Frequency of and factors associated with antiseizure medication discontinuation discussions and decisions in patients with epilepsy: a multicenter retrospective chart review

Abstract

SummaryObjectiveGuidelines suggest considering antiseizure medication (ASM) discontinuation in patients with epilepsy who become seizure-free. Little is known about how discontinuation decisions are being made in practice. We measured the frequency of, and factors associated with, discussions and decisions surrounding ASM discontinuation.MethodsWe performed a multicenter retrospective cohort study at the University of Michigan (UM) and two Dutch centers: Wilhelmina Children’s Hospital (WCH) and Stichting Epilepsie Instellingen Nederland (SEIN). We screened all children and adults with outpatient epilepsy visits in January 2015 and included those with at least one visit during the subsequent two years where they were seizure-free for at least one year. We recorded whether charts documented 1) a discussion with the patient about possible ASM discontinuation and 2) any planned attempt to discontinue at least one ASM. We conducted multilevel logistic regressions to determine factors associated with each outcome.ResultsWe included 1,058 visits from 463 patients. Of all patients who were seizure-free at least one year, 248/463 (53%) had documentation of any discussion and 98/463 (21%) planned to discontinue at least one ASM. Corresponding frequencies for patients who were seizure-free at least two years were 184/285 (65%) and 74/285 (26%). The probability of discussing or discontinuing increased with longer duration of seizure-freedom. Still, even for patients who were ten years seizure-free, our models predicated that in only 49% of visits was a discontinuation discussion documented, and in only 16% of visits was it decided to discontinue all ASMs. Provider-to-provider variation explained 18% of variation in whether patients discontinued any ASM.SignificanceOnly approximately half of patients with prolonged seizure-freedom had a documented discussion about ASM discontinuation. Discontinuation was fairly rare even among low-risk patients. Future work should further explore barriers to and facilitators of counseling and discontinuation attempts.Key points boxWe performed a multicenter cohort study evaluating factors associated with discussions and decisions to discontinue antiseizure medications (ASMs).Of all patients seizure-free at least one year, 53% had documentation of any discussion and 21% planned to discontinue at least one ASM. Corresponding frequencies for patients seizure-free at least two years were 65% and 26%.While discussions and discontinuations increased with increasing seizure-free interval, even for patients who were ten years seizure-free, in only 49% of visits did providers discuss the possibility of discontinuation, and in only 16% of visits did patients decide to discontinue all ASMs.Provider-to-provider variation explained 18% of variation in whether patients discontinued any ASM.ASM discontinuation was fairly rare even among low-risk patients. Future work should further explore barriers to and facilitators of counseling and discontinuation attempts, including the role that differences in physician counseling play in determining whether patients discontinue.