Objective:

The objective of this evidence report was to systematically review the best available evidence in the published literature regarding health care services pertinent to the diagnosis, treatment, and monitoring of patients with a first diagnosis of epilepsy.

Search Strategy:

Literature published in English from 1980 through November 1999 was searched using MEDLINE and Current Contents, supplemented by a manual review of the bibliographies of all accepted papers, the Cochrane Library of Systematic Reviews, and various Internet sources.

Selection Criteria:

Interventional or observational studies of at least 10 patients, adults, or children, with a first seizure, or at first presentation, or at the time of a new diagnosis of epilepsy, were eligible. Studies had to report results of any of the following interventions: (a) diagnostic: history and physical examination; neuropsychologic examination; imaging with computed tomography (CT), magnetic resonance imaging (MRI), or positron emission tomography (PET) scan; electroencephalogram (EEG) -- standard, video, invasive, ambulatory; lumbar puncture; or blood tests; (b) monitoring: EEG, blood tests, drug levels, or clinical/pharmacologic expertise; (c) treatment: clinical/pharmacologic expertise, antiepileptic drug monotherapy or polytherapy, counseling and psychosocial support, surgery, physical or occupational therapy, speech therapy, or education.

Data Collection and Analysis:

Data on study, patient, and intervention characteristics and results were extracted from accepted studies. Studies were scored for quality and level of evidence. Study and patient-level characteristics were summarized, and the results were synthesized qualitatively. A panel of diverse technical experts and peer reviewers provided review and commentary on the results.

Main Results:

Of 13,128 citations, 120 studies covering 21,213 patients met all eligibility criteria. Diagnostic interventions to rule in a diagnosis of epilepsy, as well as predict remission outcomes, are a complete history and physical examination, including neuropsychologic assessment, and a standard EEG. Other diagnostic interventions (e.g., CT or MRI) are more important to rule out secondary causes of seizures or to resolve uncertain diagnoses (e.g., video EEG) in a minority of selected patients. The monitoring interventions that may have an impact on outcomes are clinical/pharmacologic expertise, periodic blood tests (routine hematology and chemistries) for antiepileptic drug (AED)-related side effects, and possibly cognitive assessments in certain populations. Compliance with AED regimens predicts remission, but approaches to ensure compliance are not substantiated. Treatment interventions important for patients with a first diagnosis include clinical/pharmacologic expertise to inform choices of AED treatment, which are dictated more by differing side effect profiles than efficacy. Monotherapy AEDs appear comparable in efficacy for many epilepsy syndromes, but not all, for example juvenile myoclonic epilepsy, which require expertise not only to diagnose but to inform treatment choice.

The literature has multiple limitations, including lack of a universally accepted gold standard for diagnosis, low methodologic rigor, widespread terminology confusion, lack of patient-centered outcomes, including quality of life, health care utilization and costs, and gaps in coverage of virtually all nonclinical/pharmacologic treatment interventions in newly diagnosed patients.

Conclusions:

The best available evidence from the literature is not conclusive regarding the appropriate and necessary diagnostic, monitoring, and treatment services for patients with newly diagnosed epilepsy. This literature review, however, can be used to generate testable hypotheses. We urge the health services research community to test these hypotheses in new and more rigorous studies in the future.