Abstracts

Rationale: Seizure is a common emergency department (ED) complaint. ED overutilization for people with epilepsy can be due to severity of the disease, or a failure to develop a system of outpatient care. A cycle of insufficient care can develop & is often associated with low socioeconomic status, loss of employment or insurance, medication noncompliance, and further use of the ED as the primary seizure care source. Many of these individuals have poor mental health and executive function; often times epilepsy may be a sequela of alcoholism or head trauma. We investigated clinical characteristics of people who use the ED more than 3 times per year.Methods: A retrospective chart review was undertaken to identify clinical characteristics of patients with epilepsy who visited the ED at least 3 times in a 12-month period. ED charts from January 2009 to December 2009 were evaluated by searching for ICD-9 diagnosis codes: 780.39 (non-febrile convulsions) and 345.0-9 (epilepsy). Diagnostic elements included: age, gender, anti epileptic drug (AED) types, number of AEDs, and AED blood levels. Social status, including insurance status, zip code (as a measure of socioeconomic status), & history of substance abuse were reviewed. Mental handicap or psychiatric illness, if documented was recorded. Data was derived from ED or hospital record.Results: 113 patients with the above ICD-9 codes were evaluated of which 21 met the criteria of greater than 3 ED visits for epilepsy within that year. Of the 21 patients, the mean number of ED visits was 5.47 visits. Average age was 48. Regarding socioeconomic status, 20 of the 21 received Medicare or Medicaid, (MA); one individual was uninsured. Witnessed seizure was the most common chief complaint, noted in 20 patients. 19% of patients presented in status epilepticus. Phenytoin (PHT) was the most common AED with 62% taking it. AED levels were measured in 86% of the patients. Of those subjects, levels were subtherapeutic in 44%; supratherapeutic in 11%. Seizure related injury occurred in 19%. Four of these subjects had well defined non-epileptic seizures. Nineteen resided in zip codes within a 3 mile radius of the hospital (19140, 19134, 19133, 19132, 19125, 19122, & 19121). This is a severely economically depressed area with mean household cost of $30,430 and mean income of $19,150 per year. Low serum AED level was documented in 47.6%. Alcohol dependence and drug dependence were both documented in 19% of the patients. Additional challenges included the prevalence of psychiatric illness, most commonly depression, present in 52.3% of the patients. Conclusions: Patients with frequent ED utilization are commonly insured by managed MA and of low socioeconomic status. Comorbid psychiatric illness and low AED levels characterize this group. Some also were found to have documented heavy alcohol and substance use. Sequelae in this population include seizure related injury, status epilepticus and AED toxicity. Aggressive outpatient management should be developed to meet this treatment gap with focus on urban patients with severe epilepsy.