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June 16, 2020; 94 (24) Article

Socioeconomic disparities in SUDEP in the US

View ORCID ProfileEsma Cihan, View ORCID ProfileDale C. Hesdorffer, Michael Brandsoy, Ling Li, David R. Fowler, Jason K. Graham, Michael Karlovich, Elizabeth J. Donner, Orrin Devinsky, View ORCID ProfileDaniel Friedman
First published April 23, 2020, DOI: https://doi.org/10.1212/WNL.0000000000009463
Esma Cihan
From the Department of Neurology (E.C., M.K., O.D., D.F.), NYU School of Medicine; Department of Epidemiology (D.C.H.), Columbia University Medical Center, New York, NY; San Diego County Medical Examiner’s Office (M.B.), CA; Maryland Office of the Chief Medical Examiner (L.L., D.R.F.), Baltimore; New York City Office of Chief Medical Examiner (J.K.G.), NY; and Department of Paediatrics (E.J.D.), Division of Neurology, The Hospital for Sick Children, Toronto, Ontario, Canada.
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Dale C. Hesdorffer
From the Department of Neurology (E.C., M.K., O.D., D.F.), NYU School of Medicine; Department of Epidemiology (D.C.H.), Columbia University Medical Center, New York, NY; San Diego County Medical Examiner’s Office (M.B.), CA; Maryland Office of the Chief Medical Examiner (L.L., D.R.F.), Baltimore; New York City Office of Chief Medical Examiner (J.K.G.), NY; and Department of Paediatrics (E.J.D.), Division of Neurology, The Hospital for Sick Children, Toronto, Ontario, Canada.
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Michael Brandsoy
From the Department of Neurology (E.C., M.K., O.D., D.F.), NYU School of Medicine; Department of Epidemiology (D.C.H.), Columbia University Medical Center, New York, NY; San Diego County Medical Examiner’s Office (M.B.), CA; Maryland Office of the Chief Medical Examiner (L.L., D.R.F.), Baltimore; New York City Office of Chief Medical Examiner (J.K.G.), NY; and Department of Paediatrics (E.J.D.), Division of Neurology, The Hospital for Sick Children, Toronto, Ontario, Canada.
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Ling Li
From the Department of Neurology (E.C., M.K., O.D., D.F.), NYU School of Medicine; Department of Epidemiology (D.C.H.), Columbia University Medical Center, New York, NY; San Diego County Medical Examiner’s Office (M.B.), CA; Maryland Office of the Chief Medical Examiner (L.L., D.R.F.), Baltimore; New York City Office of Chief Medical Examiner (J.K.G.), NY; and Department of Paediatrics (E.J.D.), Division of Neurology, The Hospital for Sick Children, Toronto, Ontario, Canada.
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David R. Fowler
From the Department of Neurology (E.C., M.K., O.D., D.F.), NYU School of Medicine; Department of Epidemiology (D.C.H.), Columbia University Medical Center, New York, NY; San Diego County Medical Examiner’s Office (M.B.), CA; Maryland Office of the Chief Medical Examiner (L.L., D.R.F.), Baltimore; New York City Office of Chief Medical Examiner (J.K.G.), NY; and Department of Paediatrics (E.J.D.), Division of Neurology, The Hospital for Sick Children, Toronto, Ontario, Canada.
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Jason K. Graham
From the Department of Neurology (E.C., M.K., O.D., D.F.), NYU School of Medicine; Department of Epidemiology (D.C.H.), Columbia University Medical Center, New York, NY; San Diego County Medical Examiner’s Office (M.B.), CA; Maryland Office of the Chief Medical Examiner (L.L., D.R.F.), Baltimore; New York City Office of Chief Medical Examiner (J.K.G.), NY; and Department of Paediatrics (E.J.D.), Division of Neurology, The Hospital for Sick Children, Toronto, Ontario, Canada.
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Michael Karlovich
From the Department of Neurology (E.C., M.K., O.D., D.F.), NYU School of Medicine; Department of Epidemiology (D.C.H.), Columbia University Medical Center, New York, NY; San Diego County Medical Examiner’s Office (M.B.), CA; Maryland Office of the Chief Medical Examiner (L.L., D.R.F.), Baltimore; New York City Office of Chief Medical Examiner (J.K.G.), NY; and Department of Paediatrics (E.J.D.), Division of Neurology, The Hospital for Sick Children, Toronto, Ontario, Canada.
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Elizabeth J. Donner
From the Department of Neurology (E.C., M.K., O.D., D.F.), NYU School of Medicine; Department of Epidemiology (D.C.H.), Columbia University Medical Center, New York, NY; San Diego County Medical Examiner’s Office (M.B.), CA; Maryland Office of the Chief Medical Examiner (L.L., D.R.F.), Baltimore; New York City Office of Chief Medical Examiner (J.K.G.), NY; and Department of Paediatrics (E.J.D.), Division of Neurology, The Hospital for Sick Children, Toronto, Ontario, Canada.
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Orrin Devinsky
From the Department of Neurology (E.C., M.K., O.D., D.F.), NYU School of Medicine; Department of Epidemiology (D.C.H.), Columbia University Medical Center, New York, NY; San Diego County Medical Examiner’s Office (M.B.), CA; Maryland Office of the Chief Medical Examiner (L.L., D.R.F.), Baltimore; New York City Office of Chief Medical Examiner (J.K.G.), NY; and Department of Paediatrics (E.J.D.), Division of Neurology, The Hospital for Sick Children, Toronto, Ontario, Canada.
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Daniel Friedman
From the Department of Neurology (E.C., M.K., O.D., D.F.), NYU School of Medicine; Department of Epidemiology (D.C.H.), Columbia University Medical Center, New York, NY; San Diego County Medical Examiner’s Office (M.B.), CA; Maryland Office of the Chief Medical Examiner (L.L., D.R.F.), Baltimore; New York City Office of Chief Medical Examiner (J.K.G.), NY; and Department of Paediatrics (E.J.D.), Division of Neurology, The Hospital for Sick Children, Toronto, Ontario, Canada.
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Socioeconomic disparities in SUDEP in the US
Esma Cihan, Dale C. Hesdorffer, Michael Brandsoy, Ling Li, David R. Fowler, Jason K. Graham, Michael Karlovich, Elizabeth J. Donner, Orrin Devinsky, Daniel Friedman
Neurology Jun 2020, 94 (24) e2555-e2566; DOI: 10.1212/WNL.0000000000009463

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Abstract

Objective To determine the impact of socioeconomic status (SES) on sudden unexpected death in epilepsy (SUDEP) rates.

Methods We queried all decedents presented for medico-legal investigation at 3 medical examiner (ME) offices across the country (New York City, Maryland, San Diego County) in 2009 to 2010 and 2014 to 2015. We identified all decedents for whom epilepsy/seizure was listed as cause/contributor to death or comorbid condition on the death certificate. We then reviewed all available reports. Decedents determined to have SUDEP were included for analysis. We used median income in the ZIP code of residence as a surrogate for SES. For each region, zip code regions were ranked by median household income and divided into quartiles based on total population for 2 time periods. Region-, age-, and income-adjusted epilepsy prevalence was estimated in each zip code. SUDEP rates in the highest and lowest SES quartiles were evaluated to determine disparity. Examined SUDEP rates in 2 time periods were also compared.

Results There were 159 and 43 SUDEP cases in the lowest and highest SES quartiles. ME-investigated SUDEP rate ratio between the lowest and highest SES quartiles was 2.6 (95% confidence interval [CI] 1.7–4.1, p < 0.0001) in 2009 to 2010 and 3.3 (95% CI 1.9–6.0, p < 0.0001) in 2014 to 2015. There was a significant decline in overall SUDEP rate between the 2 study periods (36% decrease, 95% CI 22%–48%, p < 0.0001).

Conclusion ME-investigated SUDEP incidence was significantly higher in people with the lowest SES compared to the highest SES. The difference persisted over a 5-year period despite decreased overall SUDEP rates.

Glossary

ASD=
antiseizure drug;
BMI=
body mass index;
CDC=
Centers for Disease Control and Prevention;
CI=
confidence interval;
IRR=
incident rate ratio;
MD=
Maryland;
ME=
medical examiner;
NYC=
medical examiner;
PWE=
people with epilepsy;
RR=
rate ratio;
SDC=
San Diego County;
SES=
socioeconomic status;
SUDEP=
sudden unexpected death in epilepsy

Footnotes

  • Go to Neurology.org/N for full disclosures. Funding information and disclosures deemed relevant by the authors, if any, are provided at the end of the article.

  • Received April 9, 2019.
  • Accepted in final form December 5, 2019.
  • © 2020 American Academy of Neurology
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