Neurologist adherence to clinical practice guidelines and costs in patients with newly diagnosed and chronic epilepsy in Germany.

PURPOSE: The aim of this study was to evaluate physician adherence to the German Neurological Society guidelines of 2008 regarding initial monotherapy and to determine the cost-of-illness in epilepsy. METHODS: This was an observational cohort study using health data routinely collected at 55 outpatient neurology practices throughout Germany (NeuroTransData network). Data on socioeconomic status, course of epilepsy, anticonvulsive treatment, and direct and indirect costs were recorded using practice software-based questionnaires. RESULTS: One thousand five hundred eighty-four patients with epilepsy (785 male (49.6%); mean age: 51.3±18.1years) were enrolled, of whom 507 were newly diagnosed. Initial monotherapy was started according to authorization status in 85.9%, with nonenzyme-inducing drugs in 94.3% of all AEDs. Drugs of first choice by guideline recommendations were used in 66.5%. Total annual direct costs in the first year amounted to €2194 (SD: €4273; range: €55-43,896) per patient, with hospitalization (59% of total direct costs) and anticonvulsants (30%) as the main cost factors. Annual total direct costs decreased by 29% to €1572 in the second year, mainly because of a 59% decrease in hospitalization costs. The use of first choice AEDs did not influence costs. Chronic epilepsy was present in 1077 patients, and total annual direct costs amounted to €1847 per patient, with anticonvulsants (51.0%) and hospitalization (41.0%) as the main cost factors. Potential cost-driving factors in these patients were active epilepsy and focal epilepsy syndrome. CONCLUSION: This study shows excellent physician adherence to guidelines regarding initial monotherapy in adults with epilepsy. Newly diagnosed patients show higher total direct and hospital costs in the first year upon diagnosis, but these are not influenced by adherence to treatment guidelines.

Guideline conform initial monotherapy increases in patients with focal epilepsy: A population-based study on German health insurance data.

PURPOSE: To examine the implementation of the clinical practice guideline "first epileptic seizure and epilepsy in adulthood" published in 2008 to patients with newly diagnosed epilepsy between 2008 and 2014. METHOD: This retrospective, population-based analysis was performed on patient data of 4.1 million insurants from the German statutory health insurance. Prevalent and incident cases in adults were identified based on ICD-10 codes, using a hierarchical diagnosis selection algorithm. The first anticonvulsive agent in a newly diagnosed epilepsy patient was validated against the clinical practice guideline. RESULTS: We determined an annual crude prevalence rate in adults between 0.946% and 1.090% and incidence rates of at least 156 per 100,000. A significant increase in guideline compliant monotherapy was found in patients with a focal epilepsy syndrome, while, among patients with idiopathic generalised epilepsies, the share of guideline noncompliant monotherapy increased. Both changes are likely due to the overall increase in prescription of levetiracetam from 19.6% in 2008 to 58.9% in 2014 in all newly treated patients. Overall, the proportion of enzyme-inducing anticonvulsants fell significantly from 20.7% in 2008 to 4.3% in 2014 (p<0.001). The likelihood to receive non-enzyme-inducing antiepileptic drugs was 5.82 (95% CI 4.62-7.33) higher in 2014 than in 2008. CONCLUSION: Initial monotherapy for focal epilepsy is in line with current clinical practice guidelines and mainly implemented by prescription of levetiracetam. Further evaluations should address the question of whether patients treated in line with the guidelines have a favorable outcome, compared to patients not treated in line with current guidelines.