Abstracts

Rationale: Epilepsy outcomes depend on the extent to which, and the speed with which, patients who benefit from referrals to specialists get those referrals. At the invitation of an Institute of Medicine Committee, we collected data on epilepsy referrals from the Emergency Department (ED) or Primary Care (PC) to Neurology. Our goal was to describe "pathways of epilepsy care" in a vertically integrated health care system. Methods: We identified individuals with a primary or secondary ICD-9 diagnostic code of epilepsy or seizure between 2009 and 2010 at Henry Ford Health System (HFHS), a large, vertically integrated system with a health plan, a multispecialty group practice, 6 hospitals, and a tertiary Epilepsy Center in Southeast Michigan. We used an administrative HFHS patient encounter database (Corporate Data Store:CDS) to collect data on the site of care for the first encounter. To validate the accuracy of the ICD-9 codes, we completed a review of a randomly selected sample of electronic charts. We calculated time intervals between initial presentation for epilepsy and consult with a neurologist and "flow patterns" between the Emergency Department, other sites of care (i.e. PC) and Neurology. Results: Of 9,588 patients with epilepsy, the first known point of contact was Neurology for 4,269 (44%). At some time point, 7,107 (74%) saw a Neurologist at HFHS. The majority of epilepsy patients seen in Neurology (4,269 of 7,107; 61%) were referrals outside the HFHS. Of the patients who had a first point of contact for epilepsy other than Neurology, 2,838 saw a Neurologist in the system at some point; 2,481 did not see a Neurologist in the system. The Emergency Department (ED) was the second most common first point of known contact other than Neurology (n=2,199). Of those patients, 52% did not have a subsequent visit in Neurology, 32% (n=697) had a visit in some other HFHS department before being seen by Neurology and 16% referred from the ED to Neurology (n=349). For the patients who had a first point of contact other than Neurology, the average time from first contact to a Neurology visit was 15.3 months (range : 0 - 192 months). The average time was longer for African American patients than Caucasians (16.4 vs. 15.4 months). Of the 4,269 patients seen first in Neurology, 3,303 had subsequent epilepsy care provided in HFHS by both PC and neurologists; the remainder were either one-time consults (n=939) or were subsequently seen exclusively by primary care (n=27). Conclusions: Our study showed that even in communities with large integrated health systems with tertiary epilepsy care, the ED is the first point of contact for the diagnosis of epilepsy for a significant number of epilepsy patients. However, the great majority of epilepsy patients received care by a neurologist in our system at some time point, and most patients who had a first system contact in Neurology continued to receive care in the system rather than having just the one visit. Using administrative data validated by electronic patient charts, we can obtain important information about "patterns" and "flow" of care for epilepsy patients.