The burden of decisional uncertainty in the treatment of status epilepticus.

OBJECTIVE: Treatments for convulsive status epilepticus (SE) have a wide range of effectiveness. The estimated effectiveness of non-intravenous benzodiazepines (non-IV BZDs) ranges from approximately 70% to 90% and the estimated effectiveness of non-benzodiazepine antiseizure medications (non-BZD ASMs) ranges from approximately 50% to 80%. This study aimed to quantify the clinical and economic burden of decisional uncertainty in the treatment of SE. METHODS: We performed a decision analysis that evaluates how decisional uncertainty on treatment choices for SE impacts hospital admissions, intensive care unit (ICU) admissions, and costs in the United States. We evaluated treatment effectiveness based on the available literature. RESULTS: Use of a non-IV BZD with high estimated effectiveness, like intranasal midazolam, rather than one with low estimated effectiveness, like rectal diazepam, would result in a median (p25 -p75 ) reduction in hospital admissions from 6 (3.9-8.8) to 1.1 (0.7-1.8) per 100 cases and associated cost reductions of $638 ($289-$1064) per pediatric patient and $1107 ($972-$1281) per adult patient. For BZD-resistant SE, use of a non-BZD ASM with high estimated effectiveness, like phenobarbital, rather than one with low estimated effectiveness, like phenytoin/fosphenytoin, would result in a reduction in ICU admissions from 9.1 (7.3-11.2) to 3.9 (2.6-5.5) per 100 cases and associated cost reduction of $1261 ($445-$2223) per pediatric patient and $319 ($-93-$806) per adult patient. Sensitivity analyses showed that relatively minor improvements in effectiveness may lead to substantial reductions in downstream hospital admissions, ICU admissions, and costs. SIGNIFICANCE: Decreasing decisional uncertainty and using the most effective treatments for SE may substantially decrease hospital admissions, ICU admissions, and costs.

Estimating the cost of status epilepticus admissions in the United States of America using ICD-10 codes.

PURPOSE: Estimate the cost of status epilepticus (SE) admissions in the USA using claim databases based on ICD-10 codes. METHOD: Descriptive retrospective study using national estimates for the year 2016 from the KID's Inpatient Database (KID) for pediatric patients and from the National Inpatient Sample (NIS) for adults. These databases are comprehensive collections of all-payer, encounter-level hospital care data in the United States of America. RESULTS: From a population of 6,106,405 pediatric admissions there were 580 admissions related to SE. From a population of 29,274,158 adult admissions there were 1,405 admissions related to SE. The median (p25-p75) cost of pediatric admissions related to SE was $8,749 ($4,875-$19,067) in 2016 USA dollars [$9,295 ($5,180-$20,258) in inflation-adjusted 2019 USA dollars], and for adult admissions related to SE it was $14,678 ($7,203-$28,388) in 2016 USA dollars [$15,595 ($7,653-$30,161) in inflation-adjusted 2019 USA dollars]. Transforming to 2019 USA dollars, the values from the current study are consistent with prior estimates in the literature from the KID and NIS databases with a progressive increase, except for the cost of super-refractory SE in children that has increased disproportionately. CONCLUSIONS: This study estimates that the cost of admissions related to SE in the USA is approximately $9,000 in children and $15,000 in adults and shows that the cost estimates have not markedly changed with the advent of ICD-10.

Burden and epidemiology of status epilepticus in infants, children, and adolescents: A population-based study on German health insurance data.

OBJECTIVE: Status epilepticus (SE) is an important medical emergency condition with particularly unfavorable outcome in refractory and superrefractory SE (SRSE). The economic impact of SE and especially of SRSE in the pediatric population remains unclear. We aimed to determine the burden of illness of SE in a pediatric patient population. METHODS: Insurance records for patients aged 0-18 years admitted between 2008 and 2015 were selected from a nationwide insurance research database utilizing International Classification of Diseases and Related Health Problems, 10th Revision (ICD-10) codes for SE (G41), epilepsy (G40), or febrile convulsions (R56). Patients were further classified based on admission to the intensive care unit and use of mechanical ventilation. RESULTS: The algorithm identified 11 693 seizure-related admissions and classified 4% as SE. Of these cases, 282 (60.4%) were classified by the algorithm as nonrefractory SE (NRSE), 125 (26.8%) as refractory SE (RSE), and 60 (12.8%) as SRSE. The crude SE incidence was 17.6/100 000, with NRSE being 11.4/100 000, RSE 3.9/100 000, and SRSE 2.3/100 000. SRSE incidence peaked in the 0- to 1-year-old age subgroup accounting for 48.3% of all pediatric SRSE admissions. The median length of stay (LOS) for all SE cases was 7 days, with median 44.5 days in SRSE, 5 days in NRSE, and 12 days in RSE. Mean admission costs for total SE were €15 880, with a mean expense for SRSE of €75 358, for NRSE of €4119, and for RSE of €13 864. The mean LOS for non-SE epilepsy admissions was 3 days, with mean costs of €2697 for epilepsy and €1614 for febrile convulsion admissions. There were no deaths in non-SE and NRSE admissions, whereas the overall mortality for SE was 3%, with 5.6% in RSE and 11.7% in SRSE. SIGNIFICANCE: Although cases classified as SE represented 4% of the seizure-associated admissions, they accounted for 22% of the overall costs. These costs were disproportionately represented by SRSE cases, which accounted for 62% of all SE-associated costs.

The burden of pediatric status epilepticus: Epidemiology, morbidity, mortality, and costs.

PURPOSE: To summarize the epidemiology, morbidity, mortality, and costs of status epilepticus (SE) in the pediatric population. METHOD: Review of the medical literature. RESULTS: The overall incidence of pediatric SE is roughly 20 per 100,000 children per year, with overall mortality of 3%. Underlying etiology is the biggest risk factor for SE, with symptomatic (acute > remote) etiologies associated with worse outcomes. The most common cause of SE in children is febrile SE, though this entity occurs primarily in early childhood. After a first episode, the risk of recurrence is similar to the risk after a first unprovoked seizure (25-40%). SE is expensive, regularly costing more than $10,000 per episode and often more than $100,000 for refractory cases. CONCLUSION: SE is not an uncommon neurologic emergency and depending on the associated etiology can carry significant morbidity, mortality, and cost especially if treatment is not performed in a timely manner.

Cost of status epilepticus (SE): Effects of delayed treatment and SE duration.

BACKGROUND: The health expenditure related to status epilepticus (SE) is high because of lengthy hospitalization requirements and possible sequelae. We aimed to study the factors associated with this cost including the different timings of the treatment and SE duration. METHODS: We evaluated retrospectively all SE recorded in 2 hospitals. The factors studied included the mean cost of hospitalization, demographics, clinical data, duration of hospitalization, in-hospital/out-of-hospital debut, time from onset to treatment, duration of SE, and destination at discharge. RESULTS: Three hundred five patients were evaluated (December/2012-July/2017), 195 with out-of hospital and 110 with in-hospital debut. The cost of SE with out-of-hospital onset was significantly lower (6559€ vs 15,174€; p = 0.0001). In out-of-hospital cases, the factors independently related to expenditure were the level of consciousness (p < 0.001), presence of complications (p = 0.005), a potentially fatal etiology (p = 0.008), and duration of the episode (p = 0.003). Duration was significantly higher in patients discharged to a convalescence center (p = 0.006); this variable was significantly related to the time SE onset-arrival to hospital, and SE onset-administration of the treatment. In the in-hospital cases, cost was related to male sex (p = 0.002), the development of complications (p = 0.003), and the etiology (p = 0.016) but was not directly related to the SE duration or to the time onset-treatment. CONCLUSIONS: The duration of SE and the speed with which proper management is applied have a direct impact on the healthcare expenditure resulting from out-of-hospital SE. In contrast, the etiology and development of complications are the main factors responsible for expenditure related to in-hospital SE.

Estimating the cost of admissions related to convulsive status epilepticus in the United States of America.

PURPOSE: To estimate the cost of admissions related to status epilepticus (SE) in the USA and to evaluate SE mortality. METHOD: Descriptive retrospective study using national estimates from the KID's Inpatient Database (KID) for children and from the National Inpatient Sample (NIS) for adults for the years 2007-2012, the largest collection of all-payer, encounter-level hospital care data in the United States. The individual observation in this study is hospital admission. RESULTS: From a population of 186,013,640 admissions, a total of 184,500 admissions were related to SE. The median (p25-p75) cost of admissions related to SE was $7690 ($3893-$17,247) in the KID 2010-2012, $6529 ($3,370-$14,854) in the KID 2007-2009, $13,874 ($6699-$29,176) in the NIS 2012, $13,313 ($6,483-$28,598) in the NIS 2011, $12,999 ($6,366-$27,505) in the NIS 2010, $11,833 ($5721-$24,657) in the NIS 2009, $11,479 ($5,611-$24,326) in the NIS 2008, and $10,759 ($5493-$22,928) in the NIS 2007. Costs were more than two times higher for super-refractory SE admissions than for refractory SE admissions. Costs stratified by age followed an "U"-shaped distribution with higher costs in admissions of young children and older adults. Mortality ranged from 2.5% to 3% in children and from 12.7% to 14.9% in adults. CONCLUSIONS: This study estimates the cost of admissions related to SE in the USA to be approximately $7000 in children and $13,000 in adults, and quantifies how costs markedly increase once SE becomes super-refractory.

Treatment gap for convulsive status epilepticus in resource-poor countries.

The magnitude of the treatment gap (TG) for convulsive status epilepticus (CSE) in resource-poor countries is unknown. Hospital-based cohort studies from developing countries revealed that the management of CSE was usually suboptimal due to lack of advanced diagnostic and treatment facilities, significant delay in patient's presentation at hospital, and shortages of essential antiepileptic drugs (AEDs). However, there were no significant differences in the proportion of refractory status epilepticus, short-term mortalities, and morbidities of CSE between the developed and the developing countries. Therefore, the presence of significant TG for CSE in developing countries is still an assumption without evidence. We conducted an expert survey in Asia for potential sources of TG. Experts from 16 Asian countries responded to the questionnaire. An injectable form of diazepam was available in all 16 countries even at the primary care level, but intravenous lorazepam was available only in four countries. Second-line AEDs were widely available at tertiary care hospitals, but not at primary care hospitals. Lack of second-line AEDs at primary care hospitals, significant delay in patient transportation to the hospital, shortages of intensive care unit facilities, and absence of trained physicians were important contributing factors to TG in Asia.

Examining health service utilization, hospital treatment cost, and mortality of individuals with epilepsy and status epilepticus in New South Wales, Australia 2012-2016.

This study examined the health service utilization and hospital treatment cost of individuals with epilepsy by age group, mortality within 30days, and surgical outcomes for individuals with refractory epilepsy in New South Wales (NSW), Australia. A retrospective examination of linked hospitalization and mortality data for individuals hospitalized with a diagnosis of epilepsy during 2012-2016. Hospitalized incidence rates per 1000 population were calculated, and negative binomial regression was used to examine temporal trends. Mortality within 30days of hospitalization was identified, along with cause of death. There were 44,722 hospitalizations during the five-year period, with a hospitalization rate of 85.6 per 1000 population (95% confidence interval (CI): 84.7-86.4). Total hospital treatment costs were AUD$402.9 million. Children aged ≤17years accounted for 32.0% of hospitalizations. Just over half to two-thirds of hospitalizations for each age group were for a principal diagnosis of epilepsy, with 2976 hospitalizations of individuals for status epilepticus. The overall mean hospital length of stay (LOS) for epilepsy hospitalizations was 5.1days (standard deviation (SD)=9.0). Thirty-day mortality was highest for individuals aged ≥65years (6.7%), and epilepsy was identified as the underlying cause of death for 18.2% of deaths. This research has provided insight into the healthcare utilization profiles of individuals with epilepsy at different ages. Epilepsy hospitalizations constitute a substantial cost to the healthcare system, and better overall management of seizures and comorbid conditions is likely to lead to a reduction in the need for hospitalization.

Costs, length of stay, and mortality of super-refractory status epilepticus: A population-based study from Germany.

OBJECTIVE: Super-refractory status epilepticus (SRSE) is a severe condition in which a patient in status epilepticus (SE) for ≥24 h does not respond to first-, second-, or third-line therapy. The economic impact of SRSE treatment remains unclear. A health insurance research database was used for a population-based estimation of SRSE-associated inpatient costs, length of stay, and mortality in Germany. METHODS: An algorithm using International Classification of Diseases, 10th Edition coding and treatment parameters identified and classified patients in a German statutory health insurance database covering admissions from 2008 to 2013 as having refractory SE (RSE) or SRSE. Admissions data in our study refer to these classifications. Associated patient data included costs, procedures, and demographics. RESULTS: The algorithm identified 2,585 (all type) SE admissions, classified as 1,655 nonrefractory SE (64%), 592 (22.9%) RSE, and 338 (13.1%) SRSE, producing database incidence rates of 15.0 in 100,000, 5.2 in 100,000, and 3.0 in 100,000 per year, respectively. Median cost per admission was €4,063 for nonrefractory SE, €4,581 (p < 0.001) for RSE, and €32,706 (p < 0.001) for SRSE. Median length of stay varied significantly between 8 days (mean = 13.6) in nonrefractory SE, 14 days in RSE, and up to 37 days in SRSE. Discharge mortality increased from 9.6% in nonrefractory SE to 15.0% (p < 0.001) in RSE and 39.9% (p < 0.001) in SRSE. SIGNIFICANCE: This study evaluated the hospital treatment costs associated with admissions classified by the algorithm as SRSE in Germany. SRSE represented 13% of all SE admissions, but resulted in 56% of all SE-related costs. The lack of approved treatments and limited number of evidence-based treatment guidelines highlight the need for further evaluations of the SRSE burden of illness and the potential for further optimization of treatments for SRSE.

Nonintravenous rescue medications for pediatric status epilepticus: A cost-effectiveness analysis.

OBJECTIVE: To quantify the cost-effectiveness of rescue medications for pediatric status epilepticus: rectal diazepam, nasal midazolam, buccal midazolam, intramuscular midazolam, and nasal lorazepam. METHODS: Decision analysis model populated with effectiveness data from the literature and cost data from publicly available market prices. The primary outcome was cost per seizure stopped ($/SS). One-way sensitivity analyses and second-order Monte Carlo simulations evaluated the robustness of the results across wide variations of the input parameters. RESULTS: The most cost-effective rescue medication was buccal midazolam (incremental cost-effectiveness ratio ([ICER]: $13.16/SS) followed by nasal midazolam (ICER: $38.19/SS). Nasal lorazepam (ICER: -$3.8/SS), intramuscular midazolam (ICER: -$64/SS), and rectal diazepam (ICER: -$2,246.21/SS) are never more cost-effective than the other options at any willingness to pay. One-way sensitivity analysis showed the following: (1) at its current effectiveness, rectal diazepam would become the most cost-effective option only if its cost was $6 or less, and (2) at its current cost, rectal diazepam would become the most cost-effective option only if effectiveness was higher than 0.89 (and only with very high willingness to pay of $2,859/SS to $31,447/SS). Second-order Monte Carlo simulations showed the following: (1) nasal midazolam and intramuscular midazolam were the more effective options; (2) the more cost-effective option was buccal midazolam for a willingness to pay from $14/SS to $41/SS and nasal midazolam for a willingness to pay above $41/SS; (3) cost-effectiveness overlapped for buccal midazolam, nasal lorazepam, intramuscular midazolam, and nasal midazolam; and (4) rectal diazepam was not cost-effective at any willingness to pay, and this conclusion remained extremely robust to wide variations of the input parameters. SIGNIFICANCE: For pediatric status epilepticus, buccal midazolam and nasal midazolam are the most cost-effective nonintravenous rescue medications in the United States. Rectal diazepam is not a cost-effective alternative, and this conclusion remains extremely robust to wide variations of the input parameters.

A systematic review of economic evaluations of treatments for patients with epilepsy.

The increasing number of treatment options and the high costs associated with epilepsy have fostered the development of economic evaluations in epilepsy. It is important to examine the availability and quality of these economic evaluations and to identify potential research gaps. As well as looking at both pharmacologic (antiepileptic drugs [AEDs]) and nonpharmacologic (e.g., epilepsy surgery, ketogenic diet, vagus nerve stimulation) therapies, this review examines the methodologic quality of the full economic evaluations included. Literature search was performed in MEDLINE, EMBASE, NHS Economic Evaluation Database (NHS EED), Econlit, Web of Science, and CEA Registry. In addition, Cochrane Reviews, Cochrane DARE and Cochrane Health Technology Assessment Databases were used. To identify relevant studies, predefined clinical search strategies were combined with a search filter designed to identify health economic studies. Specific search strategies were devised for the following topics: (1) AEDs, (2) patients with cognitive deficits, (3) elderly patients, (4) epilepsy surgery, (5) ketogenic diet, (6) vagus nerve stimulation, and (7) treatment of (non)convulsive status epilepticus. A total of 40 publications were included in this review, 29 (73%) of which were articles about pharmacologic interventions. Mean quality score of all articles on the Consensus Health Economic Criteria (CHEC)-extended was 81.8%, the lowest quality score being 21.05%, whereas five studies had a score of 100%. Looking at the Consolidated Health Economic Evaluation Reporting Standards (CHEERS), the average quality score was 77.0%, the lowest being 22.7%, and four studies rated as 100%. There was a substantial difference in methodology in all included articles, which hampered the attempt to combine information meaningfully. Overall, the methodologic quality was acceptable; however, some studies performed significantly worse than others. The heterogeneity between the studies stresses the need to define a reference case (e.g., how should an economic evaluation within epilepsy be performed) and to derive consensus on what constitutes "standard optimal care."

Burden of illness for super-refractory status epilepticus patients.

OBJECTIVE: To provide an estimate of the annual number of super-refractory status epilepticus (SRSE) cases in the US and to evaluate utilization of hospital resources by these patients. METHODS: The Premier Hospital Database was utilized to estimate the number of SRSE cases based on hospital discharges during 2012. Discharges were classified as SRSE cases based on an algorithm using seizure-related International Classification of Diseases-9 (ICD-9) codes, Intensive Care Unit (ICU) length of stay (LOS), and treatment protocols (e.g. benzodiazepines, anti-epileptic drugs (AEDs), and ventilator use). Secondary analyses were conducted using more restrictive algorithms for SRSE. RESULTS: A total of 6,325 hospital discharges were classified as SRSE cases from a total of 5,300,000 hospital discharges. Applying a weighting based on hospital characteristics and 2012 US demographics, this projected to an estimated 41,156 cases of SRSE in the US during 2012, an estimated incidence rate of ∼13/100,000 annually for SRSE in the US. Secondary analyses using stricter SRSE algorithms resulted in estimated incidence rates of ∼11/100,000 and 8/100,000 annually. The mean LOS for SRSE hospitalizations was 16.5 days (median =11; interquartile range [IQR] = 6-20), and the mean ICU LOS was 9.3 days (median =6; IQR =3-12). The mean cost of an SRSE hospitalization was $51,247 (median = $33,294; 95% CI = $49,634-$52,861). LIMITATIONS: The analysis uses ICD-9 diagnostic codes and claims information, and there are inherent limitations in any methodology based on treatment protocol, which created challenges in distinguishing with complete accuracy between SRSE, RSE, and SE on the basis of care patterns in the database. CONCLUSION: SRSE is associated with high mortality and morbidity, which place a high burden on healthcare resources. Projections based upon the findings of this study suggest an estimated 25,821-41,959 cases of SRSE may occur in the US each year, but more in-depth studies are required.

Costs and cost-driving factors for acute treatment of adults with status epilepticus: A multicenter cohort study from Germany.

OBJECTIVE: To provide first data on inpatient costs and cost-driving factors due to nonrefractory status epilepticus (NSE), refractory status epilepticus (RSE), and super-refractory status epilepticus (SRSE). METHODS: In 2013 and 2014, all adult patients treated due to status epilepticus (SE) at the university hospitals in Frankfurt, Greifswald, and Marburg were analyzed for healthcare utilization. RESULTS: We evaluated 341 admissions in 316 patients (65.7 ± [standard deviation]18.2 years; 135 male) treated for SE. Mean costs of hospital treatment were €14,946 (median €5,278, range €776-€152,911, €787 per treatment day) per patient per admission, with a mean length of stay (LOS) of 19.0 days (median 14.0, range 1-118). Course of SE had a significant impact on mean costs, with €8,314 in NSE (n = 137, median €4,597, €687 per treatment day, 22.3% of total inpatient costs due to SE), €13,399 in RSE (n = 171, median €7,203, €638/day, 45.0% of total costs, p < 0.001), and €50,488 in SRSE (n = 33, median €46,223, €1,365/day, 32.7% of total costs, p < 0.001). Independent cost-driving factors were SRSE, ventilation, and LOS of >14 days. Overall mortality at discharge was 14.4% and significantly higher in RSE/SRSE (20.1%) than in NSE (5.8%). SIGNIFICANCE: Acute treatment of SE, and particularly SRSE and ventilation, are associated with high hospital costs and prolonged LOS. Extrapolation to the whole of Germany indicates that SE causes hospital costs of >€200 million per year. Along with the demographic change, incidence of SE will increase and costs for hospital treatment and sequelae of SE will rise.

A retrospective cross-sectional study of the prevalence of generalized convulsive status epilepticus in traumatic brain injury: United States 2002-2010.

PURPOSE: To determine the incidence, predictors, and outcomes of generalized convulsive status epilepticus (GCSE) in traumatic brain injury (TBI) patients. METHODS: We conducted a retrospective cross-sectional study of adult patients with acute TBI using the 2002-2010 Nationwide Inpatient Sample (NIS) database of USA. We used multivariable logistic regression analyses to identify independent predictors of GCSE in patients with TBI and to determine the impact of GCSE on outcomes (in-hospital mortality, length of stay, total hospital charges, and discharge disposition). RESULTS: Among 1,457,869 patients hospitalized with TBI, 2315 (0.16%) had GCSE. In-hospital mortality was significantly higher in patients with GCSE (32.5% vs. 9.6%; unadjusted OR 4.54, 95% CI 4.16-4.96; p<0.001; adjusted OR 3.41; 95% CI 3.09-3.76 p<0.001). Patients with GCSE had longer length of stay (17.3 ± 21.9 vs. 6.8 ± 11.1 days; p<0.001), higher total hospital charges ($147,415 ± 162,319 vs. $54,041 ± 90,524; p<0.001), and were less likely to be discharged home (19.8% vs. 52.7%; p<0.001). Using multivariable logistic regression analysis, age >35 years (OR 2.15; 95% CI 1.87-2.47), CNS infections (OR 4.86; 95% CI 3.70-6.38), anoxic brain injury (OR 9.54; 95% CI 8.10-11.22), and acute ischemic stroke (OR 4.09; 95% CI 3.41-4.87) were independent predictors of GCSE in TBI patients. Epilepsy was an independent negative predictor of GCSE (OR 0.74; 95% CI 0.55-0.99). CONCLUSION: Despite its low incidence, GCSE in TBI patients was associated with worse outcomes with threefold higher in-hospital mortality, prolonged hospitalization, higher hospital charges, and worse discharge disposition. Surprisingly, epilepsy is a negative predictor of GCSE in this population.

Cost of status epilepticus in a tertiary care hospital in India.

PURPOSE: Status epilepticus (SE) is one of the most important neurological emergencies. The present study evaluated both direct cost of SE and predictors of cost in an Indian tertiary care teaching hospital in Lucknow India. METHODS: SE was defined as continuous seizure for ≥ 5 min or recurrent seizures without regaining consciousness. Etiologies of SE were categorized as acute central nervous system (CNS) pathology, acute non-CNS pathology, chronic CNS pathology, congenital disorders and others. Patients requiring mechanical ventilation (MV) received ventilators free of cost. Mortality and disability on discharge were noted. RESULTS: Fifty-five patients aged 8-90 years were included (males, 33). Fifty (89.3%) patients had generalized convulsive SE. The severity of SE as assessed by Status Epilepticus Scoring Scale was unfavorable (score, 3-6) in 41 (74.5%) patients. The etiology of SE was categorized as acute CNS pathology in 28 (51%) patients, non-CNS and chronic CNS pathology in 11 (19.6%) patients each, remote congenital pathology in 2 (3.6%), and others in 3 (5.6%). Thirty (53.6%) patients had comorbidities. Median duration of hospitalization was 7 (range, 1-72) days.Twenty six patients were hospitalized for >7 days. SE was controlled by 2 drugs in 47 (85.5%) patients and refractory to 2 intravenous antiepileptic drugs in 8 (14.5%). Nineteen (34.5%) patients died, and 29 (51.8%) showed favorable outcomes on discharge. Median hospital expenditure per case was INR 19,900 ($309.87; range, INR 1600-574,000). On multivariate analysis, SE hospitalization costs were determined by refractoriness of SE and mechanical ventilation (MV). Hospitalization cost of SE was lower than those of stroke. CONCLUSION: Acute non-CNS pathology is largely responsible for the high cost of SE, particularly refractory SE requiring mechanical ventilation.

Short-term outcomes and major barriers in the management of convulsive status epilepticus in children: a study in Georgia.

AIM: Convulsive status epilepticus is the most common childhood neurological emergency in developing countries, where poor healthcare organisation could play a negative role in the management of the condition. Unavailability of second-line injectable anticonvulsants is an additional hindering factor in Georgia. This report reflects the results of the first study aimed at evaluating the epidemiological features of convulsive status epilepticus, as well as identifying obstacles influencing the management of patients with convulsive status epilepticus in Georgia. METHODS: A prospective, hospital-based study was performed. Paediatric patients with convulsive status epilepticus, admitted to the emergency department of a referral academic hospital from 2007 to 2012, were included in the study. RESULTS: Forty-eight paediatric patients admitted to hospital met the criteria for convulsive status epilepticus. Seizure duration was significantly shorter among the group with adequate and timely pre-hospital intervention. Moreover, patients with appropriate pre-hospital treatment less frequently required mechanical ventilation (p=0.039). Four deaths were detected during the follow-up period, thus the case fatality rate was 8%. Only 31% of patients received treatment with intravenous phenytoin. CONCLUSION: The study results show that adequate and timely intervention could improve outcome of convulsive status epilepticus and decrease the need for mechanical ventilation. Mortality parameters were comparable to the results from other resource-limited countries. More than one third of patients did not receive appropriate treatment due to unavailability of phenytoin.

Cost of status epilepticus: A systematic review.

The objective of this review is to give an overview of published cost of illness (COI) studies on status epilepticus (SE). For identifying COI studies that evaluated the direct and indirect costs of SE, a systematic literature review was performed. We used a standardized assessment form for extracting information on the study design, methodological framework, and data sources from each publication. The results were systematically reported. We identified only two studies worldwide, which included prevalence- or incidence-based data on the direct costs of SE: one from Germany and one from the USA. Both used a bottom-up approach and a prospective design. The estimated mean inpatient costs summed up to US$18,834 in the USA and to €8347 in Germany per admission with an average length of stay of 12.9 and 14.0 days. The mean annual direct costs for SE had been estimated at US$4 billion in the USA and at €83 million (adults only) in Germany. Both available studies indicate that SE is a cost-intensive disorder with an acute CNS aetiology as a cost-driving factor. In conclusion, there is a paucity of data on the costs of SE. Further studies are warranted to determine costs, its predictors, quality of life, mortality data due to SE and its sequelae and to provide a basis for further cost-effectiveness calculations for new drugs and other interventions in SE and prolonged seizures.

Inpatient treatment costs of status epilepticus in adults in Germany.

PURPOSE: Status epilepticus (SE) is an important neurological emergency and a significant source of direct costs related to hospitalization; however, no cost-of-illness (COI) studies have been performed in Europe. The objective of this study was to determine and characterize hospital costs related to the acute inpatient treatment of SE and to provide national estimates of SE hospitalization costs. METHODS: Adult inpatient treatment costs related to SE and costs attributable to epilepsy-related hospital admissions were derived from billing data of participating hospitals. RESULTS: During the 4-month study period a total of 96 patients (59.5 ± 21.6 years; 52 male) received inpatient treatment for epilepsy-related reasons, 10 of these (10.4%) were treated for SE. Epilepsy was newly diagnosed in 30/96 patients (31.3%), of whom five presented with SE. The admission costs related to SE (€8347 ± 10,773 per patient per admission) were significantly higher than those related to admissions of patients with newly diagnosed (€1998 ± 1089; p = 0.014) or established epilepsy (€3475 ± 4413; p = 0.026). Of the total inpatient costs (€346,319) 24.4% were attributable to SE, 14.4% to newly diagnosed epilepsy without SE (n = 25) and 61.2% to complications of established epilepsy (n = 61). Extrapolation to the whole of Germany (population 82 million) indicates that SE causes hospital costs of more than €83 million per year while the total of epilepsy-related inpatient treatment costs amounts to €342 million. CONCLUSION: Acute treatment of SE is responsible for a high proportion of hospital costs associated with epilepsy. With a high incidence of SE in the elderly population, the health care systems will face an increasing number of presentations with SE and its associated costs, underlining the necessity to further evaluate the burden and optimize the treatment of SE.