Abstracts

Rationale: Disparities in access to specialized epilepsy care, especially epilepsy surgery have long been suspected, but available studies have focused only on the impact of individual characteristics such as age, race, and income. The impact of community characteristics, such as socioeconomic status of the neighborhood and health system resources, on access to specialized care in persons with epilepsy has never been investigated. We evaluate the association between individual-level and contextual-level characteristics and access to video-EEG monitoring (VEEG) and epilepsy surgery, with specific emphasis on insurance status and proximity to an epilepsy center. Methods: This study is a retrospective cross-sectional study using data between 2005 and 2009 from the California State Inpatient Sample (SID), the State Ambulatory Surgery Database (SASD), and the State Emergency Department Database (SEDD), which provided information on all hospital discharges, ambulatory surgeries, and ER visits. These datasets were linked with 2009 Area Resource File, which provided health resource information and socioeconomic characteristics at the county level. A two-level hierarchical logistic regression model was used to model the probability that an individual would receive VEEG or surgery. Individual-level predictors included insurance status, age, race/ethnicity, gender, and comorbidities, while county level predictors included proximity to a comprehensive epilepsy center (EC) and social and economic characteristics. Results: Our study included 195,166 adults with epilepsy, among whom 4,707 had VEEG monitoring and 779 underwent surgery during the study period. The uninsured individuals were less likely to have VEEG (Adjusted odds ratio (AOR), 0.16; 95% Confidence Interval (CI), 0.13-0.19) and surgery (AOR, 0.05; 95%CI, 0.04-0.08). Similarly, those with Medicaid had lower odds of receiving VEEG (AOR, 0.65; 95%CI, 0.58-0.73) and surgery (AOR, 0.38; 95%CI, 0.29-0.50) compared to private insurance. In addition, Blacks, Hispanics, older age, and the presence of comorbid conditions were also associated with low likelihood of VEEG and surgery. These individual characteristics remained significant after adjusting for community characteristics. Moreover, individuals who routinely received their services in the area where ECs are located were more likely than those who had regular source of care elsewhere to undergo VEEG (AOR, 1.61; 95%CI, 1.02-2.54) and surgery (AOR, 2.64; 95%CI, 1.23-5.67). Conclusions: Our findings show clear disparities in access to specialized epilepsy care. While almost half of the study population had public insurance, this group had significantly less access to a treatment modality that has proven to be highly effective. Both individual-level (e.g., age, race, and insurance status) and community-level characteristics (e.g., the availability of ECs) play important roles in determining access to high quality epilepsy care. Policy interventions that incorporate strategies to address disparities at both levels are necessary to improve access to specialized care for people with epilepsy.