Abstracts

Rationale: The creation of Epilepsy Centers of Excellence (ECoE) has provided a more comprehensive approach to the care of Veterans with epilepsy. The ECoE identified Veterans with epilepsy for Fiscal Years (FY) 09-11 using an algorithm previously validated for VHA geriatric patients (Neurology 2008; 70:2171-2178). Comparison of FY10 and FY11 epilepsy patient counts indicated a decrease of 7,818 (from 68,909 down to 61,091) Veterans. The primary objectives of this study were to investigate causes of reduced patient counts between FY10 and FY11 and to validate the used algorithm for general VHA population. The secondary objectives were to determine trends in ICD coding and clinician types. Methods: Using administrative databases for FY09-FY11, epilepsy patients were identified as patients having a seizure diagnosis (ICD-9-CM: 345.xx or 780.3x) on at least one encounter and prescribed at least one anti-epileptic drug (AED) during the same fiscal year. Epilepsy specialists at three ECoE sites (Durham, NC, Tampa and Miami, FL) reviewed electronic charts of 527 FY10 patients who were not captured in FY11. Confirmed epilepsy was defined as diagnosis of unprovoked seizures in clinical notes and prescribed AEDs for treatment by a physician. Chart audits were conducted for demographics, confirmation of epilepsy diagnosis, ICD-9-CM codes on problem list, use of AEDs for conditions other than epilepsy and clinician types. Results: Out of 527 patients evaluated 308 had confirmed epilepsy. The positive predictive value of the algorithm was 58.4% (95% confidence interval (CI) 54.2% to 62.7%). Major causes of FY10 patients lost in FY11 were: death (16.1%), capture of non-epileptic patients prescribed AEDs for other conditions in FY10 (25.3%), patients not receiving any VA care in FY11 (12.5%) and lack of seizure diagnosis documentation for epilepsy patients during FY11 (25.6%). On the problem list ICD-9-CM 780.39 was documented for 72.1%, ICD-9-CM 345.xx for 8.1% and no seizure code for 19.2% of epilepsy patients. Among epilepsy patients 37.0% were seen by general neurologists, 13.0% by epileptologists and 50.0% by primary care providers. Deceased epilepsy patients were predominantly males (97%) and their mean age was 69.9 years (95% CI, 66.9 to 72.9).Conclusions: The previously validated algorithm for geriatric patients is unsuitable for general epilepsy patients in the VHA. This algorithm underestimated epilepsy patients due to inadequate documentation of clinical encounters. On the other hand, it captured patients who were on AEDs for conditions other than epilepsy. Chart audits revealed that most epilepsy patients were not assigned a specific diagnosis. The average age of deceased male patients in the VHA was noticeably less than the average life expectancy of males in the US (76.3 years) in 2011. Our findings suggest that stable algorithms should be developed for surveillance decisions and research. Access to specialty care is limited and can be enhanced through ECoE initiatives to improve quality of care for Veterans.