Rationale:
Healthcare utilization (HCU) and disability are higher in people with epilepsy (PWE) with versus without depressive symptoms. Though Hispanics represent the largest minority group in the United States, healthcare utilization in this group is lower than in non-Hispanic whites due to limited English proficiency, distinct cultural values and beliefs, and stigma. Little is known about the impact of depression or its treatment on healthcare utilization and disability in Hispanic PWE. UPLIFT (Using Practice and Learning to Increase Favorable Thoughts) is an 8-week program adapted from mindfulness-based cognitive therapy to teach self-management skills for depressive symptoms to small groups of PWE via telephone. The purpose of this analysis is to examine the effects of UPLIFT versus UC on disability and healthcare utilization.
Method:
After translating and culturally adapting UPLIFT, we performed a randomized controlled trial (RCT) of UPLIFT vs usual care (UC) in English- and Spanish-speaking Hispanic PWE at Bellevue Hospital and New York University Langone Health, both in New York City. Subjects completed questionnaires at baseline, post-intervention (~2 months), 6 and 12 months. Disability was assessed by a single item on self-reported activity impairment due to epilepsy from the Workplace Productivity and Activity Impairment Questionnaire (WPAI). Health care utilization was assessed as self-reported total acute care days during the study: number of ED encounters and inpatient nights. Unpaired t-tests were used to compare differences between groups for total acute care days.
Results:
There were a total of 72 Hispanic PWE, with a mean±SD age of 42.8±11.3, 70.8% were female, 48 (66.7%) were Spanish-speaking, and 58 (80.6%) reported elevated depressive symptoms at baseline (PHQ-9 ≥5). Nearly three-quarters (72.1%) were born outside the U.S. but had lived in the U.S. for mean 25.7±12.6 years. Unemployment was high: 70.8% of participants reported not working for pay at baseline. Median activity impairment due to epilepsy at baseline was 3.5 (range 0-10) on 0 to 10 scale. Activity impairment was fairly stable throughout follow-up in the UPLIFT arm and somewhat increased in the UC arm, but changes from baseline levels were not significantly different between arms at any time point (Figure 1). Over the 12-month follow-up period, total acute care days was median 2 days (range 1-10) among UPLIFT participants (n= 29) compared to 1 day (range 1-6) among UC participants (n=9). This self-reported healthcare utilization was not significantly different between the UPLIFT and UC groups (p=0.18) or between English and Spanish speakers (p=0.16).
Conclusion:
In this pilot RCT, self-reported activity impairment due to epilepsy was no different between Hispanic PWE randomized to UPLIFT vs UC over 12 months. Total acute care days were not substantially different at baseline or post-intervention between treatment arms. Further study is warranted to better understand both outpatient and acute healthcare utilization. Evaluation of these patterns of healthcare utilization and activity impairment in Hispanic PWE and depression will enable tailoring of self-management interventions for this underserved population.
Funding:
:CDC U48 DP 005008-01S4 and Epilepsy Foundation's Clinical Research Apprenticeship Award to Susanna O'Kula
FIGURES
Figure 1