The economic burden of caregiving in epilepsy: An estimate based on a survey of US caregivers.

OBJECTIVE: The burden of caregiving for persons with epilepsy (PWEs) has not been examined previously in the United States. We assessed the clinical impact and direct and indirect economic costs for caregivers of PWEs. METHODS: An internet survey of 500 caregivers of PWEs was conducted from May to July 2015 using a combination of validated instruments and questions designed specifically for this survey. Caregivers were stratified by PWE age (adult/child) and disease severity (low: 0 vs high: 1 + seizures in the prior month). Annual self-reported direct and indirect costs were reported per caregiver and extrapolated to all US caregivers. The economic burden of caregiving for PWEs was defined as the difference between costs for caregivers and the general population. RESULTS: Caregivers reported that PWEs averaged 11.4 seizures in the prior month. Eighty percent of respondents were female and the average age was 44.3. Since becoming a caregiver, many reported anxiety (52.8%), depression (41.0%), and insomnia (30.8%). Annual mean direct medical costs for caregivers of children with low vs high seizure frequency were $4344 and $10 162, respectively. Costs for caregivers of adult PWEs were $4936 and $8518. Mean indirect costs associated with caregiving for a child with low vs high seizure frequency were $20 529 and $40 137; those for caregivers of an adult were $13 981 and $28 410. The cost estimates are higher vs the general US population; annual per-person healthcare utilization costs were $2740 and productivity loss costs were $5015. When extrapolating to the US population of PWE caregivers, annual costs exceeded $62 billion vs $14 billion for the general population, resulting in a caregiver burden of nearly $48 billion. SIGNIFICANCE: The clinical and economic burden of caregivers for PWE were substantial, and greatest for those caring for children with frequent seizures. The impact on caregivers should be considered when estimating the value of interventions that control epilepsy.

The primary prevention of epilepsy: A report of the Prevention Task Force of the International League Against Epilepsy.

Among the causes of epilepsy are several that are currently preventable. In this review, we summarize the public health burden of epilepsy arising from such causes and suggest priorities for primary epilepsy prevention. We conducted a systematic review of published epidemiologic studies of epilepsy of 4 preventable etiologic categories-perinatal insults, traumatic brain injury (TBI), central nervous system (CNS) infection, and stroke. Applying consistent criteria, we assessed the quality of each study and extracted data on measures of risk from those with adequate quality ratings, summarizing findings across studies as medians and interquartile ranges. Among higher-quality population-based studies, the median prevalence of active epilepsy across all ages was 11.1 per 1000 population in lower- and middle-income countries (LMIC) and 7.0 per 1000 in high-income countries (HIC). Perinatal brain insults were the largest attributable fraction of preventable etiologies in children, with median estimated fractions of 17% in LMIC and 15% in HIC. Stroke was the most common preventable etiology among older adults with epilepsy, both in LMIC and in HIC, accounting for half or more of all new onset cases. TBI was the attributed cause in nearly 5% of epilepsy cases in HIC and LMIC. CNS infections were a more common attributed cause in LMIC, accounting for about 5% of all epilepsy cases. Among some rural LMIC communities, the median proportion of epilepsy cases attributable to endemic neurocysticercosis was 34%. A large proportion of the overall public health burden of epilepsy is attributable to preventable causes. The attributable fraction for perinatal causes, infections, TBI, and stroke in sum reaches nearly 25% in both LMIC and HIC. Public health interventions addressing maternal and child health care, immunizations, public sanitation, brain injury prevention, and stroke prevention have the potential to significantly reduce the burden of epilepsy.

Rationale and Design of a Statewide Cohort to examine efficient resource utilization for patients with Intracerebral hemorrhage (EnRICH).

BACKGROUND: Intracerebral hemorrhage is a devastating disease with no specific treatment modalities. A significant proportion of patients with intracerebral hemorrhage are transferred to large stroke treatment centers, such as Comprehensive Stroke Centers, because of perceived need for higher level of care. However, evidence of improvement in patient-centered outcomes for these patients treated at larger stroke treatment centers as compared to community hospitals is lacking. METHODS / DESIGN: "Efficient Resource Utilization for Patients with Intracerebral Hemorrhage (EnRICH)" is a prospective, multisite, state-wide, cohort study designed to assess the impact of level of care on long-term patient-centered outcomes for patients with primary / non-traumatic intracerebral hemorrhage. The study is funded by the Texas state legislature via the Lone Star Stroke Research Consortium. It is being implemented via major hub hospitals in large metropolitan cities across the state of Texas. Each hub has an extensive network of "spoke" hospitals, which are connected to the hub via traditional clinical and administrative arrangements, or by telemedicine technologies. This infrastructure provides a unique opportunity to track outcomes for intracerebral hemorrhage patients managed across a health system at various levels of care. Eligible patients are enrolled during hospitalization and are followed for functional, quality of life, cognitive, resource utilization, and dependency outcomes at 30 and 90 days post discharge. As a secondary aim, an economic analysis of the incremental cost-effectiveness of treating intracerebral hemorrhage patients at higher levels of care will be conducted. DISCUSSION: Findings from EnRICH will provide much needed evidence of the effectiveness and efficiency of regionalized care for intracerebral hemorrhage patients. Such evidence is required to inform policy and streamline clinical decision-making.

m-Health Policy Readiness and Enabling Factors: Comparisons of Sub-Saharan Africa and Organization for Economic Cooperation and Development Countries.

BACKGROUND: As an innovative solution to poor access to care in low- and middle-income countries (LMICs), m-health has gained wide attention in the past decade. INTRODUCTION: Despite enthusiasm from the global health community, LMICs have not demonstrated high uptake of m-health promoting policies or public investment. MATERIALS AND METHODS: To benchmark the current status, this study compared m-health policy readiness scores between sub-Saharan Africa and high-income Organization for Economic Cooperation and Development (OECD) countries using an independent two-sample t test. In addition, the enabling factors associated with m-health policy readiness were investigated using an ordinal logistic regression model. The study was based on the m-health policy readiness scores of 112 countries obtained from the World Health Organization Third Global Survey on e-Health. RESULTS: The mean m-health policy readiness score for sub-Saharan Africa was statistically significantly lower than that for OECD countries (p = 0.02). The enabling factors significantly associated with m-health policy readiness included information and communication technology development index (odds ratio [OR] 1.57; 95% confidence interval [CI] 1.12-2.2), e-health education for health professionals (OR 4.43; 95% CI 1.60-12.27), and the location in sub-Saharan Africa (OR 3.47; 95% CI 1.06-11.34). DISCUSSION: The findings of our study suggest dual policy goals for m-health in sub-Saharan Africa. First, enhance technological and educational support for m-health. Second, pursue global collaboration for building m-health capacity led by sub-Saharan African countries with hands-on experience and knowledge. CONCLUSION: Globally, countries should take a systematic and collaborative approach in pursuing m-health policy with the focus on technological and educational support.

Delays in Seeking Health Care: Comparison of Veterans and the General Population.

OBJECTIVES: Recent reports of delays in receiving care among U.S. Veterans have received national attention. Such delays may have an effect on veterans' propensity to seek healthcare as well, which could be detrimental to their health. There exists no evidence at the national level of the magnitude of perceived care delay in the Veterans Affairs (VA) system and how it compares to populations with other types of insurance coverage in the U.S. STUDY DESIGN AND METHODS: This cross-sectional study analyzed a recent nationally representative survey database (n = 10,907). Descriptive and multivariate regression analyses were performed to determine how care delay for veterans compares with the general population. RESULTS: We found that 17.2% of Americans delayed seeking needed healthcare in 2010-2011, but the figure was 29% for veterans. Also, there was a significant association of care delay with VA health care coverage after adjusting for other personal factors and region of the country. CONCLUSIONS: Study results suggest a possible link between VA access problems and veterans' behavior in seeking needed healthcare, which may be creating disparities in the effectiveness of care for this vulnerable and deserving population. Our study provides evidence of self-reported care delay among veterans. More studies are necessary to further understand factors in relation to delaying seeking care among veterans.

Predictors of psychiatric readmission among patients with bipolar disorder at an academic safety-net hospital.

OBJECTIVE: Even with treatment, approximately one-third of patients with bipolar disorder relapse into depression or mania within 1 year. Unfavorable clinical outcomes for patients with bipolar disorder include increased rates of psychiatric hospitalization and functional impairment. However, only a few studies have examined predictors of psychiatric hospital readmission in a sample of patients with bipolar disorder. The purpose of this study was to examine predictors of psychiatric readmission within 30 days, 90 days and 1 year of discharge among patients with bipolar disorder using a conceptual model adapted from Andersen's Behavioral Model of Health Service Use. METHODS: In this retrospective study, univariate and multivariate logistic regression analyses were conducted in a sample of 2443 adult patients with bipolar disorder who were consecutively admitted to a public psychiatric hospital in the United States from 1 January to 31 December 2013. RESULTS: In the multivariate models, several enabling and need factors were significantly associated with an increased risk of readmission across all time periods examined, including being uninsured, having ⩾3 psychiatric hospitalizations and having a lower Global Assessment of Functioning score. Additional factors associated with psychiatric readmission within 30 and 90 days of discharge included patient homelessness. Patient race/ethnicity, bipolar disorder type or a current manic episode did not significantly predict readmission across all time periods examined; however, patients who were male were more likely to readmit within 1 year. The 30-day and 1-year multivariate models showed the best model fit. CONCLUSION: Our study found enabling and need factors to be the strongest predictors of psychiatric readmission, suggesting that the prevention of psychiatric readmission for patients with bipolar disorder at safety-net hospitals may be best achieved by developing and implementing innovative transitional care initiatives that address the issues of multiple psychiatric hospitalizations, housing instability, insurance coverage and functional impairment.

Physician report of industry gifts and quality of care.

BACKGROUND: Physician financial conflict of interest is a concern in the delivery of medicine because of its possible influence on the cost and the quality of patient care. There has been an extensive discussion of the ethical, economic, and legal aspects of this issue but little direct empirical evidence of its magnitude or effects. METHODOLOGY: A nationally representative survey (n = 4,720) was used to empirically examine physician self-report of receipt of financial gifts from the pharmaceutical and medical devices industry and its association with their ability to provide quality care. FINDINGS: Results indicate that the vast majority of physicians receive industry gifts in various forms, and the receipt of gifts is associated with lower perceived quality of patient care. There is also an inverse relationship between the frequency of received gifts and the perceived quality of care. PRACTICE IMPLICATIONS: Physicians need to be aware of the widespread receipt of industry gifts in medical practice and the potential adverse impact of such receipts on the delivery of care.

The direct cost of epilepsy in the United States: A systematic review of estimates.

OBJECTIVE: To develop estimates of the direct cost of epilepsy in the United States for the general epilepsy population and sub-populations by systematically comparing similarities and differences in types of estimates and estimation methods from recently published studies. METHODS: Papers published since 1995 were identified by systematic literature search. Information on types of estimates, study designs, data sources, types of epilepsy, and estimation methods was extracted from each study. Annual per person cost estimates from methodologically similar studies were identified, converted to 2013 U.S. dollars, and compared. RESULTS: From 4,104 publications discovered in the literature search, 21 were selected for review. Three were added that were published after the search. Eighteen were identified that reported estimates of average annual direct costs for the general epilepsy population in the United States. For general epilepsy populations (comprising all clinically defined subgroups), total direct healthcare costs per person ranged from $10,192 to $47,862 and epilepsy-specific costs ranged from $1,022 to $19,749. Four recent studies using claims data from large general populations yielded relatively similar epilepsy-specific annual cost estimates ranging from $8,412 to $11,354. Although more difficult to compare, studies examining direct cost differences for epilepsy sub-populations indicated a consistent pattern of markedly higher costs for those with uncontrolled or refractory epilepsy, and for those with comorbidities. SIGNIFICANCE: This systematic review found that various approaches have been used to estimate the direct costs of epilepsy in the United States. However, recent studies using large claims databases and similar methods allow estimation of the direct cost burden of epilepsy for the general disease population, and show that it is greater for some patient subgroups. Additional research is needed to further understand the broader economic burden of epilepsy and how it varies across subpopulations.

Newer antiepileptic drug use and other factors decreasing hospital encounters.

A retrospective analysis was conducted in one claims database and was confirmed in a second independent database (covering both commercial and government insurance plans between 11/2009 and 9/2011) for the understanding of factors influencing antiepileptic drug (AED) use and the role of AEDs and other health-care factors in hospital encounters. In both datasets, epilepsy cases were identified by AED use and epilepsy diagnosis coding. Variables analyzed for effect on hospitalization rates were as follows: (1) use of first-generation AEDs or second-generation AEDs, (2) treatment changes, and (3) factors that may affect AED choice. Lower rates of epilepsy-related hospital encounters (encounters with an epilepsy diagnosis code) were associated with use of second-generation AEDs, deliberate treatment changes, and treatment by a neurologist. Epilepsy-related hospital encounters were more frequent for patients not receiving an AED and for those with greater comorbidities. On average, patients taking ≥1 first-generation AED experienced epilepsy-related hospitalizations every 684days, while those taking ≥1second-generation AED were hospitalized every 1001days (relative risk reduction of 31%, p<0.01). Prescriptions for second-generation AEDs were more common among neurologists and among physicians near an epilepsy center. Use of second-generation AEDs, access to specialty care, and deliberate efforts to change medications following epilepsy-related hospital encounters improved outcomes of epilepsy treatment based on average time between epilepsy-related hospital encounters. These factors may be enhanced by public health policies, private insurance reimbursement policies, and education of patients and physicians.

Impact of the 2011 heat wave on mortality and emergency department visits in Houston, Texas.

BACKGROUND: Heat waves have been linked to increased risk of mortality and morbidity, and are projected to increase in frequency and intensity in a changing climate. Houston and other areas in Texas experienced an exceptional heat wave in the summer of 2011 producing the hottest August on record. This study aims to assess the health-related impact of this heat wave. METHODS: Distributed lag models were used to estimate associations between the 2011 heat wave and all-cause mortality and emergency department (ED) visits from May 1 through September 30 for the five-year period 2007-2011. The 2011 heat wave is defined as a continuous period from August 2 through 30, 2011 according to the heat advisories issued by the local National Weather Service office, and is included in the models as a dummy variable. We compared the estimated excess risk among the models with and without adjustment of continuous temperature and ozone. RESULTS: The 2011 heat wave in Houston was associated with a 3.6% excess risk in ED visits (95% CI: 0.6%, 6.6%) and 0.6% increase in mortality risk (95% CI: -5.5%, 7.1%). The elderly over 65 years of age were at the greatest risk in ED visits. These patterns are consistent across different heat-wave definitions, and results are similar when adjusting for continuous temperature and ozone. CONCLUSIONS: The 2011 heat wave in Houston had a substantial impact on ED visits and no significant impact on mortality. Our findings provide insights into local heat-wave and health preparations and interventions.

Survival Benefits of Treatment Access Among Underserved Breast Cancer Patients Diagnosed Through the Texas Breast and Cervical Cancer Services Program.

PURPOSE: The Texas Breast and Cervical Cancer Services (BCCS) program was established to address socioeconomic disparities in breast and cervical cancer screening and survival. This study examined the impact of the program on treatment and survival of breast cancer patients. METHODS: A retrospective analysis was performed using the Texas Cancer Registry data linked to the BCCS program data. The sample consisted of 40- to 64-year-old women screened and diagnosed with breast cancer through the BCCS program (participants) and similar women living in low socioeconomic status census tracts and diagnosed outside the program (comparison group) during 1995-2008. Regular screeners among the participants were also compared with the comparison group. RESULTS: Participants had lower rates of breast surgery and higher rates of chemotherapy as compared with the comparison group. Participants undergoing surgery had higher rates of mastectomy (as compared with breast-conserving surgery) and lower rates of adjuvant radiation therapy. Unadjusted survival rates were similar between the participants and the comparison group, and higher among regular screeners, which was primarily driven by stage at diagnosis. Adjusted survival rates were similar between the 3 groups. CONCLUSIONS: Although there are differences in the types of treatment provided to the participants and the comparison group, there is no evidence of guideline noncompliance or stage-inappropriate treatment provision in either of the groups. Despite being diagnosed with a more advanced stage, the participants had similar unadjusted and adjusted survival rates as the comparison group. Access to timely treatment improved survival and brought the underserved participants on par with the comparison group.

Surveillance of epilepsy and prevention of epilepsy and its sequelae: lessons from the Institute of Medicine report.

PURPOSE OF REVIEW: The Institute of Medicine's report, Epilepsy across the Spectrum: Promoting Health and Understanding contains two recommendations for increased epilepsy surveillance and one recommendation on prevention in epilepsy. Evidence supporting these recommendations and the information that can be gained from them is reviewed. RECENT FINDINGS: Existing epilepsy surveillance data are inadequate to address factors such as seizure type, syndrome, socioeconomic status, and race/ethnicity in large representative populations. Ongoing surveillance is needed with follow-up of people with epilepsy for adverse epilepsy outcomes so that interventions to prevent these outcomes can be formulated. Substantial barriers to receiving appropriate medical care exist for minorities and the uninsured with epilepsy; more information on these differences and their causes is needed. Lack of standardized study methods and data sources results in differences in medical service costs, care and treatments, and limited information on cost-effectiveness of specific healthcare services for epilepsy. SUMMARY: Future epilepsy surveillance should track incidence and prevalence over time, access to epilepsy care, direct and indirect costs, and the cost-effectiveness of treatment. Prevention efforts to decrease the occurrence of epilepsy and improve access and effectiveness of care will ameliorate adverse outcomes in epilepsy.

Research implications of the Institute of Medicine Report, Epilepsy Across the Spectrum: Promoting Health and Understanding.

In March 2012 the Institute of Medicine (IOM) released the report, Epilepsy Across The Spectrum: Promoting Health and Understanding. This report examined the public health dimensions of the epilepsies with a focus on the following four areas: public health surveillance and data collection and integration; population and public health research; health policy, health care, and human services; and education for providers, people with epilepsy and their families, and the public. The report provided recommendations and research priorities for future work in the field of epilepsy that relate to increasing the power of data on epilepsy; prevention of epilepsy; improving health care for people with epilepsy; improving health professional education about epilepsy; improving quality of life for people with epilepsy; improving education about epilepsy for people with epilepsy and families; and raising public awareness about epilepsy. For this article, the authors selected one research priority from each of the major chapter themes in the IOM report: expanding and improving the quality of epidemiologic surveillance in epilepsy; developing improved interventions for people with epilepsy and depression; expanding early identification/screening for learning impairments in children with epilepsy; evaluating and promoting effective innovative teaching strategies; accelerating research on the identification of risk factors and interventions that increase employment and improve quality of life for people with epilepsy and their families; assessing the information needs of people with epilepsy and their families associated with epilepsy-related risks, specifically sudden unexpected death in epilepsy; and developing and conducting surveys to capture trends in knowledge, awareness, attitudes, and beliefs about epilepsy over time and in specific population subgroups. For each research priority selected, examples of research are provided that will advance the field of epilepsy and improve the lives of people with epilepsy. The IOM report has many other research priorities for researchers to consider developing to advance the field of epilepsy and better the lives of people with epilepsy.

Standards for epidemiologic studies and surveillance of epilepsy.

Worldwide, about 65 million people are estimated to have epilepsy. Epidemiologic studies are necessary to define the full public health burden of epilepsy; to set public health and health care priorities; to provide information needed for prevention, early detection, and treatment; to identify education and service needs; and to promote effective health care and support programs for people with epilepsy. However, different definitions and epidemiologic methods complicate the tasks of these studies and their interpretations and comparisons. The purpose of this document is to promote consistency in definitions and methods in an effort to enhance future population-based epidemiologic studies, facilitate comparison between populations, and encourage the collection of data useful for the promotion of public health. We discuss: (1) conceptual and operational definitions of epilepsy, (2) data resources and recommended data elements, and (3) methods and analyses appropriate for epidemiologic studies or the surveillance of epilepsy. Variations in these are considered, taking into account differing resource availability and needs among countries and differing purposes among studies.

Physician switching after drug request refusal.

Physician switching is a barometer of the quality of the relationship between a patient and a physician. Understanding the factors associated with physician switching in the context of direct-to-consumer advertising (DTCA) of prescription drugs has been largely unexamined. A total of 818 of 2,988 participants in a national telephone survey (27.4%) who had received DTCA reported asking their physician for a prescription drug, and 196 (24.0%) reported that their physician refused to prescribe the drug. Of those whose physicians refused, 13.9% (n = 27 of 194 with data) switched doctors. We found that individuals with regular medical-seeking behavior, full prescription drug coverage, with certain chronic conditions, and of African American origin were significantly more likely to switch physicians in this context.

Socioeconomic status and self-management in epilepsy: comparison of diverse clinical populations in Houston, Texas.

We compared the scores on self-management and associated psychosocial scales of patients with epilepsy at two clinics in Houston, TX, USA, to determine if there were systematic differences associated with socioeconomic status (SES). Patients of low SES reported higher scores on overall, information, and safety management (P<0.03) and no differences on medication, seizure, and lifestyle management. The two groups were similar with respect to the pattern of high and low scores. Reported levels of self-efficacy, depression, social support, stigma, desire for control, and outcome expectations were higher for those of high SES (P<0.01). Knowledge of epilepsy and satisfaction with care were lower (P<0.01). Again, the patterns of high and low scores were similar. Tests of association between psychosocial factors and self-management revealed that people with higher levels of self-efficacy and social support also reported higher self-management (P<0.01) regardless of demographics, seizure frequency, and SES (P<0.05). These findings provide little support for SES-related disparities in self-management and suggest that the focus of strategies to improve self-management may be similar across diverse populations.

The prevention research centers' managing epilepsy well network.

The Managing Epilepsy Well (MEW) Network was created in 2007 by the Centers for Disease Control and Prevention's (CDC) Prevention Research Centers and Epilepsy Program to promote epilepsy self-management research and to improve the quality of life for people with epilepsy. MEW Network membership comprises four collaborating centers (Emory University, University of Texas Health Science Center at Houston, University of Michigan, and University of Washington), representatives from CDC, affiliate members, and community stakeholders. This article describes the MEW Network's background, mission statement, research agenda, and structure. Exploratory and intervention studies conducted by individual collaborating centers are described, as are Network collaborative projects, including a multisite depression prevention intervention and the development of a standard measure of epilepsy self-management. Communication strategies and examples of research translation programs are discussed. The conclusion outlines the Network's role in the future development and dissemination of evidence-based epilepsy self-management programs.

Tyrosine Kinase Inhibitors and the Relationship With Adherence, Costs, and Health Care Utilization in Commercially Insured Patients With Newly Diagnosed Chronic Myeloid Leukemia: A Retrospective Claims-Based Study.

OBJECTIVE: To examine the association among tyrosine kinase inhibitor (TKI) out-of-pocket costs, adherence, and health care costs and utilization in a large group of commercially insured patients with chronic myeloid leukemia (CML). MATERIALS AND METHODS: Patients with CML aged 18 to 64 years were identified using IBM MarketScan Commercial Database between April 1, 2011 and December 31, 2014. Patients were required to be continuously enrolled 3 months before and 12 months after TKI (imatinib, dasatinib, or nilotinib) initiation. TKI adherence is estimated using the proportion of days covered (PDC), defined as the percentage of the PDC by the prescription fill during the 12-month study period (adherent patients have PDC ≥80%). Health care cost differences between adherent and nonadherent patients were estimated using generalized linear models. Health care utilization was compared using negative binomial regression models. All models were controlled for potential confounding factors. RESULTS: The study sample consisted of 863 patients, where 355 (41.1%) patients were classified as adherent. Over the study period, nonadherent patients incurred US$10,974 more in medical costs (P<0.001), and US$1663 more in non-TKI pharmacy costs (P<0.01). Adherent patients incurred US$28,184 more in TKI pharmacy costs (P<0.001) that resulted in US$18,305 more in overall total health care costs (P<0.001). Adherent patients, however, were estimated to be less likely to have all-cause hospitalizations (incidence rate ratio, 0.32; P<0.001), or CML-specific hospitalizations (incidence rate ratio, 0.31; P<0.01). CONCLUSIONS: Patients with CML with better adherence experienced fewer hospitalizations, resulting in medical service cost savings. These lower medical costs, however, were more than offset by higher TKI medication costs observed during the first year of TKI therapy.

Sociodemographic disparities in epilepsy care: Results from the Houston/New York City health care use and outcomes study.

PURPOSE: The purpose of this study was to identify sociodemographic disparities in health care use among epilepsy patients receiving care at different sites and the extent to which the disparities persisted after adjusting for patient characteristics and site of care. METHODS: Three months of health care use data were obtained from baseline interviews of approximately 560 patients at four sites. One-half of the patients were from a Houston site and two NYC sites that serve predominantly low-income, minority, publicly insured, or uninsured patients. The other half were at the remaining site in Houston that serves a more balanced racial/ethnic and higher sociodemographic population. Differences in general and specialist visits, hospital emergency room (ER) care, and hospitalizations were associated with race/ethnicity, income, and coverage. Logistic regression was used to assess the extent to which the differences persisted when adjusting for individual patient characteristics and site of care. RESULTS: Compared to whites, blacks and Hispanics had higher rates of generalist visits [odds ratio (OR) = 5.3 and 4.9, p < 0.05), ER care (OR = 3.1 and 2.9, p < 0.05) and hospitalizations (OR = 5.4 and 6.2, p < 0.05), and lower rates of specialist visits (OR = 0.3 and 0.4, p < 0.05). A similar pattern was found related to patient income and coverage. The magnitude and significance of the disparities persisted when adjusting for individual characteristics but decreased substantially or were eliminated when site of care was added to the model. DISCUSSION: There are sociodemographic disparities in health care for people with epilepsy that are largely explained by differences in where patients receive care.