How Ambulatory EEG Fits Into Private Practice
Epilepsy and seizures can develop in any person at any age. While it is more common in young children and older people, we remain unknown as to what causes the determinants as to why these develop in one person or another.
Statistics reveal that 1% of people in the U.S. will suffer an unprovoked seizure in their lifetime. One in 26 people will have recurring seizures through some form of epilepsy in their lifetime. At any given time, between 2 and 3 million people are being treated for epilepsy and over 30% are walking around with uncontrolled epilepsy in the U.S.1
Epilepsy is just one factor of many that concerns the overall care of patients requiring neurological assessment. The lack of access to care for those who suffer from such events is a growing concern. Additionally, as healthcare in the United States transitions to a value-based model, traditional EEG testing and monitoring poses challenges for providers who need reliable clinical results through cost-beneficial means.
Ambulatory EEG (aEEG) offers busy practices to a comprehensive solution by evaluating more patients without sacrificing the quality of care. In fact, the access to quality care increases with the convenience of aEEG because it offers advantages for patients who cannot, or refuse to be admitted to the hospital or even other in-patient settings due to feeling like a burden on the family.
Like many healthcare technologies, EEG has seen remarkable advancements in recent years. Whereas even cumbersome, hospital-based machinery has given way to small, wearable devices that remotely deliver video and real-time data. Ambulatory EEG can provide long-term monitoring of patients in an office or even the comfort of their own home, and has become an integral part of diagnosing, classifying, managing seizure disorders and identifying non-seizure related causes of patient-reported events, including cardiac, behavioral, and sleep disorders.
These important advances have made aEEG not only a viable option for private practitioners, but also useful and beneficial. To understand how aEEG fits well into private practice, it’s first helpful to recognize some of the clinical success aEEG has demonstrated throughout its development.
aEEG in the Clinical Setting
In a 2012 study published in Seizure, it was cited that clinical diagnosis of epilepsy was inaccurate up to 30% of the time, with common misdiagnosis of syncope or psychogenic non-epileptic attacks (due to uncertain or immediate access to trained epileptologists). The limitation is often the lack of extended EEG recordings to support the correct diagnosis. “The utility of prolonged outpatient ambulatory EEG” further noted that the International League Against Epilepsy recommends long-term EEG in cases of diagnostic uncertainty, as well as cases of confirmed epilepsy when necessary to confirm the epilepsy syndrome, and to document the electro-clinical basis of seizures prior to surgery.
The report pointed out that ambulatory EEG did not provide direct observation of events, nor did the technology provide a safe environment for the withdrawal of seizure medication that would be performed in the hospital drug reduction. However, in the absence of relevancy of these factors, allowing patients to be monitored in their own homes with typical triggers presented “an attractive option.”
The study further concluded that, “Given the limited provision and higher cost of inpatient video EEG, outpatient ambulatory EEG represents a practical initial investigation of paroxysmal neurological events.”
These conclusions were further drawn upon in a report published in 2015 by the Expert Review of Neurotherapeutics, where it was referenced that a decrease in the utility of routine EEG was possible, while the utility of prolonged EEG and video-EEG had increased dramatically.
“What type of EEG (or EEG-video) does your patient need?” called prolonged EEG with video monitoring “the gold standard” for epilepsy specialists, and pointed to advances in technological capabilities that supported the rise in aEEG use.
“With the improvement in computers, storage, processing, and remote access, most functions of EEG-video can now be obtained in an ambulatory or home setting,” the article stated.
This ability to combine video in the ambulatory setting was significant, and in 2016 a study in Epilepsy & Behavior found video-aEEG to have an overall diagnostic utility of 67% while proving highly effective for diagnosing psychogenic nonepileptic seizures.
Because of its potential for improving diagnosis of epileptic versus nonepileptic seizures, the study concluded, “Implementation of video-aEEG protocols in a secondary care center appears to have high diagnostic utility, particularly for patients with psychogenic nonepileptic seizures.”
The added capabilities of video for aEEG were further heralded in another 2016 report in Seizure. “Video ambulatory EEG: A good alternative to inpatient video telemetry?” stated, “Ambulatory EEG, until recently, had the serious disadvantage of lacking simultaneous video recording.” This lack of video left aEEG ineffective for differentiating between frontal lobe and psychogenic seizures. However, the introduction or this key technology advance changed the dynamic and utility of aEEG completely.
“The advent of new commercially available ambulatory EEG systems which have the facility of time locked synchronized video recording offers a potentially attractive, practical alternative for performing long term video EEG monitoring in the patient’s home,” the study declared, adding, “new technology providing synchronized video-EEG may well allow this system to become the default investigation for diagnostic video telemetry.”
Another more recent investigation lauded the efficacy of aEEG when a patient admission to an in-patient epilepsy monitoring unit was unsuccessful. “The Diagnostic Utility of Ambulatory EEG Following Nondiagnostic Epilepsy Monitoring Unit Admissions”, published this year in the Journal of Clinical Neurophysiology, predicted that aEEG could provide successful diagnosis following nondiagnostic EMU admissions. The research concluded that “ambulatory EEG following a nondiagnostic EMU admission may yield positive results in approximately half of all patients.”
Advantages of Ambulatory Video-EEG
The context of historical EEG, conducted largely on an in-patient basis, presents a number of challenges, ranging from minor inconveniences to clinical ineffectiveness. While admission to a facility still may be necessary in certain situations, hospitalization has additional disadvantages, such as increased risk of infection, patient anxiety, overall expenses, and an increased burden of the family to travel to a hospital setting for a 3-5 day procedure. Clinical studies have found ambulatory EEG to provide several advantages to the in-patient approach, including:
- Lower cost of service than a stay in a hospital Epilepsy Monitoring Unit (EMU)
- Quicker access to service (no long wait for availability of bed in EMU)
- In-home services eliminate the need for patient/family travel to hospital for testing
- Potentially higher likelihood of capturing epileptic events in home environment (avoiding the “hospitalization anticonvulsant” effect)
- aEEG procedures are generally better tolerated than in-patient video-EEG monitoring
- Remote real-time monitoring of patient studies ensures quality recordings with excellent clinical yield
The development of cloud technology also now provides clinicians the opportunity to take advantage of long-term, video-aEEG with full-time, real-time monitoring. Trained and experienced technologists can ensure EEG test quality by identifying events or complications that need to be addressed during the study. They can also communicate with the patient or family as needed, while allowing physicians the ability to access results during the study on demand. It’s all the benefits of in-patient monitoring with in-home convenience.
While early incarnations of aEEG may have lacked full effectiveness compared to traditional, hospital-based systems, today’s ambulatory equipment rivals any on the market while providing the benefit of seamless, real-time data capture, offering clinicians a superior diagnostic option that is more convenient for the patient.
Ambulatory EEG also limits occurrences of unsuccessful tests, which may be impacted by patient stress related to testing conditions or environment. Instead, aEEG increases the likelihood of identifying and diagnosing issues otherwise difficult to capture through traditional EEG, such as atypical histories or nocturnal events that occur only when the patient is at home surrounded by natural triggers.
Benefits to Patients, Clinicians, & Healthcare
Long anticipated as a solution to the shortcomings of traditional EEG systems, true ambulatory EEG monitoring is now available in setting once only available to hospitalized patients. Ambulatory video-EEG offers private practices accurate, high-quality EEG testing while patients receive the benefits of at home convenience and scheduling flexibility. Together, this provides the patient quality care while eliminating the need for costly re-testing and lowering the costs involved for both payers and providers.
Physician practices can also take advantage of specialized aEEG outsourcing services to further control costs. These services available from some more advanced outsourced ambulatory EEG companies may include:
- Insurance pre-authorization and scheduling
- In-Home patient set-up by qualified EEG technologists
- Full EEG montage with additional ECG electrodes and digital audio/video capabilities
- Routine EEG with patient stimulation and activation when requested
- Real-time remote monitoring of the patient study to insure high quality EEG data by experienced staff with 24/7 live patient support
- Local technologists for EEG set-up and equipment collect at the end of study
- EEG review and annotation by experienced and trained technologists
- Cloud-based study storage with secure portals for access and reporting
The advantages of aEEG extend to both patient and provider, making it a logical and practical tool for any practice. Better yet, cloud connectivity has given rise to specialized providers that can offer ambulatory video-EEG as an outsourced service, making it easier and more cost effective to add aEEG to any clinic or physician’s offerings.