By Pamela R. Kelly, MBA-HCM, Rizwana Rehman, PhD, Aatif M. Husain, MD
DURHAM, NC – Elaborating on the phrase coined by President Theodore Roosevelt “If you build it, they will come,” author Ron Adams1 asserts that they will come only if the need, cost and targeted market population are right for the right time. Adams provides guidance on market evaluation prior to building. As a government agency, VHA may not have privileges of conducting pre-evaluation market testing.
With recognized consensus that the price of freedom is truly not free, the care of our veterans remains a high priority, in the spirit of President Abraham Lincoln’s proclamation that the United States will “care for him who shall have borne the battle.” Deploying the Centers of Excellence (COE) concept is one of the options to improve specialized services. Public Law (PL) 110-387 mandated the establishment of the VA Epilepsy Centers of Excellence (ECoE).
Studies have been conducted on post-traumatic epilepsy (PTE) in various populations. According to one, penetrating brain injuries are associated with a 50% risk of PTE, compared with 30% in non-penetrating head injury.2 Studies on Vietnam War veterans indicate that the risk of PTE following war-related traumatic brain injury (TBI) is 53%.3 One study found that 12.6% of veterans inflicted with TBI had an initial onset of epilepsy up to 14 years after their injury.4
There is a possible association between post-traumatic stress disorder (PTSD), TBI and psychogenic nonepileptic seizures (PNES). A critical review of 17 studies on PNES patients reported that 10 out of the 17 documented higher rates of PTSD among PNES patients than the control groups.5
Another study of PNES-diagnosed veterans also revealed a higher rate of PTSD compared with veterans with epileptic seizures.6 In a retrospective study of TBI cohort where epilepsy was the initial diagnosis, 33% had experienced PNES.7 Current research indicates that PNES patients often are initially misdiagnosed with epilepsy and that prolonged video EEG monitoring (EMU) is the determining gold standard for diagnosis.8
It is commonly recognized that with the increasing number of veterans with TBI from recent military conflicts, the number of veterans with epilepsy will continue to increase in the foreseeable future. What is not as clearly recognized is that with the increasing number of PTSD and TBI patients entering the VA system, the number of patients with PNES is also greatly increasing. This represents a new patient population that must be evaluated in the ECoEs to ensure the best treatment for our war-injured veterans.
This article discusses the clinical perspective of seizures (or spells), population trends of seizure patients and prevalence of spells among TBI and PTSD cohorts in the VA prior to establishing ECoE to current status. Additionally, the ECoE strengths and challenges associated with meeting the quality specialized care standards expected for the veterans experiencing epileptic or nonepileptic seizures are discussed. Based on projected workload and the current status of the ECoE program, theory and data supported recommendations are offered in the spirit of program enhancements that might be exportable to other centers of excellence.