Cost and quality outcomes of comprehensive epilepsy monitoring review of referrals in a managed Medicaid program.

Medicaid members represent a higher risk group of patients. Many have chronic illnesses or disabilities, among which are seizure disorders. One of the measures of successful outcomes of seizure management and surgery is the future return to employment of the patient. However, because of other chronic health problems and social disabilities, AHCCCS members may not be employable. Therefore, this population is a more difficult one to measure for successful outcomes or functional resolution of health problems.

Expected positive outcomes of inpatient epilepsy monitoring and treatment are: * Identification of and elimination of

unnecessary treatment for nonepileptic

events. * Reduction in frequency of or elimination

of seizures. * Improved quality of life for patients. * Decreased medical costs of chronic

poorly-controlled epilepsy. * Decreased comorbidity associated with

episodes of seizures.

Over the five-year period between 1990 and 1994, 60 patients covered under the AHCCCS (managed Medicaid) program at the University of Arizona Health Sciences Center were referred to the Epilepsy Monitoring Program for management of intractable epilepsy and for consideration of inpatient monitoring. The group's ages ranged from 5 to 59; average age was 29 years. The average enrollment in the program over five years was about 15,000. Therefore, the number of cases per thousand was 4 (in 5 years), or 0.8/1,000/year in a Medicaid population. This figure does not control or account for adverse selection, which might be expected in a unique regional high technology center such as this. In fact, some patients chose this health plan because of their chronic epilepsy problems.

Of the 60 cases, 10 were treated and controlled with alteration in medications, including (in some cases) entrance into experimental antiepileptic drug studies. Because of the failure of all possible medications, the remaining 50 patients were eventually offered and received inpatient noninvasive seizure monitoring. Of the 50 patients admitted to the inpatient monitoring unit, 12 (24 percent) were discharged with diagnoses of probable "pseudoseizures," i.e., witnessed spells not associated with epileptic events on EEG monitoring. One patient had no witnessed seizures during admission. Eighteen patients (36 percent) were found to have nonlocalized seizures that would not be amenable to surgery. Another 19 (38 percent) patients underwent invasive, intracranial electrode monitoring to determine if the patient had a focus of seizures that could be surgically treated. Finally, 16 (32 percent) of these patients had surgery, undergoing a lobectomy, tumor removal, or corpus callosotomy to remove or control the seizure focus.

Assessing the Costs

It is difficult to precisely measure all the costs and cost savings associated with the surgical management of epilepsy. For instance, the cost of unemployment, although possibly measurable, is difficult to assess in a Medicaid population of disabled individuals. Changes in medication costs are also a moving target. But there are some costs or charges that are clearly definable. We will focus on the major costs to a managed care program that can be measured from claims records within a short and clearly defined time frame, i.e., inpatient costs one year before and one year after the procedures. The costs of the diagnostic and therapeutic procedures and associated testing are also readily measurable.

The average cost of Stage I (noninvasive) inpatient epilepsy monitoring of this program has averaged $5,000. The average cost of Stage II monitoring, with implanted intracranial electrodes, has been approximately $22,000. The average cost of the surgical procedures to remove the epileptic focus has been about $33,000. Thus, the overall cost of a treatable condition could be expected to be approximately $60,000.

Therefore, the cost of excluding a diagnosis of epilepsy in order to reduce the use of medications and unnecessary emergency trips and visits is $5,000. Our average emergency department visit cost is $170 (for all diagnoses, including urgent care problems), and the cost of an ambulance ride is $200 each way. An admission for the management of "uncontrolled epilepsy" may approach the cost of the Stage I monitoring $5,000). Thus, eight or fewer emergency trips, several years of unnecessary medications, or the cost of one unnecessary hospitalization for pseudoseizures could be saved for the cost trade-off of inpatient monitoring (excluding the diagnosis of epilepsy).

The cost of excluding an identifiable focus that could be surgically removed approaches $38,000. This is a cost that cannot be weighed against potential savings, because without removal of a seizure focus, there will probably be no change in expected costs. But if screening through the use of imaging technology is effective, the majority of cases will go to surgery. In our case, 84 percent of patients with invasive monitoring had surgery.

Report the Outcomes

About 32 percent of our cases underwent surgery. Of the 16 patients who had surgery, 3 (19 percent) developed postoperative complications, including infection, obstructive hydrocephalus, and a tumor recurrence. These were all resolved, with the exception of one patient who died of complications from an unexpected malignant brain tumor. One patient, who was monitored invasively but did not have surgery, contracted an infectious complication.

All but one of the surgical patients remain better controlled with reduced frequency of their seizures. Several of these patients are now seizure-free after an average period of 1.5 years. All remain on medications for the prevention of recurrent seizures. These medications may be weaned after a 12-month period following surgery, providing the patients are seizure-free.

The average cost of the epilepsy monitoring program for our enrollment has been about $250,000/year, or 18,000/case in a relatively higher risk Medicaid population. The expected costs for 0.8/1,000/cases/year would be $14,400/1,000 members/year.

Summary

Evaluation and management of patients with intractable epilepsy in a Comprehensive Epilepsy Monitoring Program must be carefully handled in a stepwise fashion, using clinical guidelines for appropriateness of each procedure. Invasive monitoring and surgery must be offered to cases with clear failure of all other possible treatments, with clearly identified and treatable foci of epilepsy, where the procedure can be as safe and nondisabling as possible.

The cost of inpatient evaluation of intractable seizures for a select population of Medicaid members, with services ranging from inpatient monitoring and imaging to surgical intervention to remove a seizure focus, has ranged from $5,000 to $60,000, with an average cost of $18,000 (the cost of 3 or 4 hospital admissions for the control of status epilepticus). The outcomes of this program for a Medicaid population have been to exclude the diagnosis of true epilepsy in 24 percent of patients and to better control or eliminate the episodes of epilepsy in 32 percent of cases. There were no deaths attributable to complications of surgery.

The cost-benefit outcome of this service is directly measurable and effective for cases in which diagnoses and treatment of seizures are excluded. Quality of life improvements are the more important outcome variables in the surgery cases. However, from a purely economic perspective, the reduction in costs of admissions, medications, and emergency visits will eventually justify the up-front expenditures on procedures.

References

[1.] USDHHS. National Institutes of Health "Consensus Development Conference on Surgery for Epilepsy." 8(2):1-16, Aug. 1990.

[2.] Litin, S. "Epilepsy Surgery for Medically Intractable Seizure Disorders." Mayo Clinical Update 10(4):I-2, Autumn 1994.