Reduced Time to Treatment After Implementation of a Standardized Guideline for the Diagnostic Evaluation and Acute Management of Suspected Autoimmune Encephalitis in Hospitalized Adult Patients
Giovanna Manzano1, Samuel Steuart3, Prashanth Rajarajan4, Bruna Leles Vieira De Souza2, Rachel Rodin5, Leigh Rettenmaier6, Caleb McEntire7, Ahmad Mashlah5, Philippe-Antoine Bilodeau8, Leah Wibecan1, Jenny Linnoila9
1Neurology, Massachusetts General Hospital/ Harvard Medical School, 2Massachusetts General Hospital/ Harvard Medical School, 3Harvard Medical School, 4Brigham and Women's Hospital, 5Massachusetts General Brigham, 6University of Pennsylvania, 7MGH-Brigham Neurology, 8Massachusetts General Hospital, 9University Neurology Associates, UPMC
Objective:
To assess the impact of institutional guidelines directing the approach to the diagnosis and acute management of autoimmune encephalitis (AE) in hospitalized adults.
Background:
AE is a neuroimmunologic condition manifesting as subacute neuropsychiatric decline, often accompanied by seizures, movement disorders, and/or dysautonomia. Its heterogenous phenotypic spectrum poses diagnostic challenges. Prompt recognition and timely treatment initiation are associated with improved outcomes. Lack of expertise may lead to unnecessary or duplicative high-cost testing, delays in diagnosis and management, and/or misdiagnoses. Implementation of institutional guidelines may improve appropriate testing and optimize care delivery.
Design/Methods:
Suspected AE cases in hospitalized adults were identified retrospectively by whether a serum autoimmune encephalopathy panel was ordered 7 months prior to and 7 months following the guideline implementation in July 2021. Defined demographic and outcome variables were compared between pre- and post-implementation cohorts. Time to treatment start was defined by duration from hospital admission to receipt of empiric first-line treatment (e.g., methylprednisolone or intravenous IgG).
Results:
269 unique cases met inclusion criteria for the entire study period [median age 66 years pre- and 60 years post-implementation]. Case characteristics including median mRS at evaluation, frequency of encephalopathy, psychiatric features, epileptic seizures, ICU level of care and associated malignancies, were comparable between the cohorts. A clinical diagnosis of AE (autoantibody-positive or negative) was confirmed in 10 (6.8%) pre-implementation cases and in 10 (8.3%) post-implementation cases (p=0.64). Average time to treatment was reduced from 13.3 days (SD 21.0) pre-implementation cohort to 6.1 days (SD 7.3) post-implementation (AFT p=0.025).
Conclusions:
Institutional guidelines outlining the diagnostic evaluation and acute management of AE positive impacted care. Although a majority in each cohort did not ultimately have a confirmed AE diagnosis, thus warranting ongoing educational initiatives and encouragement of guideline utilization, a slight improvement in diagnostic accuracy was found.
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