cEEG Monitoring in the ICU: Treating Subclinical Seizures is Cost Effective

Paul Vespa, MD, FCCM UCLA Medical Center

NCS Meeting 2007

Disclosures
No direct support from cEEG companies I am somewhat biased: I think that silence is not always golden I am dependent on my brain waves, hence I am predisposed to protecting them at all cost

Preliminary Remarks
If we had definitive data on this question we would
Know the answer already Be bored with this topic Be self-righteous about our response

cEEG is by definition a monitor. Therefore it is a

Diagnostic tool Objective instrument to define the effects of treatment Biomarker against which to titrate the intensity of treatment

Are nonconvulsive seizures a significant problem in the ICU?

Yes! 35% of NeuroICU patients found to have seizures (Jordan 1992) 22% of TBI patients have seizures, of which are nonconvulsive (Vespa 1999) 28% of ICH patients have seizures, of which are nonconvulsive (Vespa 2003) 15% of SAH patients have seizures (Claassen 2004) 44% of pediatric ICU patients have seizures on cEEG (Jette, Hirsch 2006); 39% were nonconvulsive 16% of pediatric ICU patients with mental status problems (Snead et al 2006)

Is NCSE a significant problem in the ICU?

Yes! 8% of general ICU patients were found to be in NCSE using routine portable 30 min EEG (Towne 2000) 22% of TBI patients have seizures, 6% have NCSE (Vespa 1999) 15% of mixed NICU patients have Nonconvulsive seizures, 4.5% had NCSE (Claassen 2004) ~ 20% of pediatric ICU patients in Jette 2006 had NCSE 11% of pediatric ICU patients with altered mental status have NCSE (Narayanan 2007)

Dissecting the big question of effectiveness into smaller questions

Effectiveness of a diagnostic test can be defined in many ways
Provides an accurate in diagnosis Avoids risky testing to rule out other diagnoses Permits optimal use of treatments and resources Reduces cost Improves clinical outcome

Lets consider a common ICU monitor: EKG for detecting cardiac arrythmias
Effectiveness of a diagnostic test can be defined in many ways
Provides an accurate in diagnosis Avoids risky testing to rule out other diagnoses Permits optimal use of treatments and resources Reduces cost Improves clinical outcome
Importance

Is treating cardiac arrythmias cost effective?

EKG is routinely performed on all ICU patients Costs of EKG are built into the daily ICU cost The incidence of threatening cardiac arrythmias in the Neuro-ICU is low (< 5 %) Prospective data about cost effectiveness of treating cardiac arrythmias is lacking

The setting in which Non-convulsive Seizures occurs may affect the answer
Status epilepticus or soon thereafter Primary structural brain injury Systemic illness with transient, superimposed brain dysfunction Severe irreversible injury complicated by seizures
Hypoxic ischemic injury Severe TBI

Does EEG provide an accurate diagnosis of NC Seizures ?

Yes Presence vs absence of seizures is reliably seen

Potential limitations of surface cEEG in detecting seizures

Most seizures are not clinically suspected Some important electrical events, presently an unknown number, occur in the brain and escape detection by surface cEEG
DC depolarization events (Strong et al 2005) Cortical seizures (unpublished observations)

Persistent NC Seizures after presenting with convulsive seizures

Emergency EEG, n=198, few clinical signs 37 % had nonconvulsive seizures
Privitera 1994

Does EEG provide an accurate diagnosis of NC Seizures ?

Focal and generalized nonconvulsive seizures are accurately diagnosed by cEEG
Vespa 1999; Vespa 2003; Claassen 2004

The timing, duration and frequency of seizures are reliably seen

Does EEG avoid risky testing to rule out other diagnoses ?

Yes. EEG is noninvasive. If Seizures are seen, then other invasive testing is not required.
Caveat is that non-invasive testing (ie imaging) is done

Does EEG permit optimal use of treatments and resources?

Yes. Anticonvulsant dosing in the presence of NCSz can be titrated Anticonvulant dosing can be stopped in the absence of NC Sz
Naidech et al 2005: Phenytoin is associated with functional and cognitive disability after SAH Chumnanjev et al 2007: Three day prophylaxis with phenytoin for SAH

Time to stopping status influences outcome

Young, Jordan 1996: long latency to gaining control

latency to gaining control increased OR for mortality; < 2 hours

Jaitly 1998: persistent epileptiform activity is frequent, associated with worse outcome Pellock 2004: time to treatment <30 minutes in less than 41.5% of 889 cases in Richmond Kalita 2006: EEG at 1 hour post clinical seizures is useful to tell who is controlled, and who will recur soon. Muaygil 2007: More rapid control is achieved when treatment protocols are followed Therefore, it is critical to document that the status epilepticus has stopped by EEG.

Mortality increases with the duration of undiagnosed and untreated seizures

Etiology: Remote symptomatic: 16% (4/25) Acute symptomatic: 46% (11/24) NCS only vs. NCSE - 12% vs. 54% Seizure Duration: <10 h: 10% (3/30) 10-20 h: 33% (2/6) >20 h: 85% (11/13) p = 0.009 OR = 6.0 p = 0.002 OR=10.0

p = 0.0006

OR = 1.093/h

Delay to Diagnosis <0.5 h: 36% (5/14) >1 <24 h: 39% (7/18) 24 h: 75% (6/8)

p = 0.00001

OR 1.039/h

* Young GB, Jordan KG., Doig G. Neurology, 1996

Does EEG permit optimal use of treatments and resources for NC Sz?
UCLA preliminary data cEEG monitoring applied to patients suspected to have seizures upon admission to the ICU Convenience retrospective cohort of patients admitted to ICU with suspected or witnessed seizure(s)
N = 123
Group 1: 100 had ongoing or intermittent non-convulsive seizures Group 2: 23 had no further seizures

UCLA retrospective data

Group 1: still seizing (n = 100) Mixed diagnoses: TBI, SAH, Status, Tumors, ICH Uniformly treated with additional AEDs IV drips titrated to stop seizures in 62% Effective in diagnosis and titration of drugs in all cases Avoidance of additional invasive testing or procedures 22/100 avoided angiography (SAH, AVM) 9/100 avoided EVD/Surgery (tumor, hydro) Cost savings: (Estimates) 31/100 estimated avoidance of costs for angio or surgery + 1 day of ICH LOS due to prompt diagnosis 69/100 estimated 1 day savings due to prompt diagnosis Cost/day of ICU stay = $1600-2000/day

UCLA retrospective data

Group 2: not seizing on cEEG (n = 23)
Uniformly treated with once daily AED Avoided IV drip or additional benzodiazepine No avoidance of additional testing
This is variable due to diagnoses

No estimated cost savings

This may be too conservative, but unable to measure

Costs of doing cEEG at UCLA

Expenses
Half-time EEG tech daytime, salary, benefits, nonproductive time $200/day Evening and night tech call back at overtime rate, 3hr/night* $225/day On-call pay $50/day Total fixed $475/d Supplies: disposable needles, etc. $15/pt/day Out of 19 bed ICU, 7 pts/day $105/day Tech cost of cEEG monitoring/day/= $475/7 = $68/pt/day+105 supplies/pt= $173/pt
* Excludes purchase price for cEEG system ~ $25-30,000/machine

Cost Savings due to reduction in ICU LOS in SAH with NC seizures

If Nonconvulsive seizures are present, and cEEG is done, then NCSz will be seen and treated Only SAH pts considered for this 2005-2006 data set with uniform cEEG performed for mean 4 days Conservative estimate of Savings by reducing 1 day ICU LOS in those pts who are found to be seizing (Cost/day of ICU) x (# particular Dx) x (% seizing) SAH = $1655 x 110 x 20% = $36,410 Net cost reduction = Cost of cEEG Savings ($69/day x 110 x 4 days) - $36,410 = 30,360 36,410 = - $6050 Save $6050/year by using cEEG, while providing more comprehensive treatment

Overall Net Profit for cEEG in SAH

The ICU LOS cost savings is not the whole story, since there is hospital revenue from cEEG
UCLA Estimate is $165/day revenue For SAH: Daily revenue x # days x # pts
$165 x 4 x 110 = $72,600/ year

So, net revenue

$72,600 + $6050 = $78,650 profit This is for one diagnosis only.

cEEG is profitable for hospitals

despite the costs of performing the service

Contribution Margin:
Allocated net revenue is calculated using total net revenue for patients receiving these services as a % of the total charges.

UCLA Contribution Margin

2005 2006 $402,110 $ 582, 311

Dissecting the big question of effectiveness into smaller questions

Effectiveness of a diagnostic test can be defined in many ways
Provides an accurate in diagnosis Avoids risky testing to rule out other diagnoses Permits optimal use of treatments and resources Reduces cost Improves clinical outcome

Factors that determine outcome

Primary prognostic factors of the disease
These are not modifiable

Prompt diagnosis and treatment of complications (seizure) Type of complication (seizure-type) Side effects of treatment End of life considerations