Disparities in injury death location for people with epilepsy/seizures Stephen M. Bowman * , Mary E. Aitken, Gregory B. Sharp Department of Pediatrics, University of Arkansas for Medical Sciences, Little Rock, AR, USA article info Article history: Received 12 November 2009 Revised 7 December 2009 Accepted 14 December 2009 Available online 6 January 2010 Keywords: Injury Epilepsy Seizures Disparities Location of death Drowning abstract Objective: Wide variation has been reported in the proportion of injury deaths occurring during the pre- hospital phase. Potential disparities in where injured people with epilepsy and seizure disorders die have not been examined. We compared location of death between injured patients with epilepsy and seizure disorders and similar patients without epilepsy/seizures and tested the hypothesis that injured people with epilepsy/seizures are more likely to die outside of a hospital or health care setting. Methods: U.S. vital statistics (mortality) data from the multiple cause of death files of the National Center for Health Statistics were analyzed. Patients less than 65 years of age at death who had injury as the underlying cause of death were included. Multinomial logistic regression was used to assess location of death, controlling for patient and injury characteristics. Results: Controlling for potential confounders, people with epilepsy/seizures were more likely to die at home from unintentional injuries (relative risk ratio [RRR] = 1.51, P < 0.001) and less likely to die in public places (RRR = 0.27, P < 0.001). People with epilepsy/seizures were less likely to die at home or in public places from suicide, but significantly more likely to die at home from homicide (RRR = 2.29, P < 0.001). By mechanism of injury, people with epilepsy/seizures were more likely to die at home from drowning (RRR = 2.35, P < 0.001). Discussion: Disparities in where injured people with epilepsy/seizures die deserve further attention. Identi- fying the underlying causes of these disparities will allow for the development of targeted prevention interventions. Ó 2009 Elsevier Inc. All rights reserved. 1. Introduction Wide variation has been reported in the proportion of injury deaths occurring in the prehospital phase of care, ranging from as low as 34% of deaths in an urban setting to as high as 85% in one rural study [1–5]. Estimates of the potential preventability of prehospital injury deaths range from as low as a few percent of deaths to nearly half of deaths [6–9]. Although many prehospital injury deaths are deemed unsurvivable because of the extent of central nervous system (CNS) injury, some CNS-associated deaths and other non-CNS deaths are potentially survivable, with prevent- able causes including hemorrhage and lack of airway [10,11]. Most of these studies have focused on single cities or counties, without particular focus on special populations. People with epilepsy/seizures are estimated to have a two to three times greater risk of death from any cause compared with peo- ple without epilepsy/seizures [12]. In a Swedish study of patients previously hospitalized for epilepsy/seizure, Nilsson compared actual and expected deaths (based on general population norms) and reported that people with epilepsy/seizures have excess mortal- ity, including injury-caused mortality, with a standardized mortality ratio of 5.6 [13]. In contrast, a recent study of medical examiner cases in Manitoba, Canada, reported no increased risk of accidental death among people with epilepsy/seizures, with the exception of drown- ing deaths [14]. Little is known about disparities in injury mortality for people with epilepsy/seizures and whether differences exist in the place of injury death (i.e., death occurring in the prehospital phase vs death occurring after reaching a hospital). The identifica- tion of disparities in location of injury death is an important first step in understanding potential contributing factors such as access to emergency medical services, potential discrimination and/or bias among health care professionals, and prehospital medical control protocols and practices. We sought to identify variation in place of death for injured people with epilepsy/seizures (prehospital death vs hospital death) and to test the hypothesis that injured people with epilepsy/sei- zures are more likely to die in prehospital settings than are people without epilepsy/seizures. 2. Methods We used 1999–2005 mortality data from the multiple cause of death files from the National Vital Statistics System. These data in- clude all deaths occurring within the United States. Deaths of U.S. 1525-5050/$ - see front matter Ó 2009 Elsevier Inc. All rights reserved. doi:10.1016/j.yebeh.2009.12.011 * Corresponding author. Address: Department of Pediatrics, CARE/Peds Slot 512- 26, Arkansas Children’s Hospital, 1 Children’s Way, Little Rock, AR 72202-3591, USA. Fax: +1 501 364 1552. E-mail address: bowmanstephenm@uams.edu (S.M. Bowman). Epilepsy & Behavior 17 (2010) 369–372 Contents lists available at ScienceDirect Epilepsy & Behavior journal homepage: www.elsevier.com/locate/yebeh