Abstracts

Rationale: Institutionalized, multiply handicapped patients with comorbid epilepsy are among the most challenging epilepsy patients to treat because of their potential for refractory seizures, multiple seizure types, frequent seizure emergencies, and polypharmacy. In a preliminary, retrospective review we assess the impact of a specialty epilepsy clinic on seizure control, polypharmacy, and cost at Idaho State School and Hospital (ISSH), a facility with a census of 80 patients, specializing in the care of multiply handicapped patients whose needs prevent group home placement. Methods: Prior to 9/07 these patients were care for in a general neurology clinic that tracked seizures and medications. This clinic was transferred to a an epileptologist in 9/07 and a systematic review of care was initiated. The goals of this clinic are to define seizure types and syndromic classification based on clinical history and interictal EEG, using inpatient video EEG when appropriate, to train staff to better identify seizure types, to optimize seizure control, and to improve the AED regimen by minimizing polypharmacy and minimizing the use of enzyme-inducing agents. We now present our observations of the impact of this approach on seizure frequency, medication regimen and medication cost, focusing on 26 patients who remained at our facility from 12 months before through 12 months after this transition. Results: As compared to the 12 months prior to implementation of specialty epilepsy care, we achieved a 75% reduction in the number of first generation enzyme inducing AEDs being used in our population within 12 months. While some refractory patients remained on polypharmacy, we saw a 45% increase in the number of patients on monotherapy. Our total institutional cost for all AEDs in the same time period declined by 46%, from $447.49 per day to $260.93 per day. Correcting for forced generic substitutions, our total cost would have increased by 8% had all patients been maintained on brand. During the same period of time, we saw a 10% reduction in total seizure count among our patients. Excluding two patients with transient increases in seizures while being weaned from phenobarbital, our total reduction is seizure count was 53%. From 2006 to 2009 we also saw a substantial reduction in the need for rectal diazepam rescue for seizure emergencies, reducing our institutional cost for this agent by more than 70%. Conclusions: We conclude that a systematic approach to intractable epilepsy in this setting may result in fewer seizures and fewer seizure emergencies while reducing polypharmacy and reducing medication cost despite transition to second generation AEDs. These observations merit further study.