Epilepsy-related direct medical cost in adult patients living with epilepsy

INTRODUCTION

Epilepsy is a brain disorder characterized by irregular electrical action causing seizures or abnormal behavior and sometimes loss of consciousness.^[1] The International League Against Epilepsy published a revised classification of epilepsy syndromes in 2022. Epilepsy syndromes are divided into syndromes with onset in neonates and infants (up to 2 years of age), syndromes with a variable onset age, syndromes with onset in childhood, and idiopathic generalized epilepsies.^[2]

Epilepsy is the most prevalent non-communicable disease globally. There are approximately 70 million patients with epilepsy (PwE) worldwide,^[3] and 2.4 million new cases are diagnosed annually.^[4] Around 80% of PwE reside in low- to middle-income countries.^[5] Although the burden of the disease reduced from 1990 to 2016, epilepsy remains a significant cause of disability and mortality.^[6] Epilepsy was included as one of the 30 most common causes of invalidity between 1990 and 2016.^[7] In comparison with high-income nations, low- and middle-income countries have reported an active prevalence rate of more than 10 cases per 1,000 people.^[8]

Epilepsy has a significant economic impact, medical expenditure panel survey data estimated average annual direct cost as US$ 2,515 in Texas.^[9] Other studies have shown variability drivers of treatment costs such as time elapsed since diagnosis, antiepileptic drug (AED) effectiveness, disease severity, and health insurance coverage.^[10,11] Economic analysis in a direct aspect is an indispensable tool for different diseases, in particular epilepsy, which aims at producing preventive means and efficient therapeutic strategies,^[12] and also allows to provide references for the concerned state authorities to adapt the different actions to their needs.

In Morocco, according to the 2018 National Health Accounts, total health expenditures per capita reached 184 US dollars and 489 dollars in terms of purchasing power parity $.^[13,14] In Morocco, the Mandatory Health Insurance covers employees, civilian servants, and self-employed individuals. The system is administered by the National Social Security Fund for the private sector and by the National Fund for Social Security Organizations for the public sector. Meanwhile, the Medical Assistance Scheme (RAMED) program provides health coverage for the most poor and vulnerable populations, ensuring access to essential healthcare services.^[15]

A population-based study carried out in 2022 estimated the lifetime and active epilepsy prevalence rates to be 19.8 (15– 24.6) and 17.6 (13.3–22.8) per 1,000, respectively.^[16] However, epilepsy has not been considered a public health priority in Morocco. Its treatment encounters the low priority accorded to it by the health authorities.

Furthermore, no original data on its management are available. The purpose of this research is to estimate the direct medical cost (DMC) of managing epilepsy in Morocco.

MATERIALS AND METHODS

RESULTS

DMC of epilepsy and associated factors

The median DMC for managing epilepsy in Morocco was US$ 425.1 (mean of US$ 566.6). More than half of it (56.2%) US$ 260.7 (154.3–412.2) corresponded to medication costs. Radiological explorations accounted for almost 20% of the costs US$ 28.7 (0–220.5), followed by hospitalization which constitutes 15.3% of the DMC, consultations (4.7%) US$ 23.01 (23.01–34.5), and biological tests (1.6%). The rest (1.4%) were costs related to surgery, which were the least expensive component, as shown in Table 4 and Figure 1.

Table 4: Details of the direct medical cost of epilepsy.

	Median in USD (IQR)	Percentage
Radiological explorations	28.7 (0–220.5)	20.8
Biological tests	0.0 (0.0–0.0)	1.6
Consultations	23.01 (23.01–34.5)	4.7
Hospitalization	0.0 (0.0–0.0)	15.3
Medications	260.7 (154.3–412.2)	56.2
Surgery	0.0 (0.0–0.0)	1.4
Total direct medical cost	425.1 (259.8–777.2)	100

IQR: Interquartile range.

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Figure 1:

Average direct medical cost of epilepsy according to its components.

Export to PPT

DMCs were significantly higher among patients who reported frequent seizures during the month before the survey (US$ Median [IQR]) US$ 839.8 (426.5–1111.2) versus 395.7 (249.3–689.8) (P = 0.003), those who had a seizure in the past 4 weeks 505.0 (309.2–849.5) versus 348.7 (215.7–503.4) (P = 0.005), individuals with critical crisis-related trauma US$ 501.05 (299.7–831.1) versus 362.1 (240.9–611.6) (P = 0.036), patients with comorbidities such as psychogenic crises 868.5 (576.3–1225.8) versus 420.5 (255.3–759.4) (P = 0.038), those on polytherapy US$ 625.6 (336.7–879.4) (P < 0.001), patients who had undergone surgery US$ 1441.7 (589.05–1441.7) (P = 0.027), radiological explorations US$ 495.4 (337.9–841.1) (P < 0.001), and individuals who had been hospitalized US$ 899.8 (827.9–1310.03) (P < 0.001). These findings are detailed in Table 5.

Table 5: Factors associated with direct medical cost of epilepsy.

Factors	Median in USD (IQR)	P-value
Treatment
Monotherapy	333.6 (201.4–436.04)	0.000***
Polytherapy	625.6 (336.7– 879.4)
Number of seizures in the past month
<10	395.7 (249.3–689.8)	0.003**
≥10	839.8 (426.5–1111.2)
Seizure in the past 4 weeks
Absent	348.7 (215.7–503.4)	0.005**
Present	505.0 (309.2–849.5)
Trauma
No	362.1 (240.9–611.6)	0.036*
Yes	501.05 (299.7–831.1)
Comorbidities
Psychogenic crisis
No	420.5 (255.3–759.4)	0.038*
Yes	868.5 (576.3–1225.8)
Hospitalization
No	348.7 (229.06–501.5)	0.000***
Yes	899.8 (827.9–1310.03)
Surgery
No	423.4 (255.8–767.2)	0.027*
Yes	1441.7 (589.05–1441.7)
Radiological explorations
No	281.4 (193.0–497.6)	0.000***
Yes	495.4 (337.9–841.1)

***Significant with P<0.001; **Significant with P≤0.01; *Significant with P≤0.05, IQR: Interquartile range.

DISCUSSION

This research is the first to assess the DMC of epilepsy in Morocco. The median DMC of epilepsy management was US$ 425.1 (mean of US$ 566.6) per patient per year. Our results are similar to those of a study carried out in Rwanda (DMC = US$ 248.9).^[22] However, our findings are higher compared to Northwest Ethiopia (US$ 37 ± 27.3)^[23] and Bhutan (US$ 91).^[24] Conversely, data from Nigeria (DMC = US$ 3,947.2),^[25] Moscow Russia 955€ (IQR 521–2134; range 51–10,904),^[26] and Spain (1055.2€)^[27] reported that cost of epilepsy management is higher than our results (US$ 425.1). A study conducted in Poland reported that direct costs of epilepsy increased over time, ranging from 84 mln € in 2014 to approximately 88 mln € in 2016 for patients diagnosed between 2014 and 2016.^[28]

The observed differences between countries may result from variations in patient management protocols (including medications, treatment procedures, and medical technologies) and cost estimation methodologies (inclusion and exclusion criteria of patients, sampling size, and statistical analysis).^[11] In addition, these differences may also be attributed to the fact that we based on a prevalence approach and that the majority of the tests were completed in the 1^st year of diagnosis for all subjects, who had all previously received an epilepsy diagnosis. The study period corresponded with the COVID-19 pandemic, and there was a low rate of healthcare utilization.

This study showed that a considerable portion of the DMC for epilepsy management was attributed to medications (56.2%), followed by radiological explorations (20.8%) and hospitalization (15.3%). Similar findings were observed in studies from Rwanda^[22] and Nigeria^[25] where AEDs accounted for a substantial portion of the average individual cost of epilepsy management, representing 65% and 81.3% of the total annual DMCs, respectively.

A German study reported an annual direct cost of 1698€ for epilepsy treatment, with the majority of expenses attributed to AEDs (59.9%) and hospitalization (30%).^[29] Similarly, research from China found that the largest portions of the overall expenditure were allocated to medications (US$394.53) and diagnostic procedures (US$59.34).^[30] A comparable result was observed in Northwest Ethiopia, where AEDs (US$21.5) and investigations (US$12.4) accounted for the largest share of costs,^[23] emphasizing the significant financial burden associated with medicines and diagnostic interventions. These studies highlighted that patients on polytherapy incurred higher treatment costs than those on monotherapy, likely due to the elevated cost of AEDs.

Psychiatric comorbidities are among the most common comorbidities of epilepsy.^[6,31] In this present study, we measured the association between DMC and the presence of comorbidities. The findings revealed a significant association between psychogenic seizure and the total DMC (P = 0.038).

Both the occurrence and the number of seizures were associated with the DMC of epilepsy in this study (P = 0.005) and (P = 0.003), respectively. This finding aligns with results obtained in China^[30] and Bhutan.^[24] This similarity may be due to the fact that frequent seizures require additional treatment and care.

Surgery was associated with DMCs in this analysis (P = 0.027). A significant French study demonstrated the role of surgery on a clinical, medicoeconomic, or quality of life level in the treatment of drug-resistant partial epilepsies in adults. After 5 years of surgery, the DMCs for these patients dropped from 4110 euros at the time of inclusion to 1233 euros.^[32] To limit cognitive decline and psychological and social disability, surgery should not be the last resort treatment option.

The cost determined in this study corresponds to 0.16 times the per capita gross domestic product (GDP), which was valued at 36274 MAD (US$ 3477.8) in 2022 based on (High Commission for Planning).^[33] The fact that about 12.7% of Moroccans are poor and 7.3% are vulnerable according to data for the year 2020^[34] shows that patients are unable to cover the expenses associated with epilepsy treatment and had to adopt negative coping strategies like relying on family or social networks for assistance. Our results show that 78.2% of patients in our target population are covered by RAMED, reflecting the national coverage levels in Morocco.^[20]

This study had several limitations. First, the retrospective collection of patient data may have led to information bias and an underestimation of costs. Second, the research was conducted in a public hospital and did not include PwE followed in private sectors who may differ from our population on sociodemographic characteristics and health expenditure. Finally, we did not estimate direct non-medical and indirect costs, which would give an idea of the overall cost of epilepsy.

Despite these limitations, our method was developed based on international standards of disease burden estimation. Our study provides the first available cost data for epilepsy treatment in Morocco.

Kissani et al. highlighted the difficulties in the treatment and managing epilepsy and the limitations of available AEDs.^[35] The healthcare budget is limited, with resources primarily allocated to other diseases. Another potential factor for undermedication is the ignorance of treatment options for epilepsy, as a result of lack of education and awareness. Our findings are useful for policymakers, and they suggest more resource allocation for epilepsy management to improve accessibility to AEDs comprising generics. Other actions need to be implemented to promote preventive strategies for conditions that contribute to epilepsy, including perinatal events and febrile convulsions.

In terms of research, our data may provide a useful basis for pharmacoeconomic evaluations (cost-effectiveness modelization) of anti-epilepsy interventions.

CONCLUSION

This analysis could assist in the healthcare allocation of scarce resources and pharmaco-economic analysis of anti-epileptic drugs.