Rationale:
According to the CDC, the prevalence of active epilepsy cases in Missouri is around 61,200 people. While the disease afflicts individuals of all colors, creeds, and means, both minority status and low socioeconomic status correlate with a higher risk of epilepsy [1] and are markers of vulnerability. People with epilepsy (PWE) who receive specialist care have a lower risk of premature mortality [2]. Yet, patients (pts) from racial/ethnic minority groups have lower rates of referral to neurology subspecialists with Black pts being less likely to see a specialist compared to White pts [3]. Clinical practice guidelines recommend testing with EEG and neuroimaging after 1st seizure to determine the risk of recurrence and to guide clinical management [4]. Minoritized PWE are less likely to get diagnostic testing [5]. This study sought to assess the feasibility and impact of a new epilepsy-centric outpatient clinic model on reducing disparities in access to specialist care and diagnostic testing for PWE from a vulnerable population.
Methods:
The Washington University (WUSM) neurology resident clinic provides supervised care by a licensed neurologist to a pt population with a high concentration of minoritized PWE. A new pilot outpatient model was implemented in this clinic for pts being evaluated for epilepsy as of July 1 2023. A board-certified epileptologist is present weekly to staff resident cases. Pts with new-onset seizures, refractory epilepsy, or “complex” epilepsy management are preferentially scheduled on this clinic day. A prospective cohort study was used to compare pts in the pilot model with pts in the standard clinic. An EMR audit of all cohort pts seen from 7/1/2023 to 9/13/2023 was conducted by a board-certified epileptologist. The primary measures of interest were the proportion of pts staffed by an epilepsy specialist and rates of EEG and brain MRI.
Results:
A total of 213 pts were included in the entire cohort comprised predominantly of Black (51.6%) and White (46.3%) pts. A total of 126 pts were included in the intervention group, but 30.9% did not arrive for the appointments. A total of 87 pts were included in the comparison group, but 26.4% did not arrive for the appointments. The intervention group had odds ratio (OD) = 35.8 for being exposed to an epilepsy specialist compared with pts in comparison group. The MRI and EEG completion proportion baseline was between 78-86% with a positive trend between 89-91% after clinic timepoint for both groups. There was no significant difference between the two groups in terms of baseline and follow-up completion rates.
Conclusions:
The pilot clinic model is feasible and improved access to epilepsy specialist care among the intervention cohort (OD=35.8). There was no significant difference in MRI and EEG completion rate between the two groups. In fact, the baseline test completion rates were high in both groups. Confounders such as biases (e.g., referral or selection biases) can exist for pts at academic centers compared to community centers that distort results.
References: 1 Szaflarski M. Epil Behav. 2014. 2 Lowerison MW et al. Jama Neuro. 2019. 3 Willis, AW et al. Neuro. 2011. 4 Krumholz A et al. Neuro. 2015. 5 Schiltz NK et al. Epil Res. 2013.
Funding: None