By Robert McInnis, MD
Synopsis: This retrospective study found telemedicine (TM) visits to be noninferior to in-person (IP) visits for key outpatient epilepsy care outcomes, including medication adjustment, surgery discussions, and avoiding emergency visits. TM was less effective for assessing the neurologic exam, and seizure freedom rates were inconclusive with respect to noninferiority. Although not a full replacement for IP care, TM remains an effective option since its future in healthcare delivery is being reassessed in the wake of the COVID-19 pandemic.
Source: Yardi R, McLouth CJ, Roman Guzman AM, et al. Unlocking the potential of telemedicine in epilepsy: Noninferiority analysis of efficacy and identifying patient preferences. Neurol Clin Pract. 2025;15(2):e200459.
Epilepsy is a common disorder for which timely diagnosis and treatment can improve quality of life and reduce seizure-related morbidity. Many people with epilepsy (PWE) face barriers to accessing neurologic care for several reasons, of which restrictions in driving privileges are an important example. The expansion of telemedicine (TM) during the COVID-19 pandemic was an unprecedented change in the delivery of medical care, with great potential to improve access for PWE. Although TM use has persisted beyond the pandemic, its long-term support by hospitals and payors remains uncertain, and its effectiveness compared to in-person (IP) visits for PWE is understudied.
Yardi and colleagues sought to address this knowledge gap by performing a noninferiority analysis comparing TM to IP visits through retrospective chart review at the University of Kentucky adult epilepsy clinic from July 2021 through September 2022. Patients could choose a video (TM) or IP visit; out-of-state patients were excluded because of licensing constraints. Data collected included demographic characteristics, insurance type (federal vs. private), relationship status, distance from the clinic, and mean annual income (both extrapolated using patient ZIP codes). Visit variables were tracked including the type (IP vs. TM), date, and time. Clinical characteristics, including visit diagnosis, seizure frequency, history of seizure generalization, type of epilepsy, and presence of medical refractoriness, were tracked.
The primary outcome of the study focused on epilepsy care quality measures (whether visits involved adjustment of anti-seizure medications [ASMs], identifying abnormal findings on a neurologic exam, discussion of epilepsy surgery) associated with post-visit seizure freedom or post-visit emergency department (ED) visits for seizures. The IP vs. TM groups were compared and the degree of difference was quantified with a standardized difference metric (> 0.1 was considered meaningful). Confounding was addressed using stabilized inverse probability of treatment weights (IPTW), calculated from the propensity scores predicting selection of TM.
The probability of selecting a TM appointment was calculated with a statistical model that imputed the demographic, insurance, geographic, and clinical information as covariates. Noninferiority analyses comparing visit type with respect to primary outcomes were performed after removing the measured confounders through IPTW, setting a noninferiority margin of 0.1. Confidence intervals (CIs) of proportional differences were plotted, with CIs excluding the noninferiority margin but containing the null (0) considered noninferior.
A total of 590 encounters from 370 unique patients were identified. Fifty of these patients completed a mix of IP and TM visits, prompting exclusion. Additional exclusions for missing data yielded an analytic sample composed of 303 patients (442 visits); 37% of patients selected IP, while 62% selected TM visits. TM users were significantly younger (mean age 32 vs. 40 years), more likely to be in a relationship or married (34.4% vs. 22.8%), lived farther away from the clinic (44.9 vs. 36.3 miles), and had fewer prior missed appointments (7.9% vs. 19.3%). These same factors were identified as significant predictors of a TM visit after adjusting for all other variables in the statistical model.
After adjustment, TM vs. IP visits did not differ significantly in rates of ASM adjustment, discussion of epilepsy surgery, post-visit seizure freedom, and post-visit ED visits for seizures. TM visits were significantly less likely to identify an abnormal neurologic exam than IP visits. TM visits were found to be noninferior to IP for ASM adjustment, discussion of epilepsy surgery, and post-visit ED visits for breakthrough seizures. Comparisons between TM and IP were inconclusive (neither inferior nor noninferior) with respect to finding neurologic exam abnormalities and post-visit seizure freedom rates (CIs overlapped with the null and the noninferiority margin).
Commentary
This retrospective study sought to assess the effectiveness of TM compared to IP visits for people with epilepsy through a noninferiority analysis focusing on important outpatient quality standards. Adjusting for confounders, TM was found noninferior in rates of ASM adjustment, in epilepsy surgery discussions, and in after-visit ED presentations for breakthrough seizures. Unsurprising for clinicians using TM for PWE, these findings reinforce its clinical and potential cost-effectiveness at a time when hospitals and payors are reconsidering its place in healthcare delivery.
The findings suggest that TM may be less suitable for identifying abnormalities on neurologic exam, confirming an aspect of TM most clinicians already are aware of, although not detracting from the overall utility of TM in achieving most practical outpatient goals for PWE. The noninferiority analysis was inconclusive regarding TM compared to IP visits in rates of inter-visit seizure freedom, suggesting a trend toward more seizures in TM users. The specific types of seizures contributing to this trend remain unclear and warrant future investigation. That ED visits did not differ between groups offers some reassurance and highlights TM’s economic value.
Study limitations suggest areas for future research. Conducted at a single center in Kentucky, the findings may not generalize to more urban or diverse populations. Additionally, the study period overlapped with the COVID-19 pandemic, during which institutional policies and patient behavior were atypical. Reassessment in the post-pandemic era could yield additional insights.
Overall, this study supports TM as a practical, effective tool for outpatient epilepsy care. As the healthcare system evolves, evidence like this is critical for guiding optimal integration of TM into long-term care models.
Robert McInnis, MD, is Assistant Professor of Clinical Neurology, Weill Cornell Medical College.
This retrospective study found telemedicine (TM) visits to be noninferior to in-person (IP) visits for key outpatient epilepsy care outcomes, including medication adjustment, surgery discussions, and avoiding emergency visits. TM was less effective for assessing the neurologic exam, and seizure freedom rates were inconclusive with respect to noninferiority. Although not a full replacement for IP care, TM remains an effective option since its future in healthcare delivery is being reassessed in the wake of the COVID-19 pandemic.
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