Health Services Research & Development

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2007 HSR&D National Meeting Abstract

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National Meeting 2007

1033 — Racial Differences in Neurologist Diagnosis and Treatment of Older Veterans with New Epilepsy

Hope OA (Yale University, Robert Wood Johnson Clinical Scholars Program) , Kressin NR (Center for Health Quality, Outcomes and Economic Research), Zeber JE (Veterans Evidence-based Research, Dissemination, and Implementation Center), Berlowitz DR (Center for Health Quality, Outcomes and Economic Research), Cramer J (Yale University, West Haven CT VA Hospital), Amuan ME (Center for Health Quality, Outcomes and Economic Research), Pugh MJ (Veterans Evidence-based Research, Dissemination, and Implementation Center)

Objectives:
The most commonly prescribed medications for seizures, phenobarbital and phenytoin, are suboptimal first-line treatments for older patients with epilepsy. Previous research suggests that, while care received in neurology is associated with more appropriate antiepileptic drugs (AEDs), older veterans with epilepsy are seen only in primary care. Also, blacks were more likely to receive suboptimal AEDs. The purpose of this study was to determine the relationship between race, setting of initial diagnosis, and choice of AED in older veterans with new onset epilepsy.

Methods:
National VA and Medicare databases identified veterans 66 years and older with a new diagnosis of epilepsy between FY00-FY05 who also received an AED from VA. We classified the setting of diagnosis as: emergency, neurology, hospital, primary care, other specialty, and miscellaneous. We classified the initial AED regimen as suboptimal (phenobarbital/phenytoin) or not. We used mixed-effects logistic regression models to determine if race was associated with epilepsy diagnosis in a neurology clinic, and whether diagnosis in neurology mediates the relationship between race and suboptimal AED. Analyses controlled for age, sex, comorbid diseases, copay status, and station.

Results:
Of 9624 new-onset epilepsy patients, 27% received a first diagnosis in neurology. Being Black or Hispanic decreased the likelihood of diagnosis in neurology (OR=0.7 CI 0.6-0.8, OR=0.6 CI 0.5-0.8 respectively). Seventy percent of all patients received a suboptimal agent. Diagnosis in settings besides neurology clinic doubled the odds of receiving a suboptimal AED (Emergency, OR=2.4, CI 2.0-2.8; primary care, OR= 1.8 CI 1.6-2.0). The effect of black race on suboptimal AED was partially mediated by neurology diagnosis.

Implications:
Epilepsy diagnosis within neurology confers an advantage of more appropriate medication, yet rates of use of suboptimal agents remain unacceptably high in all treatment settings. The racial/ethnic disparity in AED choice appears to be mediated by poor access to neurology care.

Impacts:
Research identifying relationships among race, age, and healthcare system factors, including access to neurology care, is needed if effective interventions to improve prescribing for older veteran with epilepsy are to be developed and implemented.