Background: Children with pharmacoresistant epilepsy usually receive ketogenic diet (KD) as an inpatient, which makes it an expensive treatment. Objective: To compare the effectiveness, safety, and costs of outpatient versus inpatient initiated KD. Design: Retrospective observational non-inferiority study. Patients/setting: Patients (1–18 years of age) who started KD either inpatient or outpatient. Main outcome measures: Effectiveness was defined as ≥50% seizure reduction. Safety was measured by the numbers of emergency visits and complications. Economic impact was analyzed by calculating total costs of treatment. Statistical analyses: Non-inferiority of outpatient initiation was tested using 95% confidence intervals of the differences in effectiveness and safety endpoints between groups with non-inferiority margins of 10%. Nonparametric bootstrap techniques were used to derive a 95% confidence interval for the mean difference in total costs between the groups. Results: Hundred and five patients started KD in the period 2001 to 2017: 43 inpatient and 62 outpatient. At three months, the KD was effective in 61% of outpatients versus 63% of inpatients. The KD was considered safe in 36% of the outpatients, as compared to 29% in the inpatients. Outpatient initiation was shown to be non-inferior to inpatient initiation in terms of safety. Total health care costs of outpatient initiation were € 2901, as compared to € 8195 of inpatient initiation per patient (mean difference € 5294, 95% CI; -€ 7653 to -€ 2935). Conclusions: Our study suggests that outpatient KD initiation is no worse than inpatient initiation in terms of effectiveness and safety, while carrying lower health care costs.

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Keywords Costs, Ketogenic diet, Refractory epilepsy, Seizure reduction, Side effects
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Journal European Journal of Paediatric Neurology
van der Louw, E.J.T.M, Olieman, J.F, Poley, M.J, Wesstein, T. (Tessa), Vehmeijer, F.O.L, Catsman-Berrevoets, C.E, & Neuteboom, R.F. (2019). Outpatient initiation of the ketogenic diet in children with pharmacoresistant epilepsy: An effectiveness, safety and economic perspective. European Journal of Paediatric Neurology. doi:10.1016/j.ejpn.2019.06.001