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High Prevalence of Psychiatric and Physical Conditions, Racial Disparities Identified in Epilepsy

Included participants were enrolled in Medicaid, which includes some of the most vulnerable patients in this population, investigators said.

Data from a recent study found a higher prevalence of both psychiatric and physical comorbid conditions in patients with epilepsy. Also identified were varying racial and ethnic disparities in the prevalence of these conditions, as well as combinations of conditions, within this patient population. 

A total of 81,963 patients with epilepsy were included in the study, all of whom were also on Medicaid. Participants were of varying race and ethnicity, including American or Alaskan Native (n = 599), Asian Pacific Islander (n = 1367), Hispanic (n = 10,529) Native Hawaiian or Other Pacific Islander (n = 1308), and White (n = 47,370 [56.1%]). 

Investigators, led by Wyatt P. Bensken, BS, PhD candidate, epidemiology and biostatistics, Department of Population and Quantitative Health Sciences, Case Western Research University, found the most common comorbid conditions were anxiety and mood disorders (46.5%), hypertension (36.9%), back problems (35.2%), developmental disorders (31.6%), and headache (29.5%). There was a median of 8 conditions (interquartile range [IQR], 4-14) and American and Alaskan Native had the higher prevalence of both acute and chronic conditions, at a median of 10 (IQR, 5-17). With the exception of developmental disorders, where a substantially higher prevalence was observed, Asian Pacific Islanders had a substantially lower burden of most included physical and psychiatric conditions. 

When evaluating combinations of conditions, anxiety and mood disorders were most found with back problems (24.7%), hypertension (21.8%), and headache (20.4%). Similarly, when looking at combinations of 3 conditions, anxiety and mood disorders were included in all common trios, primarily with back problems and headache (14.9%). Anxiety and mood disorders, injuries, back problems, and headache (9.1%) were the most common combination of 4 conditions. Investigators noted these groups were not mutually exclusive. 

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“By understanding which conditions most often co-occur, not only can we enhance screening, diagnosis, and management, but we can design integrated research to understand why these conditions co-occur,” Bensken et al wrote. “The combinations we identified may represent potential underlying genetic and biologic pathways that would suggest these conditions may in fact be precursors to epilepsy.”

Investigators looked further into disparities in disease burden, as singular conditions and combinations were not uniformly present across the study cohort. Black participants had a higher prevalence of hypertension (52.7%), compared with White participants (33.3%) and Asian and Pacific Islanders, who had the lowest prevalence (21.1%). For any combinations of 2 conditions that included hypertension, Black participants still had the highest prevalence, pointing to disparities in combinations. When looking at combinations of 3 conditions, American and Alaskan Native participants, Black participants, and White participants had the highest prevalence. 

Also identified was a dose-response relationship between disease burden and negative health events (NHEs), defined as all-cause hospitalizations or emergency room visits. Investigators noted that injuries were more common in high utilizers, or individuals in the top quartile of NHEs, and increased prevalence was seen in single conditions, as well of combinations of 2 and 3 conditions. 

“This study reaffirmed that to reduce utilization and provide better care for high utilizers, it is important to address not just psychiatric and physical conditions but understand the causes of these injuries and the potentially modifiable circumstantial factors to prevent injuries—a clear direction for future work,” Bensken et al wrote. “For example, fragmented care for patients with combinations of acute and chronic conditions may increase the risk of having a seizure and injury, and unsafe or unstable housing or working conditions, a lack of social support, or other social determinants of health may exacerbate dangers related to having a seizure. We also found, in our stratified analysis, a lower burden of these conditions among patients with developmental disorders.”

Investigators included 5 years of Medicaid claims data in research, diagnosing each participant’s Clinical Classification Codes over the course of the study period. Top combinations of conditions were identified via association rule mining, which were then stratified by race and ethnicity to reveal disparities. 

The study was limited due to potential selection bias, as patients were included only if they were on Medicaid for the length of the study or 60 consecutive months. This generated a secondary limitation in that consistent enrollment may have been difficult for those in a vulnerable population who lack social support. A further potential for noise or heterogeneity in the groups was also identified, due to the grouping of epilepsy or seizure diagnosis codes to a smaller number of Clinical Classification Software categories. 

REFERENCE
Bensken WP, Fernandez Baca Vaca G, Jobst BC, et al. Burden of chronic and acute conditions and symptoms in people with epilepsy. Neurology. Published online October 27, 2021. doi:10.1212/WNL.0000000000012975