Abstracts

Rationale: Up to 90% of people with epilepsy living in resource-poor countries do not receive antiepileptic drug (AED) therapy. This “treatment gap” is generally attributed to socioeconomic reasons. We studied the extent of and the reasons for patients not receiving treatment in a high-income setting where AEDs are readily accessible and affordable. Methods: We prospectively recruited adult patients who attended the First Seizure Clinics of publicly funded hospitals in Western Australia between 1 May 1999 and 31 May 2016. The tax-funded healthcare system provides universal coverage for all hospital admissions, outpatient attendance, investigations and treatment. The Clinics assess and follow up patients with new onset seizures referred from primary care physicians and emergency rooms. Patients diagnosed with epilepsy based on the ILAE (2014) criteria were included. We reviewed the medical records to determine the proportion of untreated patients based on both the ILAE diagnostic criteria and the treating neurologist’s diagnosis, and the reasons for not starting treatment at each follow-up visit. Sociodemographic factors, neuroimaging and EEG findings were compared between treated and untreated patients. Results: A total of 1,317 people attended the Clinics during the study period, of whom 677 (413 male) fulfilled the ILAE diagnostic criteria for epilepsy (Figure). They were followed for a median of 5.2 years (interquartile range [IQR] 2.2-8.4). Among these 677 patients, 288 (43%) were not commenced on AED treatment at the time of ILAE diagnosis, including 195 (29%) who were not offered treatment and 93 (14%) who declined treatment. Among the initially untreated patients, 57% (164/288) subsequently started treatment after a median delay of 108 days (IQR 35-321).Of the 636 patients diagnosed to have epilepsy by their treating neurologists, 232 (36%) were not treated immediately. The most common reason for treatment not being offered by the neurologists (n=139) were presence of seizure precipitating factors (29%), followed by having had single seizure (23%) and waiting for further investigation (18%). For patients who declined treatment (n=93), the most common reasons were being unconvinced of necessity of treatment (39%), presence of seizure precipitating factors (15%) and concerns regarding adverse effects (8%). At the time of meeting the ILAE criteria, AED therapy was more likely to be commenced in patients who were older, had lower socioeconomic status, epileptogenic lesions on imaging and more seizures, compared to those untreated. Patients diagnosed with focal epilepsy were more likely to be treated than those with generalised epilepsy (Table). Analysis based on neurologist’s diagnosis yielded similar findings. Conclusions: Despite the accessibility to AEDs, more than one third of patients with newly diagnosed epilepsy were not treated or had delayed treatment. Treatment decision making in this patient population is complex and influenced by epilepsy-, patient- and neurologist-related factors. Funding: UCB Pharma