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IIR 02-274 – HSR&D Study

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IIR 02-274
Appropriateness of Antiepileptic Drug Use for Older Veterans
Mary Jo V Pugh PhD EdM MA
South Texas Health Care System, San Antonio, TX
San Antonio, TX
Funding Period: July 2005 - September 2008

BACKGROUND/RATIONALE:
The past decade has witnessed a change in recommendations for epilepsy treatment due to findings from randomized clinical trials and the development of new antiepileptic drugs (AEDs). Randomized clinical trials have demonstrated that that phenobarbital is unequivocally a suboptimal drug, and that phenytoin has pharmacokinetic and pharmacodynamic properties that make it potentially problematic for the elderly. Instead, carbamazepine, valproate, and newly developed AEDs (e.g., lamotrigine and gabapentin,) are considered more appropriate first-line alternatives due to their more favorable side-effect profiles in elderly patients. Consistent recommendations to avoid phenytoin in the elderly suggest that it is important to determine the state of treatment for these patients in the VA.

OBJECTIVE(S):
Objective 1: Identify patient, provider, and system factors predicting adoption of recommended AEDs for treatment of newly diagnosed older veterans (FY00-04).
Objective 2: Identify barriers to use of recommended AED in initial therapy for newly diagnosed older veterans with epilepsy.

METHODS:
Using existing national VA outpatient, inpatient, pharmacy and Medicare databases, we identified the extent to which treatment for older veterans newly diagnosed with epilepsy changed between FY00-FY04, and identify predictors of change at the patient (age, sex, race, disease burden), provider (specialty vs. primary care), and system levels. We used semi-structured interviews of primary care, geriatric and neurology providers to begin to identify barriers to use of recommended AED.

FINDINGS/RESULTS:
Of the 9,682 older veterans who met criteria for new-onset epilepsy between FY00-04, 2.5% received phenobarbital and 67% received phenytoin. Rates of phenobarbital decreased 42% (3.2% to 1.9%), while rates of phenytoin decreased 7% from 70.6% to 66.1%. Use of new AEDs increased significantly from 12.9% to 19.8%, due primarily to use of lamotrigine, levetiracetam and topiramate. The strongest predictors of receiving recommended AEDs were receiving the initial diagnosis of epilepsy in a neurology setting, and having a pre-existing diagnosis of multiple psychiatric comorbidities, neuropathic pain or migraine. Contrary to expectations, we found that patients treated in VA facilities that either housed epilepsy monitoring beds or that participated in VA Cooperative Study 428 were no more likely than patients in other facilities to receive recommended AEDs. System level analysis using General Estimating Equations (facility as random effect) found no significant difference for neurology "saturation" (proportion of cohort receiving neurology care) when only VA neurology clinic visits were included. However, when using both VA and Medicare data for neurology care, we found that patients in locales with low neurology saturation (less than median) were more likely to receive recommended AEDs than patients who received care in locales with high neurology saturation. Interestingly, there was no significant difference in AED type for individuals who were initially diagnosed in VA vs. Medicare settings.

Qualitative findings suggest that geriatric providers were more likely to focus on age related changes in assessing patients with new onset epilepsy or complications of chronic epilepsy treatment than Neurology or Primary Care Providers. Moreover, geriatricians and general internists were more likely than neurologists to say they would refer the patients in each scenario to an expert in geriatric epilepsy. Barriers in care focused on lack of availability of epilepsy specialists or clinical pharmacists who are knowledgeable of epilepsy medications. Providers in facilities with high rates of recommended AED use frequently acknowledged academic resources as facilitators to providing care for older veterans with epilepsy; academic resources were not identified at sites with moderate- or low-use of recommended AEDs.

IMPACT:
This study found that there has been little change in epilepsy treatment for older veterans with new onset epilepsy, despite wider availability of newer AEDs. Quantitative data suggest that geographic norms are the strongest predictor of recommended AED use, while qualitative data suggest that academic affiliates are viewed as a resource for providers at facilities with high rates of recommended AED use. Because primary care providers and geriatricians felt underprepared to care for older veterans with epilepsy, and it is likely that this population will increase, it is important to begin developing interventions to provide clinicians with the support they need to provide high quality care. While increasing the availability of neurology clinicians is ideal, clinicians identified resources such as increased home care, availability of neurologically focused clinical pharmacists, interdisciplinary clinics, and additional training as possible avenues to improve support to generalists caring for these patients.

PUBLICATIONS:

Journal Articles

  1. Makris UE, Pugh MJ, Alvarez CA, Berlowitz DR, Turner BJ, Aung K, Mortensen EM. Exposure to High-Risk Medications is Associated With Worse Outcomes in Older Veterans With Chronic Pain. The American journal of the medical sciences. 2015 Oct 1; 350(4):279-85.
  2. Brooks DR, Avetisyan R, Jarrett KM, Hanchate A, Shapiro GD, Pugh MJ, Berlowitz DR, Thurman D, Montouris G, Kazis LE. Validation of self-reported epilepsy for purposes of community surveillance. Epilepsy & Behavior : E&B. 2012 Jan 1; 23(1):57-63.
  3. Pugh MJ, Starner CI, Amuan ME, Berlowitz DR, Horton M, Marcum ZA, Hanlon JT. Exposure to potentially harmful drug-disease interactions in older community-dwelling veterans based on the Healthcare Effectiveness Data and Information Set quality measure: who is at risk? Journal of the American Geriatrics Society. 2011 Sep 1.
  4. Copeland LA, Ettinger AB, Zeber JE, Gonzalez JM, Pugh MJ. Psychiatric and medical admissions observed among elderly patients with new-onset epilepsy. BMC health services research. 2011 Apr 19; 11:84.
  5. Pugh MJ, Berlowitz DR, Rao JK, Shapiro G, Avetisyan R, Hanchate A, Jarrett K, Tabares J, Kazis LE. The quality of care for adults with epilepsy: an initial glimpse using the QUIET measure. BMC health services research. 2011 Jan 3; 11:1.
  6. Zeber JE, Copeland LA, Pugh MJ. Variation in antiepileptic drug adherence among older patients with new-onset epilepsy. The Annals of pharmacotherapy. 2010 Dec 1; 44(12):1896-904.
  7. Pugh MJ, Vancott AC, Steinman MA, Mortensen EM, Amuan ME, Wang CP, Knoefel JE, Berlowitz DR. Choice of initial antiepileptic drug for older veterans: possible pharmacokinetic drug interactions with existing medications. Journal of the American Geriatrics Society. 2010 Mar 1; 58(3):465-71.
  8. VanCott AC, Cramer JA, Copeland LA, Zeber JE, Steinman MA, Dersh JJ, Glickman ME, Mortensen EM, Amuan ME, Pugh MJ. Suicide-related behaviors in older patients with new anti-epileptic drug use: data from the VA hospital system. BMC medicine. 2010 Jan 11; 8:4.
  9. Ettinger AB, Copeland LA, Zeber JE, Van Cott AC, Pugh MJ. Are psychiatric disorders independent risk factors for new-onset epilepsy in older individuals? Epilepsy & Behavior : E&B. 2010 Jan 1; 17(1):70-4.
  10. Hope OA, Zeber JE, Kressin NR, Bokhour BG, Vancott AC, Cramer JA, Amuan ME, Knoefel JE, Pugh MJ. New-onset geriatric epilepsy care: Race, setting of diagnosis, and choice of antiepileptic drug. Epilepsia. 2009 May 1; 50(5):1085-93.
  11. Pugh MJ, Knoefel JE, Mortensen EM, Amuan ME, Berlowitz DR, Van Cott AC. New-onset epilepsy risk factors in older veterans. Journal of the American Geriatrics Society. 2009 Feb 1; 57(2):237-42.
  12. Pugh MJ, Zeber JE, Copeland LA, Tabares JV, Cramer JA. Psychiatric disease burden profiles among veterans with epilepsy: the association with health services utilization. Psychiatric services (Washington, D.C.). 2008 Aug 1; 59(8):925-8.
  13. Pugh MJ, Van Cott AC, Cramer JA, Knoefel JE, Amuan ME, Tabares J, Ramsay RE, Berlowitz DR, Treatment In Geriatric Epilepsy Research (TIGER) team. Trends in antiepileptic drug prescribing for older patients with new-onset epilepsy: 2000-2004. Neurology. 2008 May 27; 70(22 Pt 2):2171-8.
  14. Van Cott AC, Pugh MJ. Epilepsy and the elderly. Annals of Long-Term Care: Clinical Care and Aging. 2008 Jan 1; 16(1):28-32.
  15. Pugh MJ, Berlowitz DR, Montouris G, Bokhour BG, Cramer JA, Bohm V, Bollinger M, Helmers S, Ettinger A, Meador KJ, Fountain N, Boggs J, Tatum WO, Knoefel J, Harden C, Mattson RH, Kazis LE. What constitutes high quality of care for adults with epilepsy? Neurology. 2007 Nov 20; 69(21):2020-7.
  16. Zeber JE, Copeland LA, Amuan M, Cramer JA, Pugh MJ. The role of comorbid psychiatric conditions in health status in epilepsy. Epilepsy & Behavior : E&B. 2007 Jun 1; 10(4):539-46.
  17. Berlowitz DR, Pugh MJ. Pharmacoepidemiology in community-dwelling elderly taking antiepileptic drugs. International Review of Neurobiology. 2007 Jan 1; 81:153-63.
  18. Pugh MJ, Berlowitz DR, Kazis L. The impact of epilepsy on older veterans. International Review of Neurobiology. 2007 Jan 1; 81:221-33.
  19. Pugh MJ, Foreman PJ, Berlowitz DR. Prescribing antiepileptics for the elderly: differences between guideline recommendations and clinical practice. Drugs & aging. 2006 Nov 1; 23(11):861-75.
  20. Pugh MJ, Copeland LA, Zeber JE, Cramer JA, Amuan ME, Cavazos JE, Kazis LE. The impact of epilepsy on health status among younger and older adults. Epilepsia. 2005 Nov 1; 46(11):1820-7.
Journal Other

  1. Pugh MJ, Tabares J, Finley E, Bollinger M, Tortorice K, Vancott AC. Changes in antiepileptic drug choice for older veterans with new-onset epilepsy: 2002 to 2006. [Letter to the Editor]. Journal of the American Geriatrics Society. 2011 May 1; 59(5):955-6.
Conference Presentations

  1. Marcum ZA, Amuan ME, Hanlon JT, Aspinall SL, Handler SM, Ruby SM, Pugh MJ. Therapeutic failures and adverse drug withdrawal events leading to hospitalization among older outpatient Veterans. Presented at: Pharmacoepidemiology and Therapeutic Risk Management Annual International Conference; 2011 Aug 17; Chicago, IL.
  2. Pugh MJ, Berlowitz DR, Knoefel J, Hope O, VanCott A, Mortensen E. Epilepsy in the elderly: Risk factors as targets for prevention? Paper presented at: AcademyHealth Annual Research Meeting; 2008 Jun 10; Washington, DC.
  3. Pugh. Geriatric epilepsy: Issues related to presentation, diagnosis and treatment. State-of-the-art clinical updates session. Paper presented at: American Geriatrics Society Annual Meeting; 2008 Apr 30; Washington, DC.
  4. VanCott A, Knoefel J, Berlowitz D, Mortensen E, Cramer J, Pugh MJ. Epilepsy in the elderly: Stroke and epilepsy risk factors. Poster session presented at: American Academy of Neurology Annual Meeting; 2008 Apr 12; Chicago, IL.
  5. Pugh MJ. Potential drug interactions among older veterans newly treated for epilepsy: A common event. Poster session presented at: American Epilepsy Society Annual Meeting; 2007 Dec 4; Philadelphia, PA.
  6. Van Cott AC, Omotola AH, Pugh MJV. Treatment of elderly veterans with new onset of epilepsy. Poster session presented at: American Academy of Neurology Annual Meeting; 2007 May 1; Boston, MA.
  7. Pugh MJ, Zeber JE, Mortensen E, Berlowitz DR. Profound rates of drug-drug interactions among older veterans newly diagnosed with epilepsy. Paper presented at: VA HSR&D National Meeting; 2007 Feb 22; Arlington, VA.
  8. Pugh. Profound comorbidity in older patients with epilepsy. Poster session presented at: American Epilepsy Society North American Regional Annual Congress; 2006 Dec 1; San Diego, CA.
  9. Pugh MJ, Knoefel J, Ramsay RE, Gidal B. Epilepsy in the Elderly: Manifestation, Treatment and Outcomes [panelist]. Paper presented at: American Geriatrics Society Annual Meeting; 2006 Jan 1; Chicago, IL.


DRA: Aging, Older Veterans' Health and Care
DRE: Epidemiology, Treatment - Observational
Keywords: Clinical practice guidelines, Pharmaceuticals, Quality assessment
MeSH Terms: none

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