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Identification of epilepsy patients from administrative data in large managed healthcare organizations is a challenging task. The objectives of this report are to describe the implementation of an established algorithm and different modifications for the estimation of epilepsy prevalence in the Veterans Health Administration (VHA). For the prevalence estimation during a given time period patients prescribed anti-epileptic drugs and having seizure diagnoses on clinical encounters were identified. In contrast to the established algorithm, which required inclusion of diagnoses data from the time period of interest only, variants were tested by considering diagnoses data beyond prevalence period for improving sensitivity. One variant excluded data from diagnostic EEG and LTM clinics to improve specificity. Another modification also required documentation of seizures on the problem list (electronic list of patients’ established diagnoses). Of the variants tested, the one excluding information from diagnostic clinics and extending time beyond base period of interest for clinical encounters was determined to be superior. It can be inferred that the number of patients receiving care for epilepsy in the VHA ranges between 74,000 and 87,000. In the wake of the recent implementation of ICD-10 codes in the VHA, minor tweaks are needed for future prevalence estimation due to significant efforts presented. This review is not only beneficial for researchers interested in VHA related data but can also be helpful for managed healthcare organizations involved in epilepsy care aiming at accurate identification of patients from large administrative databases.

INTRODUCTION Epilepsy, a medical condition characterized by recurrent seizures, is the fourth most common neurological disorder in the United States. Veterans are at a higher risk of developing seizures than the general public, in part due to the increased rate of traumatic brain injuries (TBIs) experienced during combat and while in service [1-5]. In response to concerns of increased posttraumatic epilepsy among returning servicemembers from current conflicts, the U.S. Congress passed the Veterans' Mental Health and Other Care Improvements Act of 2008, mandating the establishment of the Veterans Health Administration (VHA) Epilepsy Centers of Excellence (ECoE). The ECoE are expected to leverage technology, enhance affiliation, expand research opportunities, and improve access for specialized quality care for cost-intensive epilepsy services. A recent Institute of Medicine (IOM) report, "Epilepsy across the spectrum: Promoting health and understanding," emphasized improving surveillance and early identification so that disease management programs can efficiently utilize resources, standardize practice patterns, and improve prevention and intervention outcomes [6]. This report also echoed recommendations by the International League Against Epilepsy that actions are needed to improve reporting on key attributes of epilepsy, including prevalence, incidence, and comorbidities in addition to other factors [7]. The VHA is the United States' largest integrated health system that serves a distinct patient population [8]. In order to maximize and centralize VHA ECoE resources, understanding the population of Veterans who will be referred for treatment of seizures is important. It is noteworthy that not all Veterans suspected of having seizures actually have epilepsy. For example, comorbid mild TBI, which is the majority of TBI, and posttraumatic stress disorder (PTSD) are associated with psychogenic nonepileptic seizures (PNES) [9-10]. Thus, patients' treatment should be appropriately individualized to address their needs. Understanding the frequency and demographics of Veterans treated for seizures could lead to better distribution of resources and to better care of Veterans. Currently, the VHA population mostly consists of Veterans of older wars. In the wake of the more recent Iraq and Afghanistan conflicts (Operation Iraqi Freedom [OIF]/Operation Enduring Freedom [OEF]/ Operation New Dawn [OND]) and multiple deployments of military personnel, monitoring of returning Veterans becomes imperative. A systemic review on complications of mild TBI estimated that 12 to 23 percent of service-members returning from OIF/OEF/OND experienced a TBI in deployment [11]. A congressional study found that among OIF/OEF patients treated by the VHA from 2004 through 2009, 21 percent were diagnosed with PTSD [12]. Among OIF/OEF/OND Veterans who used the VHA from October 01, 2001, to September 30, 2012, approximately 28.9 percent had a diagnosis of PTSD [13]. As the members of this subcohort of Veterans separate from Active Duty, their use of VHA resources is expected to increase. While prevalence and incidence estimates of epilepsy for fiscal year (FY)05-FY06 for geriatric and FY08-FY09 for OIF/OEF populations were published in the 2012 IOM report [6], to date, similar estimates are not available for general VHA patients. This article is the result of an initiative of the ECoE to determine the demographic profile of patients diagnosed with seizures and treated with antiepileptic drugs (AEDs) in the VHA for monitoring purposes. Results are important for data-driven decisions for distribution of resources. In this article, we review data on the prevalence and incidence of seizure diagnoses among Veterans being treated with AEDs in the VHA during FY11 (October 01, 2010-September 30, 2011). Estimates of sex, age, and comorbid diseases, including TBI and PTSD, are provided. Analyses of OIF/OEF/OND Veterans with seizures as a subgroup are also presented. …

Biofeedback therapy is a valuable modality in children with dysfunctional voiding. However, it is unclear what factors contribute to the outcome. To define who may or may not benefit from biofeedback therapy we reviewed our experience with this treatment.We retrospectively reviewed the charts of 77 children referred between July 2005 and September 2008 for biofeedback therapy. An MR 20 Synergy trainer (Prometheus Group, Dover, New Hampshire) provided nonanimated and animated biofeedback. Uroflowmetry was performed at the start and end of each session. A total of 67 females and 10 males with a mean age of 9.0 years (range 4.8 to 18.2) comprised the cohort group. The primary referral diagnosis was nonfebrile urinary tract infection in 52 patients (67.5%), daytime and nighttime wetting in 47 (61%), voiding postponement in 14 (18.2%) and daytime incontinence in 10 (13%). Children were categorized by an outcome of success, improvement or failure. Results were analyzed using the chi-square, Fisher exact probability and Student t tests.Success, improvement and failure were achieved in 22 (26.8%), 29 (37.7%) and 26 cases (33.7%), respectively. Age and gender were not statistically significant predictors of outcome. A median of 3.0 sessions (range 1 to 8) was administered. Children with 3 or greater sessions were more likely to succeed (p0.005). The improvement in urinary tract infections was statistically significant (p0.001). Of 37 children 20 (54%) transformed a staccato voiding pattern to a normal one on uroflowmetry.Biofeedback therapy can be effective in children with dysfunctional voiding and urinary tract infection. Children with a staccato voiding pattern may require a minimum of 3 visits to improve the voiding pattern. Children who complete 3 sessions are more likely to succeed.