Does Specialized Care Lead to Improved Seizure Control in Epilepsy?

PHILADELPHIA—Although second-generation antiepileptic drugs (AEDs) have been associated with fewer side effects in clinical trials than older, more established AEDs, the newer agents have not been shown to be any more effective in controlling seizures. However, researchers have observed that patients who transitioned from care at a general neurology practice to an epilepsy center experienced significant improvement in seizure control.

Now, a follow-up study, presented at the 61st Annual Meeting of the American Epilepsy Society, by the same research group indicates that improved seizure control is related not to medication factors but to the physicians’ level of training and experience and that the improvement seen with care by epilepsy specialists occurs independently of what AED a patient takes. The findings have implications for the management of patients whose initial AED therapy fails to adequately control the frequency of their seizures.

PHYSICIAN VERSUS MEDICATION FACTORS

Jerzy P. Szaflarski, MD, PhD, and colleagues conducted a retrospective chart review of 100 patients followed at an epilepsy center—50 who were institutionalized (eg, in a nursing home or residential care facility) and 50 who were not. The main outcome measure was change in seizure frequency, and the primary outcome predictor was whether the prior and current providers attempted to use second-generation AEDs.

The investigators found no differences in how the AEDs were used by general neurologists versus epileptologists, either with the institutionalized or noninstitutionalized patients. However, the researchers detected an overall decrease in seizure frequency when the patients were treated by an epilepsy specialist compared with when they were treated by a general neurologist.
Seizure frequency was not affected by whether the current provider (ie, the epilepsy specialist) tried a second-generation AED, and no association with the rate of seizures was found with prior versus current provider attempts to use these newer agents. The findings point to enhanced care that patients can receive when referred to an epilepsy specialist, according to Dr. Szaflarski, Associate Professor of Neurology at the University of Cincinnati Academic Health Center, and lead author of the study.

“Overall, whether the patient was placed on new, old, or a combination of old and new AEDs did not affect the outcomes,” he said in an interview with Neurology Reviews. “It is not the medications but rather the care provided at an epilepsy center that leads to improvements in seizure control….

“The most important finding is that the epilepsy specialists provide incremental improvement in seizure control over and above the care that is provided by general neurologists. Therefore, when a patient with epilepsy fails two to three AEDs, he or she should be referred for further diagnosis and management to an epilepsy specialist.”

The findings regarding improved seizure control at epilepsy centers were bolstered by a related study by the same research team, which includes investigators at the University of Cincinnati and at UCB, Inc, based in Smyrna, Georgia. In this second study, the investigators sought to determine whether epilepsy-center–derived improvements in seizure control, as detected in a 2007 study by Zakaria and colleagues of patients who transitioned from general neurology practice, would also be seen in patients treated at an epilepsy center, regardless of whether they were institutionalized.

No significant differences were found between the institutionalized and noninstitutionalized patients with regard to seizure control. However, the frequency of seizures between the time of first presentation to the epilepsy center and the last visit was reduced for all patients by approximately 76%, further demonstrating that treatment at an epilepsy center results in significant improvement in seizure control, stated the researchers.

A SETTING FOR OPTIMIZED EPILEPSY CARE

“Studies have shown that increased health care expenditures are not necessarily associated with better quality of care,” said Dr. Szaflarski. “In the current debate about health care costs, specialists and tests are blamed for the escalating costs. There is evidence that neurologists provide high-quality care to their patients, especially in stroke and Parkinson’s disease, and that the care by subspecialists in their respective areas is associated with improved outcomes but with higher costs.

“Similar data regarding epilepsy care are lacking. Therefore, we decided to examine the effects of the care provided by an epilepsy specialist versus the care of a general neurologist to determine whether epilepsy subspecialists provide incremental improvements in the outcome of epilepsy patients over the care received from general neurologists.”

Judging from the results of these two latest studies, the care that patients receive in epilepsy centers may very well justify the added costs, according to Dr. Szaflarski. He noted that the typical epilepsy center has two or more epileptologists—neurologists who have received at least one year of additional training in the treatment of patients with epilepsy. The staff also includes an epilepsy neurosurgeon and one or more neuropsychologists and epilepsy nurse coordinators. The centers typically are equipped with prolonged EEG monitoring and offer epilepsy surgery, 24/7 availability of EEG monitoring, and a setting for drug and device trials, among other forms of epilepsy research.

The optimized care such features afford may help explain why seizure control is improved and seizure freedom increased when patients are managed by an epileptologist. Among the specific reasons that Dr. Szaflarski and his coauthors cited in their conclusions are better recognition of the epilepsy syndrome, increased frequency of patient follow-up, and improved patient compliance resulting from the fewer side effects typically experienced with the use of second-generation AEDs.

Asked about the correlation between treatment compliance with AEDs and seizure control, Dr. Szaflarski replied that although further studies are needed to address the precise effects of such factors, it does not appear that compliance played a role in his group’s findings. “The old and new AEDs had the same efficacy in this study, but the side-effect profiles were better for the new drugs—this is nothing new or unexpected,” he observed. “We have not evaluated medication compliance, as this was a retrospective study. But in one arm were institutional patients who are thought to be compliant with medications due to direct supervision. Since there were no differences between groups of institutionalized and noninstitutionalized patients while cared for by general neurologists or epilepsy specialists, we do not think the improved seizure control is related to the improved compliance while being treated by an epilepsy specialist; but we cannot exclude this explanation.”

NR