of cases had a PDC < 80%; Care concordant with Quality Indicators for Epilepsy Treatment (QUIET) 15, that is, whether adjustments to AEDs were made following a seizure. Among beneficiaries with a seizure for which an emergency room (ER) visit occurred (n = 4132), 50% had AED changes and care concordant with QUIET 15; Care concordant with QUIET 6 for new cases, that is, starting AED treatment with monotherapy (>90%); Care concordant with QUIET 9 for new cases, that is, at least two non–enzyme‐inducing AEDs tried before starting enzyme‐inducing drugs (about 60%); and, Presence of drug interaction risk (care not concordant with QUIET 11) for new cases (about 25%) …”

“…Among older Americans with epilepsy, about 1.5% of older adults, minority groups may be at risk of high costs of care. Recent studies have found that African Americans, for example, have poor adherence to antiepileptic drugs (AEDs) and are more likely to have seizures resulting in emergency room visits . As shown in younger populations with epilepsy, these factors may lead to higher costs of care as well as poor health status .…”

“…In addition, in line with other studies that have shown higher costs after an epilepsy index event, we compared costs in the follow‐up period to costs in the year before to determine whether the same pattern is present in the older population. We used claims data for a cohort of Medicare beneficiaries with epilepsy that overrepresents minority groups …”

“…studies have found that African Americans, for example, have poor adherence to antiepileptic drugs (AEDs) 4 and are more likely to have seizures resulting in emergency room visits. 5 As shown in younger populations with epilepsy, these factors may lead to higher costs of care as well as poor health status. [6][7][8][9] Non-epilepsy-related comorbidities and insurance status also contribute to high costs in younger populations.…”