Epilepsy services in Ireland: 'A survey of people with epilepsy in relation to satisfaction, preferences and information provision'

Patients' knowledge about epilepsy-related risks, morbidity, and mortality: A multicenter cohort study from Germany

INTRODUCTION

Patient education is a central component of quality care. Enhancing patient knowledge can improve patients' quality of life and facilitate successful self-management. We sought to identify patients' knowledge levels and knowledge gaps regarding epilepsy-related risks, morbidity, and mortality.

METHODS

Adult patients with epilepsy presenting to the university hospitals in Frankfurt, Greifswald, and Marburg between February 2018 and May 2020 were asked to participate in this questionnaire-based study.

RESULTS

A total of 238 patients (52% women), with a mean age of 39.2 years (range: 18-77 years), participated in this study. Spontaneously, the majority of patients (51.3%) named driving a car, and other traffic-related accidents as possible causes of morbidity and mortality, and 23.9% of patients reported various causes of premature death, such as suffocation, drowning, and respiratory or cardiac arrest due to seizures. Falls due to epilepsy (19.7%) and injuries in general (17.6%) were named as further causes of morbidity and mortality. The vast majority were aware that alcohol (87.4%), sleep deprivation (86.6%), and risky activities in daily life (80.3%) increased the risk of seizure occurrence or increased morbidity and mortality. Regarding overall mortality, 52.1% thought that people with epilepsy were at greater risk of premature death, whereas 46.2% denied this fact to be true. Only 29.4% were aware of status epilepticus, and 27.3% were aware of sudden unexpected death in epilepsy (SUDEP). Driving ability, working ability, and seizure risk were named as major or moderate concerns among patients, but the risk of premature mortality was not a major concern. One-quarter of all patients (26.9%) indicated that they were not counseled about any risk factors or causes of morbidity or mortality by their physicians.

CONCLUSIONS

A lack of knowledge concerning premature mortality, SUDEP, and status epilepticus exists among adult patients with epilepsy. A substantial number of patients indicated that these issues were not discussed adequately by their physicians.

Exploring user empowerment and service improvement within an Irish epilepsy service using Checkland's 'Soft Systems' approach

AIM

To illustrate the value of Checkland's 'Soft Systems' approach to explore and analyse the interaction of human and organisational factors that affect service delivery and patient experience in one specialist epilepsy service.

BACKGROUND

Checkland's approach is underutilized in relation to health service improvement. One epilepsy service in Ireland is used as an example to illustrate the value of his approach to improve service delivery, particularly when what needs to change is not clear.

METHOD

Checkland's 'Soft Systems' seven-stage approach was used collaboratively to explore patients' and clinicians' experience of service delivery and how to improve it.

RESULTS

The research identified the practice of empowerment affected the quality of the service experience. Checkland's concept of a human activity system was particularly pertinent in identifying this issue and providing a 'map' for change.

CONCLUSION

Wider inferences for the use of Checkland's approach by nurse managers are discussed, as is the value of using Checkland's approach to improve services.

IMPLICATIONS FOR NURSING MANAGEMENT

Checkland's 'Soft Systems' is an underutilized approach in health care that could be used by managers to initiate and embed change within a health care service.

Exploring Dimensions of Empowerment from the Patients' Perspective in One Specialist Epilepsy Service in Ireland

Empowerment is integral to patient-centered practice, particularly as this relates to people with chronic conditions, though operationally it is poorly understood in this context. Empowerment, therefore, as experienced by patients with a chronic condition needs exploration. This article reports the experience of empowerment by patients in one specialist epilepsy service in Ireland as an exemplar of broader issues affecting empowerment of patients with chronic conditions. A Frameworks Approach was used to analyze in-depth interviews with patients (n = 10) in one Irish epilepsy service. Analysis was further informed by nonparticipatory observation of service delivery. Results indicate that patients' negative experiences of empowerment appear to be derived from traditional social norms relating to clinician patient power dimensions and social stigma internalized by clinicians at an unconscious level. With this in mind, educational approaches based upon critical social theory may provide a framework and guide to enable services to engage with these issues and embrace empowerment of patients with chronic conditions within therapeutic engagement.

Epilepsy monitoring units in Saudi Arabia: Where do we stand compared to developed countries?

Objectives:

To descriptively assess Epilepsy Monitoring Units (EMUs) and the provided services in Saudi Arabia and compare them based on the geographic region.

Methods:

In this cross-sectional study, an electronic questionnaire was emailed to all directors of EMUs in Saudi Arabia from July 2013 to January 2016, with constant updates being made by all respondents throughout the period of data collection.

Results:

All EMU directors participated. There were 11 EMUs in KSA operating in 8 hospitals; 8 (54.5%) EMUs in Riyadh, 2 (18.2%) in Dammam, 2 (18.2%) in Makkah and 1 (9.1%) in Jeddah. Five (54.5%) EMUs were shared for adults and pediatrics, 3 (27.3%) were devoted to adult patients, and 3 (27.3%) to pediatric patients. The average waiting time was 11 weeks (range: 2-52 weeks). The mean percentage of patients coming from an outside region was 30.6%. The average length of stay was 7 days. Less than 100 patients were monitored annually in 54.5% of the EMUs. Seven EMUs (63.6%) admitted less than 100 patients for seizure characterization. Intracranial monitoring was available in all EMUs. Most EMUs (54.5%) admitted less than 100 patients for pre-surgical workup while 36.4% admitted 100-199, and 9.1% admitted more than 300 patients per year. Epilepsy surgeries were performed for less than 50 patients annually in 81.8% of the hospitals.

Conclusion:

There are 11 EMUs in Saudi Arabia fully equipped to serve epileptic patients. However, they are underutilized considering the number of admitted patient and the number of epilepsy surgeries per year. Also, they are unequally distributed throughout the kingdom.

Rising to the challenge: Epilepsy specialist nurses as leaders of service improvements and change (SENsE study)

PURPOSE

To report the leadership role and change activities of epilepsy specialist nurses (ESNs) in Ireland; findings from the SENsE study.

METHOD

A mixed methods study design was used, involving 12 epilepsy specialist nurses working in five units in Ireland, 24multidisciplinary team members working with them, and 35 people with epilepsy and their family members. Data were collected using individual and focus group interviews, observation and documentary analysis.

RESULTS

Five key areas in which ESNs demonstrated leading on the change agenda were identified. These included: Initiating new clinical practice developments; Building capability within the multidisciplinary team; Developing education programmes and resources for people with epilepsy, family and the public; Exerting influence through membership of committees and lobbying; and Advancing the ESN role.

CONCLUSION

Though the epilepsy specialist nurse role was first established in the UK in 1988, much of the literature that discusses or describes the ESN role is founded on anecdotal evidence, or focusses on their clinical expertise. Findings from this study provide empirical evidence that the ESNs were involved as key players in leading changes within the services, in the education of others, and the continuous advancement of epilepsy care.

Neurologist-patient communication about epilepsy in the United States, Spain, and Germany

Background

Effective communication between patients and their health care providers is recognized as critically important to improve the quality of health services for individuals with epilepsy. We aimed to describe in-office neurologist-patient conversations about epilepsy and focus on disease identification, shared decision-making, and care planning.

Methods

Transcripts and audio recordings of conversations between patients and neurologists in the United States, Spain, and Germany were analyzed linguistically in the topic areas of epilepsy identification and diagnosis, disease education, treatments, and care planning. Analyses included word-level assessments, topic switching, strategies of information elicitation, identification of topics discussed, quantification of questions asked, and assessment of types of questions asked.

Results

Conversations of 17 neurologists in the United States, 12 in Spain, and 6 in Germany, with 50, 20, and 16 patients, respectively, were analyzed. Neurologists tended to utilize an event-based, patient-friendly vocabulary to refer to seizures, and in the United States, they avoided using the term "epilepsy." Regardless of who initiated the treatment discussion, the neurologists in all 3 countries were unilaterally responsible for the treatment decision and choice of medication. When describing a new medication, neurologists most often discussed potential side effects but did not review potential benefits. Neurologists rarely defined seizure control and did not ask patients what seizure control meant to them.

Conclusions

We identified opportunities related to vocabulary, decision-making, and treatment goal setting that could be targeted to improve neurologist-patient communication about epilepsy, and ultimately, the overall treatment experience and outcomes for patients.

System-Wide and Group-Specific Health Service Improvements: Cross-Sectional Survey of Outpatient Improvement Preferences and Associations with Demographic Characteristics

Efficient patient-centred quality improvement requires an understanding of the system-wide areas of dissatisfaction along with evidence to identify the programs which can be strategically targeted according to specific patient characteristics and preferences. This cross-sectional study reports the proportion of chronic disease outpatients selecting 23 patient-centred improvement initiatives. Using univariate tests and multivariable logistic regressions, this multi-site study also identifies initiatives differentially selected by outpatients according to clinical and demographic characteristics. A total of 475 outpatients participated (49% response). Commonly selected initiatives included: reducing wait-times (22.3%); convenient appointment scheduling (16.0%); and receiving up-to-date treatment information (16.0%). Within univariate tests, preferences for information and service accessibility initiatives were not significantly associated with specific subgroups. However, seven initiatives were preferred according to age, gender, diagnosis status, and chronic disease type within multivariate models. For example, neurology outpatients were more likely to select assistance to manage psychological symptoms when compared to oncology outpatients (OR: 2.89). Study findings suggest that system-wide programs to enhance information provision are strategic approaches to improve experiences across patient characteristics. Furthermore, a few initiatives can be targeted to specific groups and emphasized the importance of detailed scoping analyses and tailored implementation plans when designing patient-centred quality improvement programs.

Epilepsy services in Saudi Arabia. Quantitative assessment and identification of challenges

Objective:

To assess the epilepsy services and identify the challenges in hospitals without epilepsy monitoring units (EMUs). In addition, comparisons between governmental and private sectors, as well as between regions, are to be performed.

Methods:

A cross-sectional study conducted using an online questionnaire distributed to the secondary and tertiary hospitals without EMUs throughout the Kingdom of Saudi Arabia (KSA). The study was conducted from September 2013 to September 2015 and regular updates from all respondents were constantly made. Items in the questionnaire included the region of the institution, the number of pediatric and adult neurologists and neurosurgeons along with their subspecialties, the number of beds in the Neurology Department, whether they provide educational services and have epilepsy clinics and if they refer patients to an EMU or intend to establish one in the future.

Results:

Forty-three institutions throughout the Kingdom responded, representing a response rate of 54%. The majority of hospitals (58.1%) had no adult epileptologists. A complete lack of pediatric epileptologists was observed in 72.1% of hospitals. Around 39.5% were utilizing beds from internal medicine. Hospitals with an epilepsy clinic represented 34.9% across all regions and sectors. Hospitals with no intention of establishing an EMU represented 53.5%. Hospitals that did not refer their epileptic patients to an EMU represented 30.2%.

Conclusions:

Epilepsy services in KSA hospitals without EMUs are underdeveloped.

The social space of empowerment within epilepsy services: The map is not the terrain

Empowerment is now seen as an integral component of holistic practice and service design in healthcare, particularly as it relates to the improvement of quality of life for people with epilepsy. However, the literature suggests that empowerment is a neglected and poorly understood concept by service users and providers alike within epilepsy services. Conceptual ambiguity is a further impediment to its understanding and implementation. Bearing this in mind, a clear definition of empowerment is needed in order to realistically recognize, encourage, and prioritize empowerment as a service design philosophy. Therefore, this paper undertakes a concept analysis of empowerment with reference to epilepsy services. Results indicate that empowerment demands a transformation of consciousness and a readiness to act on this transformation in order to allow people to gain personal power and autonomy over their own life, including the self-management of their condition. With this in mind, a critical reflection on the 'micro' and 'macro' levels of power that exist within epilepsy services is warranted with reference to theoretical principles. In this context although the map is not the terrain, we argue that an educational intervention guided by critical social theory principles has the potential to encourage an understanding of empowerment and 'holds the key' to future advances for its implementation within epilepsy services.

The potential of critical social theory as an educational framework for people with epilepsy

Effective education can support people with epilepsy to develop the attributes and skills required to function as equal partners with clinical service providers, make informed decisions, and competently self-manage their healthcare. However, despite knowledge deficits, unmet information needs, and a poor sense of empowerment, the study of education for people with epilepsy is often neglected and is a poorly understood component of holistic practice within epilepsy healthcare. Historically, the only debate with regard to education and people with epilepsy has been guided either within a positivist or within a constructivist philosophy. We argue that new pedagogies are warranted, recognizing the views of people with epilepsy regarding their illness. Therefore, this paper explores the potential of an educational framework for people with epilepsy based upon critical social theory (CST). By utilizing a CST approach for education, people with epilepsy are engaged with as active 'participants'. This is a key difference that distinguishes CST from other metatheoretical frameworks. It has the potential to support people with epilepsy to acquire the skills and confidence to manage the biopsychosocial challenges associated with their condition.