Search

Purpose: To compare resective surgery and medical therapy in a cost-effectiveness analysis in a multicenter cohort of adult patients with partial intractable epilepsy., Population and Methods: Adult patients with partial, medically intractable, potentially operable epilepsy were eligible and followed every year over five years. Effectiveness was defined as one year without seizure. The long-term costs and effectiveness were extrapolated over the patients' lifetime with a Markov model. Productivity (indirect costs) and quality of life (QOLIE-31, SEALS) were also assessed. Changes before and after surgery were compared between the two groups., Results: Two hundred and eighty-nine patients were included (119 with surgery, 161 medically treated, six not eligible, three lost to follow-up). One year after surgery, 81% of the patients were seizure-free; at two and three years, this rate was 78%. In the medical group, these rates were 10, 18, and 15%, respectively. The cost of the explorations was euro 8464; including surgery, it was euro 19,700. In the medical group, the average annual direct costs were between 3500 and euro 6000. At two years after surgery, the annual direct cost decreased to euro 2768, at three years, it was euro 1233, predominately antiepileptic drug costs. Surgery became cost-effective between seven and eight years. In the surgical group, all the quality-of-life scores improved at one year after surgery and were stable during the second and third years., Conclusion: Surgical therapy was cost-effective at the middle term even though indirect costs were not considered.

The authors show that therapeutic education of the epileptic patient and his proxies is necessary but not yet organized for drug-resistant epilepsy; the objectives of this education are detailed after looking at the current status and the needs. The authors insist on the necessity of a global consideration of the patient: subjective and organic as well, taking into account the psychological and social dimensions and the experiences of the patient. The need of a specific formation for the physician and other health workers is emphasized, awaiting a status for therapeutic education. The authors propose a project of therapeutic education of the patient suffering from drug-resistant epilepsy.

Objective: Patients with medically intractable epilepsy are potential candidates for surgery if the epileptogenic tissue is localized and resectable. Surgical therapy can eliminate seizures but is very expensive. We followed a prospective adult cohort of intractable epileptic patients in order to perform a cost-effectiveness analysis., Population and Methods: Adult patients with a suspected partial medically intractable and operable epilepsy were eligible for evaluation, explorations and/or surgery. Clinical and economical data were collected at the inclusion and every 6 months over at least two years. Two patient groups were analyzed: some underwent a surgery, others did not. Clinical data were compared between both groups. As the data collection was not yet complete, we compared the surgery to a continuation of the preoperative medical management in a cost-effectiveness analysis. Direct medical and nonmedical costs were evaluated according to a societal perspective. The effectiveness was defined as one year without seizure. We assessed the incremental cost-effectiveness ratio (ICER) for the first two years after the surgery. We also modeled long-term costs and effectiveness and extrapolated the results over the patients' lifetime with a Markov model. We computed the ICER and performed a sensitivity analysis. Indirect costs were measured in physical units and intangible costs were assessed with quality-of-life measures (QOLIE-31, SEALS). Data were compared before and after surgery., Results: Among the 286 patients included, 119 did not enter in the analysis: 7 were not eligible, 44 not operable, 31 did not present a follow-up, 37 still underwent exams. Finally, 89 underwent a surgical treatment, and 78 were medically treated. Disease was more severe in surgical patients than in medical patients: seizures frequency, depressive disorders and cognitive impairment were greater. One year after the surgery, 83% patients were seizure free. During the year before inclusion and the year after surgery, direct costs were mainly due to hospitalization. During the second year after surgery, the cost of antiepileptic drugs predominated. One additional year without seizure costs 23 531 euro one year after surgery and 9533 euro two years after surgery. In a long-term perspective, the surgery became cost-effective between 7 and 8 years after the surgery., Conclusion: Surgical therapy is a cost-effective treatment in a middle-term even without indirect costs consideration.

While employment appears to be among major concerns for epileptic patients, these are confronted with a very high rate of unemployment, especially when epilepsy is pharmacoresistant. However, the persistence of seizures is not the only factor bearing on vocational training or employment; other factors may intervene as well: cognitive dysfunctions, psychological/behavioral disturbances, impact of AEDs, education, vocational training, family members and relatives' attitude, school teams' attitude, employers' attitude, occupational physicians' attitude. Educational level is lower when epilepsy started at school-age; persisting seizures together with other problems may lead the epileptic child or teenager to attend specialized schools. In France, there are few institutions dedicated to children or teenagers with severe epilepsy, and these are very unevenly distributed over the French territory. The main social measures regarding children with epilepsy in France are mentioned. Besides being seizure-free and able to drive, work is one major expectation of patients from epilepsy surgery. The results of epilepsy surgery regarding employment are somewhat controversial; in some studies, temporal lobe surgery may not raise the employment rate; other studies point out that operated-on patients need a long time (up to 6 years) to find a job after surgery. The vocational level or the previous work experiences appear to be as important factors for further employment as being seizure-free, a condition which may not be met in all favourable work outcomes. The medico-social support to patients with pharmacoresistant partial epilepsies has to deal with all the factors mentioned previously; the opportunity for epilepsy surgery may have to be considered early in order to try and prevent the detrimental impact of pharmacoresistant epilepsy on school achievement and vocational training; adult patients with pharmacoresistant epilepsy often cumulate a low qualification level, an absence of a solid work experience, a lack of motivation and a social deprivation. Neurologists may have an insufficient knowledge of social and work regulations: in this paper we describe the main possibilities for epileptic patients to obtain social supports in France. Likewise, occupational physicians seldom know much about epilepsies. We have a positive experience of a multidisciplinary approach combining neurologists, occupational physicians and insertion teams. We are convinced that a personalized follow-up of the epileptic person is useful and often

In this article, we describe the social and economic aspects of adult epileptic patients in France. The different measures to facilitate their reintegration and employment are presented. The missions of the COTOREP (Technical Commission for Professional Orientation and Reclassification) include the identification of a disability rate, the recognition of status as a disabled worker, and orientation to an individually adapted job, e.g. in a specialized center. The COTOREP provides information and training. For patients with major disabilities, the commission can decide on admission in a specialized institution. The COTOREP but also the French national Social Security propose allocations and financial assistance for patients with low income or who have a work inaptitude. In this text, we also describe the general French laws for the protection of adult patients which include measures not specific for epileptic patients.

Studies of sign language aphasia in deaf adults have provided the evidence for two separable verbal and nonverbal manual gesture systems. We report a congenitally deaf child with a idiopathic focal epilepsy of childhood who showed specific language impairment in French sign language. The child's amazing performances in miming or sketching pictures she was unable to sign support the notion of an early dissociation of the two gestural systems.