Claims data analyses unable to properly characterize the value of neurologists in epilepsy care

Abstract

Objective To determine the association of a neurologist visit with health care use and cost outcomes for patients with incident epilepsy. Methods Using health care claims data for individuals insured by United Healthcare from 2001 to 2016, we identified patients with incident epilepsy. The population was defined by an epilepsy/ convulsion diagnosis code (ICD codes 345.xx/780.3x, G40.xx/R56.xx), an antiepileptic prescription filled within the succeeding 2 years, and neither criterion met in the 2 preceding years. Cases were defined as patients who had a neurologist encounter for epilepsy within 1 year after an incident diagnosis; a control cohort was constructed with propensity score matching. Primary outcomes were emergency room (ER) visits and hospitalizations for epilepsy. Secondary outcomes included measures of cost (epilepsy related, not epilepsy related, and antiepileptic drugs) and care escalation (including EEG evaluation and epilepsy surgery). Results After participant identification and propensity score matching, there were 3,400 cases and 3,400 controls. Epilepsy-related ER visits were more likely for cases than controls (year 1: 5.9% vs 2.3%, p < 0.001), as were hospitalizations (year 1: 2.1% vs 0.7%, p < 0.001). Total medical costs for epilepsy care, nonepilepsy care, and antiepileptic drugs were greater for cases (p ≤ 0.001). EEG evaluation and epilepsy surgery occurred more commonly for cases (p ≤ 0.001). Conclusions Patients with epilepsy who visited a neurologist had greater subsequent health care use, medical costs, and care escalation than controls. This comparison using administrative claims is plausibly confounded by case disease severity, as suggested by higher nonepilepsy care costs. Linking patient-centered outcomes to claims data may provide the clinical resolution to assess care value within a heterogeneous population.

Primary care providers perform more neurologic visits than neurologists among Medicare beneficiaries

“…How to best utilise the limited pool of neurologists is complex and requires an understanding of the value of neurologic care. Across neurologic conditions and varying patient presentations, some visits with neurologists likely have very high value (eg, improved functioning 3 ), whereas others are low value (eg, increased costs without established outcome benefit 12 ). For optimal patient care and to specifically evaluate the value of neurologic care, future studies should be performed to understand the reasons underlying current practise patterns and test the effect of different models of neurologic care delivery on patient‐centred outcomes.…”

Identification of patients with drug‐resistant epilepsy in electronic medical record data using the Observational Medical Outcomes Partnership Common Data Model

“…One or more outpatient epilepsy or convulsion diagnoses within 2 years preceding an antiseizure medication (ASM) exposure. 21,22,27 There were no age restrictions, and no minimum observation period in the database was required. Prior observation requirements have been shown to improve specificity for incident epilepsy, 28 but given that it can take many years from epilepsy diagnosis to establish drug resistance, we chose not to limit our cohort to those with incident epilepsy and instead to maximize sensitivity for all patients with DRE with any encounters at our center.…”

Accuracy of ICD-10-CM claims-based definitions for epilepsy and seizure type

“…One final area for future investigation should include further development of more nuanced definitions of uncontrolled seizures, which could plausibly address one of the increasing challenges of measuring gaps in epilepsy care at the population level. (Hill et al, 2019;US DHHS, 2014) Although our novel exploratory analysis investigated just a fractional definition of uncontrolled seizures (Sapkota et al, 2018;Thurman et al, 2011;Zack and Kobau, 2017), and did not precisely align with the claims-based definition, this is a critical first step towards operationally defining aspects of quality epilepsy care and analyzing the management of people with epilepsy (Jones and Patel, 2018;Patel et al, 2018, US DHHS, 2014. This is particularly relevant as other data sources relevant to disease severity (e.g., patient-reported outcome data) are not always widely available for systematic collection at the population level.…”

“…Currently, the most powerful tool for population-based research is the use of large administrative claims datasets, which can include diagnosis codes recorded after a clinical encounter for internal administrative purposes or codes billed for health insurance (Jette et al, 2010a). These data are increasingly used to obtain population-level estimates of incidence and prevalence (Faught et al, 2012;Helmers et al, 2015;Jette et al, 2010a), measure financial burden (Begley and Durgin, 2015;Pisu et al, 2019), and measure the value of health care provided to people with epilepsy (AHRQ, 2019;Burneo et al, 2016;Hill et al, 2019). Claims data overcome many methodological challenges by enabling systematic collection at both the regional and national levels (Thurman et al, 2011).…”

“…Claims-based definitions for epilepsy using International Classification of Diseases-10 th Revision (ICD-10) have been validated in care settings in Canada and elsewhere (Jette et al, 2010b;Reid et al, 2012;Tan et al, 2015;Tu et al, 2014). The accuracy of claims-based algorithms varies considerably by region and health care system (Moura et al, 2019;Moura et al, 2017), however, which could hinder the ability of studies that use claims data to generate valid estimates of epilepsy prevalence/incidence or measure the quality of care in epilepsy (Faught et al, 2012;Hill et al, 2019). Thus, the validity of ICD-10 claims-based definitions in the U.S. for epilepsy, seizure type (Scheffer et al, 2017), and epilepsy severity (e.g., uncontrolled seizures) remains uncertain.…”