Comprehensive Epilepsy Care: The Key to Cutting Costs and Seizing Better Outcomes

Abstract

Level 4 Seizure Monitoring Unit Admissions are Associated With Reduced Long-term Health Care Costs

Josephson CB, Lethebe BC, Pang E, Clement F, Jetté N, Szostakiwskyj JH, McLeod G, Sinaei F, Delgado-Garcia G, Wiebe S; Calgary Comprehensive Epilepsy Program Collaborators. Epilepsia. 2024 (online ahead of print). https://doi.org/10.1111/epi.18165.

Objective: This study was undertaken to determine whether admission to dedicated seizure monitoring units (SMUs) result in reduced health care use (HCU). Methods: This was a retrospective open cohort study covering the years 2010–2018 of patients residing in Alberta, Canada, who were referred to the Calgary Comprehensive Epilepsy Program and admitted to a level 4 SMU. Patients were required to have ≥3 years pre- and postadmission follow-up. The outcome was the change in trajectory of composite HCU (primary care, specialist outpatient visits, emergency department visits, and hospitalizations) for the 3 years prior to and 3 years following SMU admission using the point of admission as the “index date.” Secondary outcomes were HCU limited to specific settings. We excluded the first 30 days following the point of admission to mitigate the confounding admission would have on the postadmission HCU trajectory. We used adjusted restricted maximum likelihood linear and nonlinear effects models to determine trajectories expressed as Canadian dollars. Results: A total of 315 of 600 (53%) patients met eligibility criteria. Mean age was 40 years (SD = 17.4), 176 (56%) were female, 220 (70%) had focal epilepsy, and 60 (19%) had functional seizures or physiologic seizure mimics without epilepsy as adjudicated by the attending physician at the point of discharge. Mean per person health care costs increased by CAD$341.28 (95% confidence interval [CI] = -25.17 to 707.74) for each successive 6-month interval prior to SMU admission (p = .07). Following admission, mean per person costs decreased by CAD$802.34 (95% CI = 699.62-905.06, p < .001) for each successive 6-month interval up to 3 years postdischarge. Similar trends were noted for primary and specialist care, emergency department, admitted care, and when nonlinear models were applied. Significance: Admission to an SMU is associated with significant and enduring declines in HCU. Each 6-months following discharge overall HCU declined by a mean of CAD$802.34 and acute inpatient, emergency department, and outpatient physician interactions declined by 25%, 26%, and 18% respectively. Comprehensive epilepsy care not only reduces morbidity and mortality but also reduces cost.

Commentary

When people with epilepsy turn to their healthcare system for help, they seek many things—a diagnosis, seizure control, an understanding of what to expect in the future. These challenges are so significant that comprehensive epilepsy centers (CECs) exist specifically to address them, with a cornerstone of these centers being the epilepsy monitoring unit (EMU). Numerous studies highlight the better clinical outcomes for patients treated at CECs, including a 50% reduction in mortality. ¹ However, time in the EMU comes with significant costs. The question remains: how can we best capture this return on investment?

Josephson et al ² approach this question in a novel and insightful way, by leveraging the University of Calgary's comprehensive epilepsy program patient registry. This registry is then linked to various healthcare administrative databases in Alberta, Canada, including the Discharge Abstract Database, National Ambulatory Case Reporting System, Pharmaceutical Information Network, and others. By combining these sources, the authors provide a comprehensive view of healthcare utilization before and after EMU admission. For over 300 patients with 3 years of thorough documentation before and 3 years after their index EMU admission, the authors demonstrate how healthcare costs evolve leading up to and following this critical intervention, identifying key patient factors influencing these costs.

As expected for patients seeking high-level care, healthcare costs were escalating by an average of CAD $341 every 6 months leading up to admission. However, following EMU admission, these costs dramatically fell by CAD $802 every 6 months, reflecting the EMU's role in improving disease management and understanding. This reduction was driven by significant decreases in inpatient admissions (25% fewer), outpatient clinic visits (18% fewer), and emergency room encounters (26% fewer). Importantly, these cost reductions persisted throughout the 3 years of follow-up studied, with no plateau, suggesting that the benefits may extend well beyond this period.

Diving into the details, the authors showed this cost reduction was most pronounced in patients undergoing surgery, with costs dropping by half every 6 months, emphasizing the impact of epilepsy surgery for drug-resistant patients. Costs also dropped for patients with functional seizures (∼37% reduction each 6 months), although their outpatient visits remained higher than those with focal or generalized epilepsy.

The study's findings emphasize the broader role of comprehensive epilepsy care in addressing a spectrum of needs. CECs are uniquely positioned to offer a multidisciplinary approach, integrating services such as neuropsychology, social work, and advanced neuroimaging. ³ This holistic care model ensures that patients benefit from more than just seizure monitoring; they receive guidance on managing comorbid conditions like depression and anxiety, which are common among individuals with epilepsy. ⁴ These centers also facilitate access to advanced therapeutic interventions, such as epilepsy surgery or neuromodulation, that are unavailable in general neurology settings. This approach not only improves clinical outcomes but also aligns with the goal of optimizing healthcare utilization.

The impact of CECs extends beyond individual patient care to the broader healthcare system. By reducing emergency department visits, hospitalizations and outpatient visits, CECs free up critical healthcare resources. Additionally, as Josephson et al's study demonstrates, these cost savings are enduring, potentially creating rippled effects that enhance overall system efficiency. Importantly, the study's findings may serve as a powerful justification for expanding access to CECs, particularly in regions where specialized neurological care is limited.

The economic implications of this study invite further exploration of the financial aspects of EMU admissions. While the study underscores significant post-admission savings, it also prompts questions about the upfront costs of EMU care. Identifying the break-even point—where cost reductions surpass initial expenditures—is crucial for understanding the full financial impact of these interventions. Furthermore, examining the primary drivers of cost savings, whether improved medication management, reduced imaging needs, or fewer physician fees, could help refine care strategies and maximize efficiency.

The gradual nature of cost reductions observed in the study is another intriguing aspect. While the benefits of EMU care are clear, the delayed manifestation of savings suggests opportunities for enhancing care delivery. Could earlier interventions or improved transition protocols from EMU care to outpatient management accelerate these financial benefits? Addressing this question could help optimize the care pathway and achieve cost reductions more rapidly.

Another compelling aspect of the study is its focus on healthcare utilization trends before EMU admission. The significant escalation of costs in the 3 years leading up to admission highlights an opportunity for earlier referrals to CECs. Intervening earlier in the disease course could prevent the snowballing of healthcare costs while improving patient outcomes. This finding underscores the importance of raising awareness among primary care physicians and general neurologists about the benefits of timely referrals to CECs.

Beyond direct medical expenses, the broader societal and economic benefits of comprehensive epilepsy care warrant consideration. For patients, better seizure control and disease management can lead to improved quality of life, greater independence, and the ability to return to work or school. These outcomes have downstream effects, reducing caregiver burden and contributing to overall economic productivity. Additionally, by streamlining care for individuals with complex needs, CECs help alleviate pressure on overburdened healthcare systems, allowing resources to be redirected to other areas of need.

Despite their demonstrated benefits, access to CECs remains uneven.^5,6 Geographic, financial, and systemic barriers limit the reach of these specialized centers, particularly in rural or underserved areas. Addressing these disparities is essential to ensure equitable access to life-changing care. Expanding telemedicine capabilities, ⁷ increasing funding for regional CECs, and implementing outreach programs are potential strategies for overcoming these challenges.

While these results are impressive, their generalizability remains uncertain. Since the data are derived from a single Canadian province and a single CEC, it is unclear whether other EMUs would produce comparable downstream reductions in healthcare utilization. Variability in outcomes could arise depending on the specific interventions employed by other CECs. Additionally, the study's findings may not translate seamlessly to more fragmented healthcare systems, such as in the United States. In such systems, where financial entities are often siloed (eg, a U.S.-based CEC and a community neurologist working in separate networks), the downstream savings accrued during follow-up may not directly benefit the CEC that initiates care. This misalignment of financial incentives could obscure a hospital's perception of the EMU's value and deter investment in similar interventions.

Furthermore, the study lacks a control group, which limits the ability to rule out alternative explanations for the observed cost reductions. While the benefits of EMU care are well-supported by this and other studies, natural fluctuations in healthcare utilization among patients with epilepsy could confound the results. For example, the worsening symptoms that prompted an EMU stay might have led to intensified outpatient management, which could have independently reduced healthcare costs, even in the absence of EMU intervention. However, this scenario seems less likely given the robust body of literature demonstrating the improved outcomes associated with care at CECs.^1,3

Overall, Josephson et al ² present rigorous, quantifiable evidence that the EMU is not only a cornerstone of comprehensive epilepsy care but also a pivotal driver of long-term healthcare cost savings. Their findings provide a roadmap for future research to further enhance and expedite these cost-saving benefits while reinforcing the critical role of CECs in improving patient outcomes. Access to specialized neurological services remains uneven, but studies like this could serve as a powerful justification for much-needed investments, ensuring more patients can benefit from these life-changing interventions.