Rescue medication for seizures are generally limited to intravenous and intramuscular preparations that must be administered by qualified medical personnel. One FDA-approved exception is diazepam rectal gel (Diastat). Because of the awkward route of administration, Diastat use has been severely limited. Research into a more convenient alternative, such as an intranasal spray, has been ongoing for a number of years and finally appears to have borne fruit. If the Neurelis drug receives FDA approval, it may be available before the end of 2019.
Incomplete seizure control due to intractable epilepsy or nonadherence may result in life-threatening status epilepticus. Early readmissions indicate poor seizure control after hospital discharge. The Center for Medicare and Medicaid Services (CMS) imposes financial penalties on hospitals for early readmissions for a number of conditions such as myocardial infarction and pneumonia. Although epilepsy is not yet one of the diagnoses subject to these CMS penalties, the 30-day period without readmission has become a performance benchmark for hospitals.
Rahwan and colleagues5 addressed the problem of hospital readmissions for status epilepticus in their presentation, “How often and what predicts…30-day hospital readmissions after generalized convulsive status epilepticus?” From a total population of 14,562 adults with generalized convulsive status epilepticus in the 2014 Nationwide Readmission Database, the authors identified 2520 (17.3%) patients who were readmitted within 30 days of discharge. On multivariate logistic analysis, risk factors for readmission included leaving against medical advice (OR: 1.45), length of stay greater than six days (OR: 1.42), discharge to a short-term hospital (OR: 1.39), and the presence of comorbidities (OR: 1.12). Conversely, patients aged 45 years or older and those in high-income households were less likely to suffer early readmission.
In a similar retrospective study utilizing the Nationwide Readmission database, Savani and colleagues6 expanded the study duration to 2010-2014 and examined all patients with epilepsy who were readmitted, not just those with status epilepticus. Their analysis included 622,467 patients with hospitalization for epilepsy using the primary diagnostic ICD-9CM code 345.xx. Of these, 76,911 (12.4%) were readmitted within 30 days. Risk factors for readmission included discharge to another facility (OR: 1.22), higher comorbidity index (1.10), and longer length of stay (OR: 1.01).
Relevant comorbidities included chronic kidney disease (OR: 1.35); opioid abuse (OR: 1.30); chronic liver disease (OR: 1.26); psychiatric illness (OR: 1.22); heart failure (OR: 1.19); chronic lung disease (OR: 1.17); cocaine (OR: 1.14); diabetes (OR: 1.10); hypertension (OR: 1.07) and hypothyroidism (OR 1.06). Conversely, the following variables decreased readmissions: elective admission (OR: 0.42); self-payment vs. Medicare/Medicaid (OR: 0.67); private insurance vs. Medicare/Medicaid (OR: 0.75); and teaching hospital admission (OR:0.96). The authors suggest that proactively addressing risk factors for readmission may improve patient outcomes.
In my experience in several hospitals, physicians suffer undue pressure to discharge patients at the earliest possible moment. Data such as those provided by Savani and colleagues may help bolster physician decisions to retain patients in hospital until they are truly ready to return home.
This short sample of the 2019 American Academy of Neurology’s epilepsy presentations revealed laboratory measures that may help differentiate syncope from seizure; the effect of laser ablation on intractable epilepsy; the importance of video-EEG for the diagnosis and management of PNES; the potential for intranasal diazepam to safely stop seizures; and patient characteristics associated with early hospital readmission. This research all has the potential to improve the care of people with epilepsy.
About the author
Andrew Wilner, MD, is a neurologist who blogs at www.andrewwilner.com/blog. His latest book is The Locum Life: A Physician’s Guide to Locum Tenens.
1. Kim H, Kim JB. Differential diagnosis of epileptic seizure and syncope using machine learning algorithms. American Academy of Neurology Annual Meeting, Philadelphia, PA, May 4-10, 2019 (P2.5-031).
2. Patel A, Dawit S, Mastorakos G et al. Long-term outcomes in patients with intractable mesial temporal lobe epilepsy who undergo laser ablation. American Academy of Neurology Annual Meeting, Philadelphia, PA, May 4-10, 2019 (P5.5-019).
3. Wolfe M, Singh S, Sankaraneni RM. Profile and outcome of psychogenic nonepileptic seizures patients undergoing video-EEG monitoring. American Academy of Neurology Annual Meeting, Philadelphia, PA, May 4-10, 2019 (P4.5-032).
4. Sperling M, Hogan R, Biton V, et al. A 12-month, open-label, repeat-dose safety study of Valtoco (NRL-1, diazepam nasal spray) in patients with epilepsy: Interim report. American Academy of Neurology Annual Meeting, Philadelphia, PA, May 4-10, 2019 (P2.5-029).
5. Rahwan M, Looti AL, Bishu K, Ovbiagele B. How often and what predicts…30-day hospital readmissions after generalized convulsive status epilepticus? American Academy of Neurology Annual Meeting, Philadelphia, PA, May 4-10, 2019 (S36.006).
6. Savani C, Kumar V, Richardson C et al. Predictors of 30-day readmission after index hospitalization for epilepsy: a 5-year national estimate using the Nationwide Readmission (NRD) database. American Academy of Neurology Annual Meeting, Philadelphia, PA, May 4-10, 2019 (P2.5-029).