New-onset geriatric epilepsy care: Race, setting of diagnosis, and choice of antiepileptic drug

Purpose: There is a growing movement to assess the quality of care provided to patients in the US, but few studies have examined initial care for epilepsy patients. We examined the relationships among patient race, setting of initial diagnosis, and initial treatment for older veterans newly diagnosed with epilepsy. Methods: We used Department of Veterans Affairs (VA) inpatient, outpatient, pharmacy and Medicare data (1999-2004) to identify patients 66 years and older with new-onset epilepsy. High quality care was defined as avoiding a suboptimal agent (phenytoin, phenobarbital, primidone) as defined by experts. Predictors included demographic and clinical characteristics, and the context of the initial seizure diagnosis including the setting (e.g. emergency, neurology, hospital, primary care). We used mixed-effects multivariable logistic regression modeling to identify predictors of initial seizure diagnosis in a neurology setting, and receipt of a suboptimal AED. Results: Of 9,682 patients, 27% were initially diagnosed in neurology and 70% received a suboptimal AED. Blacks and Hispanics were less likely to be diagnosed in neurology clinics (black OR = 0.7 95% CI 0.6-0.8; Hispanic OR = 0.6 95% CI 0.5-0.9). Diagnosis in a non-neurology setting increased the likelihood of receiving a suboptimal agent (e.g. Emergency Department OR = 2.3 95% CI 2.0-2.7). After controlling for neurology diagnosis, black race was independently associated with an increased risk of receiving a suboptimal agent. Discussion: We demonstrated that differences in quality of care exist for both clinical setting of initial diagnosis and race. We discussed possible causes and implications of these findings.