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Cover of Management of Newly Diagnosed Patients with Epilepsy

Management of Newly Diagnosed Patients with Epilepsy

A Systematic Review of the Literature

Evidence Reports/Technology Assessments, No. 39

Investigators: , MD, FRCPC, Principal Investigator, , RN, BSN, , MA, and , MD.

Rockville (MD): Agency for Healthcare Research and Quality (US); .
Report No.: 01-E038ISBN-10: 1-58763-103-2

Structured Abstract

Objective:

The objective of this evidence report was to systematically review the best available evidence in the published literature regarding health care services pertinent to the diagnosis, treatment, and monitoring of patients with a first diagnosis of epilepsy.

Search Strategy:

Literature published in English from 1980 through November 1999 was searched using MEDLINE and Current Contents, supplemented by a manual review of the bibliographies of all accepted papers, the Cochrane Library of Systematic Reviews, and various Internet sources.

Selection Criteria:

Interventional or observational studies of at least 10 patients, adults, or children, with a first seizure, or at first presentation, or at the time of a new diagnosis of epilepsy, were eligible. Studies had to report results of any of the following interventions: (a) diagnostic: history and physical examination; neuropsychologic examination; imaging with computed tomography (CT), magnetic resonance imaging (MRI), or positron emission tomography (PET) scan; electroencephalogram (EEG) -- standard, video, invasive, ambulatory; lumbar puncture; or blood tests; (b) monitoring: EEG, blood tests, drug levels, or clinical/pharmacologic expertise; (c) treatment: clinical/pharmacologic expertise, antiepileptic drug monotherapy or polytherapy, counseling and psychosocial support, surgery, physical or occupational therapy, speech therapy, or education.

Data Collection and Analysis:

Data on study, patient, and intervention characteristics and results were extracted from accepted studies. Studies were scored for quality and level of evidence. Study and patient-level characteristics were summarized, and the results were synthesized qualitatively. A panel of diverse technical experts and peer reviewers provided review and commentary on the results.

Main Results:

Of 13,128 citations, 120 studies covering 21,213 patients met all eligibility criteria. Diagnostic interventions to rule in a diagnosis of epilepsy, as well as predict remission outcomes, are a complete history and physical examination, including neuropsychologic assessment, and a standard EEG. Other diagnostic interventions (e.g., CT or MRI) are more important to rule out secondary causes of seizures or to resolve uncertain diagnoses (e.g., video EEG) in a minority of selected patients. The monitoring interventions that may have an impact on outcomes are clinical/pharmacologic expertise, periodic blood tests (routine hematology and chemistries) for antiepileptic drug (AED)-related side effects, and possibly cognitive assessments in certain populations. Compliance with AED regimens predicts remission, but approaches to ensure compliance are not substantiated. Treatment interventions important for patients with a first diagnosis include clinical/pharmacologic expertise to inform choices of AED treatment, which are dictated more by differing side effect profiles than efficacy. Monotherapy AEDs appear comparable in efficacy for many epilepsy syndromes, but not all, for example juvenile myoclonic epilepsy, which require expertise not only to diagnose but to inform treatment choice.

The literature has multiple limitations, including lack of a universally accepted gold standard for diagnosis, low methodologic rigor, widespread terminology confusion, lack of patient-centered outcomes, including quality of life, health care utilization and costs, and gaps in coverage of virtually all nonclinical/pharmacologic treatment interventions in newly diagnosed patients.

Conclusions:

The best available evidence from the literature is not conclusive regarding the appropriate and necessary diagnostic, monitoring, and treatment services for patients with newly diagnosed epilepsy. This literature review, however, can be used to generate testable hypotheses. We urge the health services research community to test these hypotheses in new and more rigorous studies in the future.

2101 East Jefferson Street, Rockville, MD 20852. www​.ahrq.gov

Prepared for: Agency for Healthcare Research and Quality, U.S. Department of Health and Human Services.1 Contract No. 290-97-0016. Prepared by: MetaWorks, Inc. Medford, MA.

Suggested citation:

Ross SD, Estok R, Chopra S, et al. Management of Newly Diagnosed Patients with Epilepsy: A Systematic Review of the Literature. Evidence Report/Technology Assessment No. 39 (Contract 290-97-0016 to MetaWorks, Inc.) AHRQ Publication No. 01-E038. Rockville, MD: Agency for Healthcare Research and Quality. September 2001.

This report may be used, in whole or in part, as the basis for development of clinical practice guidelines and other quality enhancement tools, or as a basis for reimbursement and coverage policies. Endorsement by the Agency for Healthcare Research and Quality (AHRQ) or the U.S. Department of Health and Human Services (DHHS) of such derivative products may not be stated or implied.

AHRQ is the lead Federal agency charged with supporting research designed to improve the quality of health care, reduce its cost, address patient safety and medical errors, and broaden access to essential services. AHRQ sponsors and conducts research that provides evidence-based information on health care outcomes; quality; and cost, use, and access. The information helps heath care decisionmakers -- patients and clinicians, health system leaders, and policymakers -- make more informed decisions and improve the quality of health care services.

The authors of this report are responsible for its content. Statements in the report should not be construed as endorsement by the Agency for Healthcare Research and Quality or the U.S. Department of Health and Human Services of a particular drug, device, test, treatment, or other clinical service.

1

2101 East Jefferson Street, Rockville, MD 20852. www​.ahrq.gov

Bookshelf ID: NBK33744
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