Inpatient long-term video-electroencephalographic monitoring event capture audiovisual diagnostic quality.

OBJECTIVES: Long-term video-electroencephalographic monitoring (LTVEM) represents the gold-standard method to evaluate whether events represent electrographic seizures, but limited work has evaluated the quality of inpatient event capture. We evaluated the frequency of audiovisual factors impairing the ideal electroclinical correlation of seizure-like episodes during LTVEM. METHODS: We retrospectively reviewed consecutive inpatient LTVEM studies (11/2019-12/2019) from three academic epilepsy centers. We evaluated all pushbutton events for audiovisual characteristics such as whether the event was narrated, whether the patient was blocked on camera, and what diagnostic challenges impaired the electroencephalographer's ability to understand either the reason the event button was pushed or clinical semiology ("electroclinical correlation"). We determined the percent of events and studies with each outcome. RESULTS: There were 154 studies with 520 pushbutton events. The pushbutton was most commonly activated by patients (41%), followed by nurses (31%) or family (17%). Twenty-nine percent of events represented electrographic seizures, and 78% occurred in the Epilepsy Monitoring Unit. The reason for the push was not stated in 45% of events, and inadequate narration impaired electroclinical correlation in 19% of events. At least one relevant part of the patient's body was blocked during 12% of events, but this impaired electroclinical correlation in only 1% of events. There was at least one factor impairing electroclinical correlation in 21% of events, most commonly due to incomplete narration (N = 99), lights off (N = 15), or blankets covering the patient (N = 15). At least one factor impaired electroclinical correlation for any event in 36% of studies. CONCLUSION: Audiovisual factors impairing the electroencephalographer's ability to render an electroclinical correlation were common, particularly related to inadequate narration from bedside observers to explain the reason for pushing the button or event semiology. Future efforts to develop targeted countermeasures should address narration challenges and improve inpatient seizure monitoring quality metrics.

Changes in the Use of Brand Name and Generic Medications and Total Prescription Cost Among Medicare Beneficiaries With Epilepsy.

OBJECTIVE: To characterize trends in antiseizure medication (ASM) fills and total prescription costs in people with epilepsy. METHODS: This was a retrospective cohort study of beneficiaries with epilepsy (ASM, plus International Classification of Diseases codes) in a 20% random Medicare sample, with continuous Fee-For-Service coverage (Parts A, B, and D) in 2008-2018. We summed the number of pill days and costs (adjusted to 2018 dollars) per person-year for each ASM. ASMs were categorized into brand versus generic, first- versus newer-generation, and enzyme-inducers versus non-inducers. RESULTS: There were 77,000-133,000 beneficiaries with epilepsy per year. The most common ASM was phenytoin in 2008, which shifted to levetiracetam in 2018 (2008: phenytoin 25%, levetiracetam 14%; 2018: phenytoin 9%, levetiracetam 27%). Brand name (2008: 56%; 2018: 14%), first-generation (2008: 55%; 2018: 32%), and enzyme-inducing ASMs (2008: 44%; 2018: 24%) each decreased over time as a proportion of pill days. The number of brand pill days per person-year initially decreased (e.g. 2008: 250; 2009: 121; 2010: 96), but then plateaued (2013-2018: between 66-69) given a notable increase in lacosamide pill days per person (2008: 0; 2018: 20). Total brand name costs per year initially decreased 2008-2010 (2008: $150 million; 2010: $72 million) but then increased after 2010 (2018: $256 million). In 2018 brand name ASMs represented 79% of costs despite representing only 14% of pill days, a one-year pill supply became 277% more expensive for brand name but 42% less expensive for generic medications over time (2008: brand ∼$2,800 versus generic ∼$800; 2018: brand ∼$10,700 versus generic ∼$460), and many common brand name ASMs cost approximately ten-fold more per pill day than their generic equivalents. CONCLUSIONS: First-generation and enzyme-inducing ASMs waned from 2008 to 2018. While brand name ASMs initially waned translating into lower costs and potentially higher value care, after 2010 brand name costs markedly increased due to increasing use of lacosamide plus a 277% increase in per-pill cost of brand name ASMs. Brand name ASMs represented a small minority of prescriptions, but the large majority of costs.

Adherence to Antiseizure vs Other Medications Among US Medicare Beneficiaries With and Without Epilepsy.

OBJECTIVE: To 1) compare adherence to antiseizure medications (ASMs) versus non-ASMs among individuals with epilepsy, 2) assess the degree to which variation in adherence is due to differences between individuals versus between medication classes among individuals with epilepsy, and 3) compare adherence in individuals with versus without epilepsy. METHODS: This was a retrospective cohort study using Medicare. We included beneficiaries with epilepsy (≥1 ASM, plus International Classification of Diseases, Ninth Revision, Clinical Modification diagnostic codes), and a 20% random sample without epilepsy. Adherence for each medication class was measured by the proportion of days covered (PDC) in 2013-2015. We used Spearman correlation coefficients, Cohen's kappa statistics, and multilevel logistic regressions. RESULTS: There were 83,819 beneficiaries with epilepsy. Spearman correlation coefficients between ASM PDCs and each of the 5 non-ASM PDCs ranged 0.44-0.50, Cohen's kappa ranged 0.33-0.38, and within-person differences between each ASM's PDC minus each non-ASM's PDC were all statistically significant (p<0.01) though median differences were all very close to 0. Fifty-four percent of variation in adherence across medications was due to differences between individuals. Adjusted predicted probabilities of adherence were: ASMs 74% (95% confidence interval [CI] 73%-74%), proton pump inhibitors 74% (95% CI 74%-74%), antihypertensives 77% (95% CI 77%-78%), selective serotonin reuptake inhibitors 77% (95% CI 77%-78%), statins 78% (95% CI 78%-79%), and levothyroxine 82% (95% CI 81%-82%). Adjusted predicted probabilities of adherence to non-ASMs were 80% (95% CI 80%-81%) for beneficiaries with epilepsy versus 77% (77%-77%) for beneficiaries without epilepsy. CONCLUSION: Among individuals with epilepsy, ASM and non-ASM adherence were moderately correlated, half of variation in adherence was due to between-person rather than between-medication differences, adjusted adherence was slightly lower for ASMs than several non-ASMs, and epilepsy was associated with a quite small increase in adherence to non-ASMs. Nonadherence to ASMs may provide an important cue to the clinician to inquire about adherence to other potentially life-prolonging medications as well. Although efforts should focus on improving ASM adherence, patient-level rather than purely medication-specific behaviors are also critical to consider when developing interventions to optimize adherence.

Clinical Practice Variability in Temperature Correction of Arterial Blood Gas Measurements and Outcomes in Hypothermia-Treated Patients After Cardiac Arrest.

Mechanical ventilation in patients treated with mild therapeutic hypothermia (MTH) for the postcardiac arrest syndrome may be challenging given changes in solubility of arterial blood gases (ABGs) with cooling. Whether ABG measurements should be temperature corrected (TC) remain unknown. We sought to describe practice variability in TC at a single institution and explored the association between TC and neurological outcome. We conducted a retrospective cohort study reviewing electronic health records of all patients treated with MTH after cardiac arrest. We examined whether the percentage of TC ABGs relative to total number of ABGs drawn for each subject during hypothermia was associated with the neurological outcome at hospital discharge and 6-12-month follow-up. The cerebral performance category of 1-2 was defined as a favorable outcome in the logistic regression models. 1223 ABGs were obtained during MTH on 122 subjects over 6 years. TC was never used in 72 subjects (59%; no TC group), made available in 1-74% of ABGs in 17 subjects (14%; intermediate TC group), and made available in ≥75% of ABGs in 33 subjects (27%; mostly TC group). Groups differed in the proportion of subjects with shockable presenting rhythms (47% vs. 47% vs. 76%, p=0.02) and admitting ICU (p=0.005). Favorable 6-month outcomes were more common in the mostly TC than no TC group (48% vs. 25%; OR [95% CI]: 2.9 [1.2-7.1]), but not after adjustment (OR 1.5, 95% CI 0.33-6.9). There was substantial practice variability in the temperature correction strategy. Availability of temperature-corrected ABGs was not associated with improved neurological outcomes after adjusting for covariates.