Abstracts

Rationale: Learning healthcare systems (LHS) use real-world data to inform clinical and operational decisions. The Veteran Healthcare Administration (VHA) is one of the largest LHS in the U.S, offering an opportunity to better understand and optimize models of care and delivery of new interventions. A primary mandate of the VHA is providing equitable access to high quality care to veterans. Although the use of newer anti-seizure medications (ASMs) does not necessarily reflect higher quality of care, they may provide a marker of equity with respect to new interventions. Conversely, given veterans’ higher prevalence of post-traumatic epilepsy and psychiatric co-morbidities, they may be at increased risk of experiencing adverse events to ASMs. This study explores the utilization of ASMs across different veteran demographics as well as the incidence of adverse events with newer ASMs.

Methods: A retrospective analysis of veterans with epilepsy (as defined by ICD-10 codes) was conducted in two parts. First, veterans diagnosed with epilepsy in fiscal years 2016 (FY16), 2020 (FY20), and 2021 (FY21) were evaluated using the data from VHA Support Service Center (VSSC) Neurology Cube. The percentage of veterans prescribed newer versus older ASMs (excluding gabapentin) were compared across gender and race. Second, in partnership with the VA Office Quality and Patient Safety Analytics and Performance Integration program, neurology notes of consecutive veterans diagnosed with epilepsy, between 1/1/2016 and 9/30/2020, across the VA were sampled to evaluate adverse events leading to ASM discontinuation. Only veterans prescribed brivaracetam (BRV), eslicarbazepine (ESL), lacosamide (LCM), perampanel (PER) were included for this analysis.

Results: In FY16, FY20, FY21, veterans with epilepsy prescribed newer ASMs were 6.6% men and 10.5% women; 11.1% men and 14.9% women; and 11.4% men and 14.8% women, respectively. In FY16, FY20, FY21, the percentage of Black and White veterans with epilepsy prescribed newer ASM were 6.4% Black and 7.2% White; 11.3% Black and 11.5% White; 11.4% Black and 11.8% White, respectively. The number of veterans sampled for newer medications included: 112 on BRV, 150 on ESL, 2269 on LCM, and 127 on PER. The most common intolerable adverse events were psychiatric and behavioral adverse events that included 6.3% with BRV, 4.1% with ESL, 1.7% with LCM, and 14.9% with PER (Table 1).

Conclusions: Women veterans with epilepsy tend to be more likely to receive newer ASMs compared to men. However, Black veterans were as likely to receive newer ASMs compared to their White counterparts. With respect to access to newer ASMs, the VA at a national level appears to be offering equitable access. However, variability across individual facilities has not been compared yet. With respect to tolerability, this preliminary analysis suggests that PER was least tolerated across newer ASMs. However, risk factors such as dose titration, history of psychiatric co-morbidity, and epilepsy severity have not been controlled for yet.

Funding: Please list any funding that was received in support of this abstract.: Research funding was provided by Eisai and Sunovion.