Abstracts

Rationale: As disparities in epilepsy treatment are not uncommon, we examined population-based estimate of initial anti-epileptic drugs (AEDs) in new-onset epilepsy among U.S. Medicare beneficiaries 65 years and older across racial/ethnic minorities. Methods: We conducted retrospective analyses of 2008-2010 Medicare administrative claims for a 5% random sample of beneficiaries augmented for minority representation. A claim-based algorithm defined new onset epilepsy cases in 2009 as having ?-1 ICD-9 345.x or ?-2 ICD-9 780.3x, and ?-1 AED, AND no seizure/epilepsy claim codes nor AEDs in preceding 365 days. We examined AED use and concordance with Quality Indicators of Epilepsy Treatment (QUIET) #6 (AED monotherapy as initial treatment: ?-30 day first prescription with no other concomitant AEDs), as well as prompt AED treatment (receiving first AED within 30 days from diagnosis). Logistic regression models examined likelihood of prompt treatment by demographics (race/ethnicity, gender, age), clinical (number of comorbid conditions, neurology care), and economic (part D coverage phase, eligibility for part D low income subsidy (LIS), and zip code level poverty) factors. Results: Among 3,706 new epilepsy cases, 18% were white, 61.2% African American, 12.3% Hispanic, 6.6% Asian, and 2% American Indian/Alaskan Native (AI/AN). Over one year follow-up, 79.6% had one AED only (77.89% of whites to 89% of AI/AN). Levetiracetam was the most commonly prescribed AED (45.5% ranging from 24.6% of AI/AN to 55.0% of whites) The second most common was phenytoin (30.6%, ranging from 18.8% of Asians to 43.1% of AI/AN). QUIET 6 concordance was 94.7% (93.9% for whites to 97.3% of AI/AN). Only 50% of all cases received prompt AED therapy: this ranged from 49.6% of whites to 53.9% of AI/AN. In adjusted analyses, factors associated with having prompt therapy were being female (Odds Ratio (OR): 1.21, Confidence Interval (CI) 1.05-1.40), and having at least one visit with a neurologist (OR 2.17, CI 1.85-2.53). Compared to age 65-84, beneficiaries 85+ were less likely to have prompt therapy (OR 0.83, 0.70-0.99). Being in Part D copay/coinsurance (OR 0.76, CI 0.63-0.92) or coverage gap OR 0.68, 0.54-0.87) was associated with lower likelihood of prompt therapy compared to the deductible phase, as was being eligible for LIS vs. not (OR 0.80, CI 0.67-0.97) Conclusions: While monotherapy is common across all racial/ethnic groups of older adults with new-onset epilepsy, older line AEDs are commonly prescribed and treatment may be delayed beyond 30 days of initial presentation. Gaps in the quality of care in receiving AEDs remain with some groups more at risk of not receiving prompt treatment, e.g., men, older old, those not receiving neurology care, with low incomes, or in drug cost-sharing coverage phases. Further research is warranted on reasons for AED treatment delays, and also on the impact of drug cost-sharing on AED treatment. Furthermore, interventions need to be developed and tested in order to develop care paradigms that lead to better care. Funding: National Institute of Neurological Disease and Stroke (1R01NS080898-01).