Smith, Brien J. MD
Dr. Smith is Medical Director of the Comprehensive Epilepsy Program at Henry Ford Hospital in Detroit, MI. In October, he testified to the Senate Committee on Veterans Affairs in support of the VA Epilepsy Centers of Excellence Act.
In this highly contentious election season, there is no shortage of information and opinion regarding our military presence in Iraq and Afghanistan. At the same time, there have been major shortcomings in the medical care for our returning soldiers evidenced by reports of poor conditions at Walter Reed Medical Center and problems coordinating care at local Veterans Affairs (VA) medical centers. Several initiatives are under way to address traumatic brain injury (TBI) and related conditions. Yet another common consequence of TBI, post-traumatic epilepsy (PTE), has not received adequate attention.
Epilepsy is a major long-term complication possible from TBI. PTE usually appears within a year of injury, although it may remain dormant for up to 15 years. This latent period before any symptoms develop may be partly why PTE frequently goes unrecognized and is not considered an issue of critical importance.
The risk for developing PTE varies depending on the TBI type. Past studies from the Vietnam War showed that more than 50 percent of service-related penetrating brain injuries resulted in PTE. Based on current Department of Defense statistics on U.S. vets in Iraq and Afghanistan with severe to moderate TBI, an estimated 8,000 veterans could also develop PTE.
Available VA Resources
Figure. Dr. Brien Sm...Image Tools
Does the VA system have the resources to handle the large population of returning soldiers at high risk of developing PTE or other seizure disorders? One would expect so, given its attention to the matter in the past. Indeed, the development of comprehensive epilepsy programs and monitoring units in the 1970s heralded a new era. Pivotal clinical antiepileptic drug trials, epilepsy surgery programs, and basic research arose from such centers as West Haven and West Los Angeles and benefited not only veterans but also the entire epilepsy community.
Despite the VA's initial strengths in epilepsy care, reorganization of the Veterans Health Administration in the mid-1990s into Veterans Integrated Service Networks had the unintended consequence of closure or severe curtailment of specialized epilepsy services. (They were viewed as money sinks by most Networks.)
Since the mid-1990s, comprehensive care for veterans with epilepsy has been mired in three issues: the VA's incapacity to develop a workable “transfer of payment mechanism” between networks; a complex and prohibitive set of regulations concerning reimbursement for travel for beneficiaries going out of network for specialized services; and the lack of a nation-wide referral system of graduated care. In an attempt to bring needed attention to epilepsy care in the VA, four Epilepsy Centers of Excellence were established in 2002, but this designation was honorific and without any additional financial support.
A Legislative Mandate
In August 2007, Senator Patty Murray (D-WA) and Larry Craig (R-ID) sponsored S. 2004, the VA Epilepsy Centers of Excellence Act of 2007. This legislation has three major goals: to establish six Centers to specialize in PTE care and make them part of an integrated national network; conduct research to prevent epilepsy from occurring as a result of TBI and for better seizure control and an eventual cure; and allow veterans living far from VA hospitals access to the care they need.
Interestingly, the only opposition voice in testimony at an October 2007 hearing on S. 2004 in the Senate Committee on Veterans Affairs came from the VA itself. Representatives from the Department of Veterans Affairs voiced concerns that statutory mandates for “disease-specific” centers could fragment care in what was otherwise a well-designed, world-class integrated health-care system. VA leadership felt that it was more important for the agency to disseminate the best in evidence-based practices across its health-care system than to establish centers that provide care for a particular disease.
One revealing example was the TBI independent study released by the VA in January 2004, designed to improve recognition and treatment of TBI-related health problems. Seizures and epilepsy were limited to a half page of discussion in a 168-page document. The information was extracted from www.emedicine.com, and was listed as a common medical complication during the acute rehabilitation period.
The authors, none of whom included a clinical neurologist, did not consider PTE as a chronic sequela of TBI and did not mention an epileptologist as a possible needed referral. Even more worrisome is that a Jan. 25 Department of Defense report determined that less than half of returning service members processed for either physical or mental health concerns were referred to VA facilities.
Last May, Dr. John Booss, former national director of neurology for the VA, testified before the Senate Committee on Veterans Affairs that the VA lacks a national program for epilepsy with clear guidelines on when to refer patients for further assessment and treatment. By contrast, VA Centers of Excellence have been the model of innovation in the delivery of highly specialized health care and research for other disabling diseases such as Parkinson disease and multiple sclerosis.
The diagnosis and management of PTE is a challenging process because of concomitant neurological and psychiatric comorbidities, which tend to overshadow its initial manifestations and long-term ramifications. Epileptic seizures may manifest as subtle simple partial or complex partial seizures. VA physicians need to be able to distinguish between epileptic and non-epileptic seizures such as those resulting from PTSD. The VA Epilepsy Centers of Excellence in combination with TBI Centers will serve as an ideal arena to bridge the gap among neurologists, psychiatrists, and physiatrists in managing these complex cases.
The VA Epilepsy Centers of Excellence Act (S.2004) was approved by the Committee on Veterans Affair on Dec. 12, 2007, and will likely be brought to the Senate floor for a vote this spring. The House companion bill, H.R. 2818, introduced by Representatives Ed Perlmutter (D-CO) and Doug Lamborn (R-CO), is scheduled for a hearing in April. Please join in asking Congress to support our veterans by co-sponsoring H.R. 2818 and S. 2004.