Evidence-based models of care for people with epilepsy

Self-management practice of people with epilepsy in Viet Nam and associated factors

OBJECTIVES

This study aimed to determine (1) the self-management practice of people with epilepsy and (2) the associated factors, including sociodemographic and clinical variables.

METHODS

This cross-sectional descriptive study was conducted at two neurology clinics in Ho Chi Minh City from October 2022 to June 2023. We included 147 adults with epilepsy and measured their self-management practices using the Vietnamese Epilepsy Self-Management Scale (V-ESMS). Additionally, we collected data on sociodemographic, clinical, and psychosocial variables through questionnaires.

RESULTS

Results showed a moderate overall V-ESMS score (131.32 ± 16.53), with Medication management subscale scoring the highest and Information management scoring the lowest. Univariate analysis revealed educational level as the significant factor influencing self-management practices (p = 0.001), with higher education correlating with better scores across all subscales except Medication and Safety.

CONCLUSION

Individuals with epilepsy who achieved higher education levels had better self-management practices. This finding suggests that educational interventions could significantly enhance self-management practices among people with epilepsy.

Integrated Care in Epilepsy Management: A Scoping Review of the Models and Components of Health and Social Care Delivery

Introduction

Epilepsy is the most common neurological condition globally. Integrating health and social care is fundamental in epilepsy management, but the scope of progress in this area is unclear. This scoping review aimed to capture the range and type of integrated care components and models in epilepsy management.

Methods

Four databases were searched for articles published since 2010 that reported on integrated care in epilepsy. Data were extracted and synthesised into components of integrated care that had been implemented or recommended only. Models of integrated care were identified, and their components tabulated.

Results

Fifteen common and interrelated components of integrated care emerged that were aligned with four broad areas: healthcare staff and pathways (e.g., epilepsy nurses); tasks and services (e.g., care coordination); education and engagement (e.g., shared decision making); and technology for diagnosis and communication (e.g., telehealth). Twelve models of integrated care were identified; seven were implemented and five were recommended.

Discussion

There is a growing evidence-base supporting integrated, person-centred epilepsy care, but implementation is challenged by entrenched silos, underdeveloped pathways for care, and deficits in epilepsy education.

Conclusion

Integrating epilepsy care relies on changes to workforce development and policy frameworks to support whole-of-system vision for improving care.

Neurosurgery for intractable epilepsy in pregnancy: A case report

We describe the management of a 39-year-old woman with intractable focal epilepsy whose condition deteriorated during pregnancy and who required emergency neurosurgery. A literature search did not identify any previous reports of epilepsy surgery in pregnancy. To our knowledge, this is the first time surgery was planned and executed in rapid order with a successful outcome, without obstetrical or surgical complications and seizure freedom achieved. The value of rapid communication between established women's health advanced nurse practitioner clinics, the multidisciplinary Epilepsy Surgery Group and specialist Obstetrical Epilepsy service is highlighted. A care cycle for pregnant women with refractory epilepsy is proposed.

Care delivery and self-management strategies for children with epilepsy

BACKGROUND

Epilepsy is a neurological disorder affecting both children and adults. Epileptic seizures are the result of excessive and abnormal cortical cell electrical activity in the brain. In response to criticism that epilepsy care for children has little impact on long-term outcomes, healthcare professionals and administrators have developed various service models and strategies to address perceived inadequacies. This is an updated version of a Cochrane Review previously published in 2018.

OBJECTIVES

To assess the effects of any specialised or dedicated intervention for epilepsy versus usual care in children and adolescents with epilepsy and their families.

SEARCH METHODS

We searched the following databases on 14 January 2020: the Cochrane Register of Studies (CRS Web), MEDLINE (Ovid, 1946 to 13 January 2020), PsycINFO (1887 to 14 January 2020), CINAHL Plus (1937 to 14 January 2020), ClinicalTrials.gov, and the World Health Organization International Clinical Trials Registry Platform. The Cochrane Register of Studies (CRS Web) includes the Cochrane Epilepsy Group Specialised Register and the Cochrane Central Register of Controlled Trials (CENTRAL). We also contacted experts in the field seeking information on unpublished and ongoing studies and checked the websites of epilepsy organisations and the reference lists of included studies.

SELECTION CRITERIA

We included randomised controlled trials recruiting children and adolescents with epilepsy.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected trials for inclusion and extracted the relevant data. We assessed the following outcomes: 1. Seizure frequency and severity; 2. Appropriateness and volume of medication prescribed (including evidence of drug toxicity); 3. Participants' reported knowledge of information and advice received from professionals; 4. Participants' reports of health and quality of life; 5. Objective measures of general health status; 6. Objective measures of social or psychological functioning (including the number of days spent on sick leave/absence from school or work, and employment status); and 7. Costs of care or treatment. The results of the data extraction and quality assessment for each study were presented in structured tables and as a narrative summary. All summary statistics were extracted for each outcome.

MAIN RESULTS

We included nine studies of eight interventions in the review, reporting on seven distinct self-management programmes for educating or counselling children with epilepsy and their parents, and one new model of care. Based largely on self-reported outcomes, each programme showed some benefits for the well-being of children with epilepsy; however, all of the included studies had methodological flaws. No single programme was evaluated with different study samples, and in no instance was the same outcome measured and reported in the same way across studies, precluding any possible meta-analysis, even if the interventions were considered sufficiently similar to include in meta-analysis.  We chose the outcomes for which data might be important for decisions about the interventions as per guidance in the Cochrane Handbook for Systematic Reviews of Interventions. We found moderate certainty evidence that one of the educational interventions reduced seizure frequency. There was low certainty evidence that two other educational interventions reduced seizure severity, seizure control, and seizure cure rates. The evidence for all other outcomes (drug adherence, knowledge, self-efficacy and self-perception of epilepsy on quality of life) was mixed.

AUTHORS' CONCLUSIONS

Whilst each of the programmes evaluated in this review showed some benefit to children with epilepsy, their impact was extremely variable. No programme showed benefits across the full range of outcomes, and all studies had methodological problems. There is currently insufficient evidence in favour of any single programme. Further evidence from randomised controlled trials using validated measures and considering clinical meaningfulness as well as statistical significance of results is required.

Determining the role and responsibilities of the Australian epilepsy nurse in the management of epilepsy: a study protocol

INTRODUCTION

Epilepsy is a common neurological condition affecting between 3% and 3.5% of the Australian population at some point in their lifetime. The effective management of chronic and complex conditions such as epilepsy requires person-centred and coordinated care across sectors, from primary to tertiary healthcare. Internationally, epilepsy nurse specialists are frequently identified as playing a vital role in improving the integration of epilepsy care and enhancing patient self-management. This workforce has not been the focus of research in Australia to date.

METHODS AND ANALYSIS

This multistage mixed-method study examines the role and responsibilities of epilepsy nurses, particularly in primary and community care settings, across Australia, including through the provision of a nurse helpline service. A nationwide sample of 30 epilepsy nurses will be purposively recruited via advertisements distributed by epilepsy organisations and through word-of-mouth snowball sampling. Two stages (1 and 3) consist of a demographic questionnaire and semistructured interviews (individual or group) with epilepsy nurse participants, with the thematic data analysis from this work informing the areas for focus in stage 3. Stage 2 comprises of a retrospective descriptive analysis of phone call data from Epilepsy Action Australia's National Epilepsy Line service to identify types of users, their needs and reasons for using the service, and to characterise the range of activities undertaken by the nurse call takers.

ETHICS AND DISSEMINATION

Ethics approval for this study was granted by Macquarie University (HREC: 52020668117612). Findings of the study will be published through peer-reviewed journal articles and summary reports to key stakeholders, and disseminated through public forums and academic conference presentations. Study findings will also be communicated to people living with epilepsy and families.

Would people living with epilepsy benefit from palliative care?

Palliative care (PC) is an approach to the care of persons living with serious illness and their families that focuses on improving quality of life and reducing suffering by addressing complex medical symptoms, psychosocial needs, spiritual well-being, and advance care planning. While PC has traditionally been associated with hospice care for persons with cancer, there is now recognition that PC is relevant to many noncancer diagnoses, including neurologic illness, and at multiple points along the illness journey, not just end of life. Despite the recent growth of the field of neuropalliative care there has been scant attention paid to the relevance of PC principles in epilepsy or the potential for PC approaches to improve outcomes for persons living with epilepsy and their families. We believe this has been a significant oversight and that PC may provide a useful framework for addressing the many sources of suffering facing persons living with epilepsy, for engaging patients and families in challenging conversations, and to focus efforts to improve models of care for this population. In this manuscript we review areas of significant unmet needs where a PC approach may improve patient and family-centered outcomes, including complex symptom management, goals of care, advance care planning, psychosocial support for patient and family and spiritual well-being. When relevant we highlight areas where epilepsy patients may have unique PC needs compared to other patient populations and conclude with suggestions for future research, clinical, and educational efforts.

Patient satisfaction with information provided by epilepsy specialist nurses: Results of an online survey

The aim of this study was to investigate the perspective of Norwegian patients with epilepsy regarding the information that they have received about epilepsy-related issues and to determine whether there was a difference in information received between those who had been followed up by an epilepsy specialist nurse (ESN) and those who had not. Further, were there differences regarding satisfaction with the information between the two groups? We conducted an online survey in close collaboration with the Norwegian Epilepsy Association. A total of 1859 respondents (1182 patients with epilepsy and 677 carers for patients with epilepsy) completed a web-based questionnaire. They were asked about epilepsy-related issues on which they had received information, the extent to which they were satisfied with this information, and whether they were being followed up by an ESN or not. Significantly more patients followed up by an ESN had received information about the epilepsy diagnosis, antiseizure drugs (ASDs), routine use of ASD, and risk of seizure-related injuries as compared to those not followed up by an ESN. In addition, patients followed by an ESN were more likely to be satisfied with the information they received. Just above or under half of the respondents had received or were satisfied with information about depression, anxiety, premature death, and sexual wellbeing. Our results indicate that follow-up by ESNs results in improvements in the information provided to patients with epilepsy; ESNs should be an integral part of comprehensive epilepsy 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.

The development of an epilepsy electronic patient portal: Facilitating both patient empowerment and remote clinician-patient interaction in a post-COVID-19 world

Objectives

The current coronavirus disease 2019 (COVID‐19) pandemic stresses an urgency to accelerate much‐needed health service reform. Rapid and courageous changes being made to address the immediate impact of the pandemic are demonstrating that the means and technology to enable new models of health care exist. For example, innovations such as electronic patient portals (ePortal) can facilitate (a) radical reform of outpatient care; (b) cost containment in the economically constrained aftermath of the pandemic; (c) environmental sustainability by reduction of unnecessary journeys/transport. Herein, the development of Providing Individualised Services and Care in Epilepsy (PiSCES), an ePortal to the Irish National Epilepsy Electronic Patient Record, is demonstrated. This project, which pre‐dates the COVID‐19 crisis, aims to facilitate better patient‐ and family‐centered epilepsy care.

Methods

A combination of ethnographic research, document analysis, and joint application design sessions was used to elicit PiSCES requirements. From these, a specification of desired modules of functionality was established and guided the software development.

Results

PiSCES functional features include “My Epilepsy Care Summary,” “My Epilepsy Care Goals,” “My Epilepsy Clinic Letters,” “Help Us Measure Your Progress,” “Prepare For Your Clinic Visit,” “Information for Your Healthcare Provider.” The system provides people with epilepsy access to, and engages them as co‐authors of, their own medical record. It can promote improved patient‐clinician partnerships and facilitate patient self‐management.

Significance

In the aftermath of COVID‐19, it is highly unlikely that the healthcare sector will return to a “business as usual” way of delivering services. The pandemic is expected to accelerate adoption of innovations like PiSCES. It is therefore a catalyst for change that will deliver care that is more responsive to individual patient needs and preferences.

Towards a pragmatic epilepsy classification: Future considerations

The Integrated Epilepsy Classification was recently proposed to merge the 2017 International League Against Epilepsy classification and the four-dimensional epilepsy classification updated in 2019. The efforts in developing the concept of an Integrated Epilepsy Classification scheme are encouraging. However, consideration of brain age, validation in contexts that differ in socioeconomic status and with poor healthcare infrastructure, and incorporation of a team-based approach are necessary. These advancements allow for better clinical management of people with epilepsy and empower people with epilepsy globally.

Barriers and facilitators to implementation of epilepsy self-management programs: a systematic review using qualitative evidence synthesis methods

BACKGROUND

Epilepsy affects nearly 50 million people worldwide. Self-management is critical for individuals with epilepsy in order to maintain optimal physical, cognitive, and emotional health. Implementing and adopting a self-management program requires considering many factors at the person, program, and systems levels. We conducted a systematic review of qualitative and mixed-methods studies to identify facilitators and barriers that impact implementation and adoption of self-management programs for adults with epilepsy.

METHODS

We used established systematic review methodologies for qualitative and mixed-methods studies. We included studies addressing facilitators (i.e., factors that aided) or barriers (i.e., factors that impeded) to implementation and adoption of self-management interventions for adults with epilepsy. We conducted a narrative thematic synthesis to identify facilitators and barriers.

RESULTS

The literature search identified 2700 citations; 13 studies met eligibility criteria. Our synthesis identified five themes that categorize facilitators and barriers to successful implementation epilepsy self-management: (1) relevance, intervention content that facilitates acquisition of self-management skills; (2) personalization, intervention components that account for the individual's social, physical, and environmental characteristics; (3) intervention components, components and dosing of the intervention; (4) technology considerations, considerations that account for individual's use, familiarity with, and ownership of technology; and (5) clinician interventionist, role and preparation of the individual who leads intervention. We identified facilitators in 11 of the 13 studies and barriers in 11 of the 13 studies and classified these by social-ecological level (i.e., patient/caregiver, program, site/system).

CONCLUSION

Identification of facilitators and barriers at multiple levels provides insight into disease-specific factors that influence implementation and adoption of self-management programs for individuals with epilepsy. Our findings indicate that involving individuals with epilepsy and their caregivers in intervention development, and then tailoring intervention content during the intervention, can help ensure the content is relevant to intervention participants. Our findings also indicate the role of the clinician (i.e., the individual who provides self-management education) is important to intervention implementation, and key issues with clinicians were identified as barriers and opportunities for improvement. Overall, our findings have practical value for those seeking to implement and adopt self-management interventions for epilepsy and other chronic illnesses.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO registration number is CRD42018098604.

Association of Child Neurology-Indian Epilepsy Society Consensus Document on Parental Counseling of Children with Epilepsy

When a child is diagnosed with epilepsy, counseling regarding the same is done by the treating doctor. Most parents are frightened and have poor knowledge about epilepsy. Therapeutic advice including drug dosage, administration and side effects takes up the major part of physician's time, thereby neglecting important issues like home seizure management, follow up and others. These lacunae in knowledge require systematic patient and family education. To address these issues, an expert group meeting of pediatric neurologists and epileptologists in India along with social workers/epilepsy educators, legal experts, parents, and teachers was held. The various aspects regarding parental counseling in children with epilepsy were discussed and a consensus document was formulated. Here authors present the group consensus statement on counseling parents and caregivers of children with epilepsy. This document is intended to help physicians and pediatricians counsel the families when a child is diagnosed with epilepsy.

The rhetoric and reality of integrated patient-centered care for healthcare providers: An ethnographic exploration of epilepsy care in Ireland

In line with healthcare reform across the world, the National Clinical Programme for Epilepsy (NCPE) in Ireland describes a model that aims to achieve holistic integrated person (patient)-centered care (PCC). While generally welcomed by stakeholders, the steps required to realize the NCPE ambition and the preparedness of those involved to make the journey are not clear. This study explored the perceptions of healthcare providers in the Irish epilepsy care ecosystem to understand their level of readiness to realize the benefits of an integrated PCC model. Ethnographic fieldwork including observations of different clinical settings across three regions in Ireland and one-to-one interviews with consultant epileptologists (n = 3), epilepsy specialist nurses (n = 5), general practitioners (n = 4), and senior healthcare managers (n = 3) were conducted. While there is a person-centered ambiance and a disposition toward advancing integrated PCC, there are limits to the readiness of the epilepsy care environment to fully meet the aspirations of healthcare reform. These are the following: underdeveloped healthcare partnerships;, poor care coordination;, unintended consequences of innovation;, and tension between pace and productivity. In the journey from policy to practice, the following multiple tensions collide: policy aims to improve services for all patients while simultaneously individualizing care; demands for productivity limit the time and space required to engage in incremental and iterative improvement initiatives. Understanding these tensions is an essential first step on the pathway to integrated PCC implementation.

Improving knowledge translation of clinical practice guidelines for epilepsy

BACKGROUND

Clinical practice guidelines (CPGs) have the potential to improve quality of care. However, implementation of CPGs into the clinical care of people with epilepsy is less than optimal. This study aimed to examine barriers and facilitators to the use of CPGs for the care of people with epilepsy.

METHODS

A cross-sectional survey of Canadian neurologists was conducted to evaluate CPG use, barriers and facilitators of CPG use, and factors associated with CPG use among neurologists. The barriers and facilitators of CPG use among neurologists that manage people with epilepsy were compared with those who do not.

RESULTS

Of 311 responders (response rate = 38.7%), 78.7% indicated that they manage people with epilepsy. Neurologists that manage people with epilepsy did not differ from those who do not with regard to demographic characteristics nor in the proportion that report using CPGs in their clinical practice. The barriers and facilitators of CPG use were largely similar between neurologist that do and do not manage people with epilepsy; except applicability of CPGs tended to be less commonly endorsed as a barrier to CPG use by those who manage people with epilepsy compared with those who do not.

CONCLUSIONS

This study suggests that knowledge, applicability, motivation, resources, and targeting of CPGs to appropriate audience are barriers and facilitators of CPG use among neurologists who manage people with epilepsy. The similarity between barriers and facilitators of CPG use among neurologists who manage people with epilepsy compared with those who do not provides support for the use of a knowledge translation (KT) strategy tailored to these barriers and facilitators of CPG use, and targeted towards neurologists. Implementation of epilepsy CPGs has the potential to improve the quality of care for people with epilepsy.

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.

The efficacy of a short-term multidisciplinary epilepsy program

RATIONALE

Epilepsy is more than having seizures. Therefore, specialized epilepsy centers in Germany offer multidisciplinary programs for inpatients with pharmacoresistant epilepsies. This monocentric study evaluated the efficacy of a short-term program that is based on a biopsychosocial model of health and conceptualized by occupational therapists, physical therapists, neuropsychologists, and social workers.

METHODS

Of the 1573 patients treated between 2008 and 2014, 1339 were rated using a 7-tiered predefined category system. Outcome domains are compliance, affect, activity, autonomy, communication, fine motor skills, and mobility. Based on a total score, the patients were classified as impaired, functional, or highly functional. Functionality at baseline and changes after the treatment were analyzed and related to demographics, medical, and neuropsychological data.

RESULTS

At baseline, 80.8% of the patients were rated as impaired according to the total score. Impairments were predominantly observed in the domains affect, autonomy, and communication. A better total score at baseline was significantly related to a better neuropsychological functioning and a lower number of concurrent antiepileptic drugs. After the intervention 50.3% of the patients showed significant improvements regarding the total score. Compliance, activity, and affect were the most responsive domains.

CONCLUSION

This study provides promising results with regard to the efficacy of a short-term multidisciplinary epilepsy program. Positive effects could be achieved referring to compliance, activity, and affect. The findings support the relevance of such programs. Subsequent research should focus on the transfer to everyday life.

Care delivery and self-management strategies for children with epilepsy

BACKGROUND

In response to criticism that epilepsy care for children has little impact, healthcare professionals and administrators have developed various service models and strategies to address perceived inadequacies.

OBJECTIVES

To assess the effects of any specialised or dedicated intervention for epilepsy versus usual care in children with epilepsy and in their families.

SEARCH METHODS

We searched the Cochrane Epilepsy Group Specialized Register (27 September 2016), the Cochrane Central Register of Controlled Trials (CENTRAL; 2016, Issue 9) in the Cochrane Library, MEDLINE (1946 to 27 September 2016), Embase (1974 to 27 September 2016), PsycINFO (1887 to 27 September 2016) and CINAHL Plus (1937 to 27 September 2016). In addition, we also searched clinical trials registries for ongoing or recently completed trials, contacted experts in the field to seek information on unpublished and ongoing studies, checked the websites of epilepsy organisations and checked the reference lists of included studies.

SELECTION CRITERIA

We included randomised controlled trials (RCTs), cohort studies or other prospective studies with a (matched or unmatched) control group (controlled before-and-after studies), or time series studies.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane.

MAIN RESULTS

Our review included six interventions reported through seven studies (of which five studies were designed as RCTs). They reported on different education and counselling programmes for children and parents; teenagers and parents; or children, adolescents and their parents. Each programme showed some benefits for the well-being of children with epilepsy, but all had methodological flaws (e.g. in one of the studies designed as an RCT, randomisation failed), no single programme was independently evaluated with different study samples and no interventions were sufficiently homogeneous enough to be included in a meta-analysis,.

AUTHORS' CONCLUSIONS

While each of the programmes in this review showed some benefit to children with epilepsy, their impacts were extremely variable. No programme showed benefits across the full range of outcomes, and all studies had major methodological problems. At present there is insufficient evidence in favour of any single programme.

The effect of a modular education program for children with epilepsy and their parents on disease management

OBJECTIVE

The objective of this study was to evaluate the efficacy of Modular Education Program for Children with Epilepsy and Their Parents on disease management. The program was prepared by researchers in an interdisciplinary team.

METHOD

Children with epilepsy and their parents were included in a randomized controlled study using a pre-posttest design. All participants of the modular education program (n=184 (92 children and their 92 parents')) answered a lot of scales immediately before the program. The researcher presented the modular education program, which included eight modules (four for the children and four for the parents), to the children and parents in the intervention group using interactive teaching methods. And all participants of the modular education program answered all scales immediately after the program and one-month, three-month follow-ups. The control group not participating in the modular education program (n=100 (50 children, 50 parents)) also answered all scales in all follow-ups. Scales used the study comprised epilepsy-specific outcome measures (e.g., knowledge, self-efficacy related to seizures, quality of life and anxiety). The statistical analyses of the study data were performed using SAS 9.3 software.

RESULTS

Children in intervention group significantly improved in knowledge (p<0.001), self-efficacy about seizures (p<0.001), and quality of life (p<0.001) compared with the control group. The parents in the intervention group also significantly improved in knowledge about epilepsy (p<0.001) compared with the control group. However, anxiety of the parents in the intervention group significantly increased (p<0.001).

CONCLUSION

The efficacy of the Modular Education Program for Children with Epilepsy and Their Parents on disease management was confirmed. The results indicate that using interactive teaching methods help children with epilepsy and their parents in improving knowledge, self-efficacy about seizures and quality of life. All health professionals who work with children with epilepsy and their parents should provide these modular education programs regularly.

Seizure care in the emergency department. Identifying and bridging the gaps. A study of care and outcomes from 644 seizure presentations

Care for seizures in an emergency department setting can be variable, and there are disparities in access to onward specialist referral. The purpose of this study was to evaluate the utilization and implementation of an evidence-based seizure care pathway in a busy urban tertiary referral center. A total of 644 seizure presentations over two time points were examined. Initial pathway utilization rates were low at 26.2% but increased to 61.6% after environmental barriers had been addressed. We found that patients placed on the care pathway had higher rates of neurological examination, documentation of safety and legal guidelines as regards driving, and lower rates of seizure readmission. Twelve patients not placed on the pathway had passed away at follow-up (1.86%); the cause of death were related to significant comorbidities rather than the seizures themselves though in five, seizures could potentially have been a contributing factor. For the first time we have demonstrated that an evidence-based guideline for seizure management can be implemented in Ireland and used to standardize care for seizures in the emergency department improving documentation rates and clinical evaluation.

"The others look at you as if you are a grave": a qualitative study of subjective experiences of patients with epilepsy regarding their treatment and care in Cape Town, South Africa

BACKGROUND

Existing evidence shows that the majority of people with epilepsy in lower and middle income countries are not receiving appropriate treatment and care. Although this problem has been reported as one of the factors affecting the quality of lives of people with epilepsy, very few studies have investigated patients' perspectives and their experiences about the problem. This qualitative study explored perspectives and subjective experiences of people with epilepsy about their illness in an urban township in South Africa.

METHODS

Individual face-to-face interviews included twelve people who had epilepsy. A semi-structured interview guide which was based on Kleinman (1980) Explanatory Models Framework was used to elicit participants' perspectives and subjective experiences about their illness and its treatment. Thematic analysis method was used to analyse the data.

RESULTS

The main theme reflecting participants' verbatim accounts was about their perceived difficulties affecting their access to treatment and care during their routine clinical follow up visits. These concerned rushed consultations which focussed on seizure frequency and adherence to medication with no attention to personal concerns. They perceived that part of the problem could be that some health care practitioners were not adequately trained and lacked empathy, interest, respect and listening skills. We argue that in a health system where patients feel that they are not respected and their concerns are not listened to or are ignored, they may lack trust in the system and this may violate their right to access treatment and care.

CONCLUSIONS

The findings provide a glimpse of the extent to which the power and nature of the routine task-centred system can lead to violation of patients' health rights - especially with epilepsy which is poorly understood and stigmatized. Appropriate interventions are needed to address health system factors affecting the treatment and care of this marginalized and vulnerable group of patients.

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.

Care delivery and self management strategies for adults with epilepsy

BACKGROUND

Researchers have criticised epilepsy care for adults for its lack of impact, stimulating the development of various service models and strategies to respond to perceived inadequacies.

OBJECTIVES

To assess the effects of any specialised or dedicated intervention beyond that of usual care in adults with epilepsy.

SEARCH METHODS

For the latest update of this review, we searched the Cochrane Epilepsy Group Specialized Register (9 December 2013), the Cochrane Central Register of Controlled Trials (CENTRAL) (2013, Issue 11), MEDLINE (1946 to June 2013), EMBASE (1988 to June 2013), PsycINFO (1887 to December 2013) and CINAHL (1937 to December 2013). In addition, we contacted experts in the field to seek information on unpublished and ongoing studies, checked the websites of epilepsy organisations and checked the reference lists of included studies.

SELECTION CRITERIA

We included randomised controlled trials, controlled or matched trials, cohort studies or other prospective studies with a control group, and time series studies.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected studies, extracted all data, and assessed the quality of all included studies.

MAIN RESULTS

Our review included 18 different studies of 16 separate interventions, which we classified into seven distinct groups. Most of the studies have methodological weaknesses, and many results from other analyses within studies need to be interpreted with caution because of study limitations. Consequently, there is currently limited evidence for the effectiveness of interventions to improve the health and quality of life in people with epilepsy. It was not possible to combine study results in a meta-analysis because of the heterogeneity of outcomes, study populations, interventions and time scales across the studies.

AUTHORS' CONCLUSIONS

Two intervention types, the specialist epilepsy nurse and self management education, have some evidence of benefit. However, we did not find clear evidence that other service models substantially improve outcomes for adults with epilepsy. It is also possible that benefits are situation specific and may not apply to other settings. These studies included only a small number of service providers whose individual competence or expertise may have had a significant impact on outcomes. At present it is not possible to advocate any single model of service provision.

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.

Care delivery and self management strategies for children with epilepsy

BACKGROUND

Epilepsy care for children has been criticised for its lack of impact. Various service models and strategies have been developed in response to perceived inadequacies in care provision for children and their families.

OBJECTIVES

To compare the effectiveness of any specialised or dedicated intervention for the care of children with epilepsy and their families to the effectiveness of usual care.

SEARCH METHODS

We searched the Cochrane Epilepsy Group Specialized Register (9 December 2013), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library, 2013,Issue 11), MEDLINE (1946 to June week 2, 2013), EMBASE (1988 to week 25, 2013), PsycINFO (1887 to 11 December 2013) and CINAHL Plus (1937 to 11 December 2013). In addition, we contacted experts in the field to seek information on unpublished and ongoing studies, checked the websites of epilepsy organisations and checked the reference lists of included studies.

SELECTION CRITERIA

We included randomised controlled trials (RCTs), controlled or matched trials, cohort studies or other prospective studies with a control group (controlled before-and-after studies), or time series studies.

DATA COLLECTION AND ANALYSIS

Each review author independently selected studies, extracted data and assessed the quality of included studies.

MAIN RESULTS

We included five interventions reported in seven study reports (of which only four studies of three interventions were designed as RCTs) in this review. They reported on different education and counselling programmes for children, children and parents, teenagers and parents, or children, adolescents and their parents. Each programme showed some benefits for the well-being of children with epilepsy, but each study had methodological flaws (e.g. in one of the studies designed as an RCT, randomisation failed) and no single programme was independently evaluated by more than one study.

AUTHORS' CONCLUSIONS

While each of the programmes in this review showed some benefit to children with epilepsy, their impacts were extremely variable. No programme showed benefits across the full range of outcomes. No study appeared to have demonstrated any detrimental effects but the evidence in favour of any single programme was insufficient to make it possible to recommend one programme rather than another. More studies, carried out by independent research teams, are needed.

The current state of epilepsy guidelines: A systematic review

OBJECTIVE

The International League Against Epilepsy (ILAE) Epilepsy Guidelines Task Force, composed of 14 international members, was established in 2011 to identify, using systematic review methodology, international epilepsy clinical care guidelines, assess their quality, and determine gaps in areas of need of development.

METHODS

A systematic review of the literature (1985-2014) was performed in six electronic databases (e.g. Medline, Embase) using a broad search strategy without initial limits to language or study design. Six gray literature databases (e.g., American Academy of Neurology [AAN], ILAE) were also searched to minimize publication bias. Two independent reviewers screened abstracts, reviewed full text articles, and performed data abstraction. Descriptive statistics and a meta-analysis were generated.

RESULTS

The search identified 10,926 abstracts. Of the 410 articles selected for full text review, 63 met our eligibility criteria for a guideline. Of those included, 54 were in English and 9 were in other languages (French, Spanish, and Italian). Of all guidelines, 29% did not specify the target age groups, 27% were focused on adults, 22% included only children, and 6% specifically addressed issues related to women with epilepsy. Guidelines included in the review were most often aimed at guiding clinical practice for status epilepticus (n = 7), first seizure (n = 6), drug-resistant epilepsy (n = 5), and febrile seizures (n = 4), among others. Most of the guidelines were therapeutic (n = 35) or diagnostic (n = 16) in nature. The quality of the guidelines using a 1-7 point scale (7 = highest) varied and was moderate overall (mean = 4.99 ± 1.05 [SD]).

SIGNIFICANCE

We identified substantial gaps in topics (e.g., epilepsy in the elderly) and there was considerable heterogeneity in methodologic quality. The findings should offer a valuable resource for health professionals caring for people with epilepsy, since they will help guide the prioritization, development, and dissemination of future epilepsy-related guidelines.

Epilepsy priorities in Europe: A report of the ILAE-IBE Epilepsy Advocacy Europe Task Force

The European Forum on Epilepsy Research (ERF2013), which took place in Dublin, Ireland, on May 26-29, 2013, was designed to appraise epilepsy research priorities in Europe through consultation with clinical and basic scientists as well as representatives of lay organizations and health care providers. The ultimate goal was to provide a platform to improve the lives of persons with epilepsy by influencing the political agenda of the EU. The Forum highlighted the epidemiologic, medical, and social importance of epilepsy in Europe, and addressed three separate but closely related concepts. First, possibilities were explored as to how the stigma and social burden associated with epilepsy could be reduced through targeted initiatives at EU national and regional levels. Second, ways to ensure optimal standards of care throughout Europe were specifically discussed. Finally, a need for further funding in epilepsy research within the European Horizon 2020 funding programme was communicated to politicians and policymakers participating to the forum. Research topics discussed specifically included (1) epilepsy in the developing brain; (2) novel targets for innovative diagnostics and treatment of epilepsy; (3) what is required for prevention and cure of epilepsy; and (4) epilepsy and comorbidities, with a special focus on aging and mental health. This report provides a summary of recommendations that emerged at ERF2013 about how to (1) strengthen epilepsy research, (2) reduce the treatment gap, and (3) reduce the burden and stigma associated with epilepsy. Half of the 6 million European citizens with epilepsy feel stigmatized and experience social exclusion, stressing the need for funding trans-European awareness campaigns and monitoring their impact on stigma, in line with the global commitment of the European Commission and with the recommendations made in the 2011 Written Declaration on Epilepsy. Epilepsy care has high rates of misdiagnosis and considerable variability in organization and quality across European countries, translating into huge societal cost (0.2% GDP) and stressing the need for cost-effective programs of harmonization and optimization of epilepsy care throughout Europe. There is currently no cure or prevention for epilepsy, and 30% of affected persons are not controlled by current treatments, stressing the need for pursuing research efforts in the field within Horizon 2020. Priorities should include (1) development of innovative biomarkers and therapeutic targets and strategies, from gene and cell-based therapies to technologically advanced surgical treatment; (2) addressing issues raised by pediatric and aging populations, as well as by specific etiologies and comorbidities such as traumatic brain injury (TBI) and cognitive dysfunction, toward more personalized medicine and prevention; and (3) translational studies and clinical trials built upon well-established European consortia.

Association of adherence to epilepsy quality standards with seizure control

OBJECTIVE

We assessed the relationship between adherence to epilepsy quality measures (EQM) and seizure control over 2-3 years in a retrospective cohort study.

METHODS

6150 patients were identified at two large academic medical centers with a primary or secondary diagnosis of epilepsy, were 18-85 years old and seen in outpatient general neurology or epilepsy units between June 2011 and May 2014. Patients were included if: their initial visit was between June 2011 and June 2012, treatment was with ≥1 anti-seizure drug, there was ≥1 visit per year during the timeframe, and seizure frequency was documented at initial and final visits, yielding 162 patients/1055 visits from which socio-demographic, clinical and care quality data were abstracted. Quality care was assessed as (1) percent adherence to up to 8 eligible EQM, and (2) defect-free care (DFC: adherence to all eligible EQM). Seizure control (SC) was defined as ≥50% reduction in average seizures/month between initial and final visits. Chi-square and t-test compared care quality with seizure control. Logistic regression was used to assess the relationships between SC, quality of care and subspecialist involvement.

RESULTS

Care quality, reflected by documentation of seizure frequency, addressing therapeutic interventions, and referral to a comprehensive epilepsy center, all exceeded 80% adherence. Care quality as reflected by documentation of seizure type, etiology or syndrome; assessment of side effects, counseling about epilepsy safety and women's issues, and screening for psychiatric disorders ranged from 40 to 57%. Mean EQM adherence across all applicable measures was associated with greater seizure control (p=0.0098). DFC was low (=8%) and did not covary with seizure control (p=0.55). The SC and non-SC groups only differed on epilepsy etiology (p=0.04). Exploratory analysis showed that mean quality scores are associated with seizure control (OR=4.9 [1.3-18.5], p=0.017) while controlling for the effect of subspecialty involvement as a possible confounding variable.

CONCLUSIONS

Average quality of care but not defect-free care was associated with seizure control in this retrospective cohort.

Quality care in epilepsy: Women's counseling and its association with folic acid prescription or recommendation

OBJECTIVE

This study aimed to determine if annual counseling about contraception and pregnancy in the setting of treatment for epilepsy is associated with increased recommending or prescribing of folate.

METHODS

This is a retrospective cohort study with medical record abstraction. We selected records from 77 women of childbearing age who had two or more visits for epilepsy at a neurology clinic. The assessment included a review of documentation from the first three visits for epilepsy within a 24-month follow-up window. We defined perfect adherence to annual counseling about the impact of epilepsy treatment on contraception or pregnancy as defect-free care for women (DFCW). A recommendation that the patient take over-the-counter folate or a prescription for folate was independently abstracted from the chart at each visit.

RESULTS

The group of patients who received DFCW (N=28, 36.36%) and the group who did not receive DFCW (N=49, 63.63%) were comparable with respect to age, disease duration, baseline history of drug-resistant epilepsy (DRE), presence of concurrent psychiatric disease, epileptologist involvement, number of antiepileptic drugs (AEDs) prescribed, seizure type, and etiology. Twenty (71.4%) patients in the DFCW group and 42 (85.7%) in the non-DFCW group were not recommended or prescribed folic acid (p=0.12).

CONCLUSIONS

Even with annual documentation of counseling about how epilepsy treatment may affect contraception and pregnancy, the "action" of prescribing or recommending folic acid during the ensuing 24months is frequently omitted.

Technology and its ethics in nursing and caring journals: An integrative literature review

BACKGROUND

Over the past 20 years, the impact of technology has increased significantly in health care. The diversity of technology is growing and its knowledge scattered. The concept of technology is ambiguous in caring and nursing sciences and its ethics remains unidentified.

AIM

To find evidence on how the concept of technology and its ethics are defined in caring and nursing sciences and practice. The purpose of this study is to describe and summarize the concept of technology and its ethics in the past nursing and caring literature.

METHOD

The integrative literature review of the past nursing and caring literature. The data were collected from caring and nursing journal articles from 2000 to 2013 focusing on technology and its ethics.The results were summarized and themed.

RESULTS

Technology as a concept has three implications. First, technology is devices and products, including ICT and advanced, simple and assistive technology. Second, technology refers to a process consisting of methods for helping people. Third, technology as a service indicates the production of care by technology. The ethics of technology has not been established as a guiding principle. Some studies excluded ethical reflection completely. Many studies discussed the ethics of technology as benefits such as improved communication and symptoms management, and the simple use of e-health services whilst others remained critical presenting ethical problems such as unwillingness and the inability to use technology, or conflicts with human aspects or questions of inequality.

CONCLUSION

In conclusion, this study indicates that technology as a concept is described diversely. The relation between technology and ethics is not a truism. Despite some evidence, more is needed to promote ethical care when using technology.

Using electronic patient records in practice: a focused review of the evidence of risks to the clinical interaction

Electronic patient records (EPRs) are increasingly being viewed as key to high quality chronic disease management, and have been advocated for epilepsy care. Whether EPRs can really deliver on their promise, however, remains a matter of debate. In this focused review, I highlight one set of risks associated with EPR use: risks to the interaction between health professional and patient. This review summarises a small body of evidence derived from studies that examined - in fine-grained detail - recordings of real consultations. These show that EPRs are often used in ways that prioritise the demands of the system over the needs of the patient. However, they also demonstrate that health professionals sometimes integrate EPRs in ways that enhance the clinical encounter. I argue that we not only need more of this kind of interaction-based research - as opposed to focusing on the single EPR user - but that the findings from these previous studies need to be acted upon. They indicate a need both for the design of EPRs and the training of EPR users to be sensitive to the impact of EPR use on the interaction between health professional and patient.

General practitioners' perceptions on management of epilepsy in primary care settings in Cape Town, South Africa: an exploratory pilot study

In a context where there are few neurologists, excellent management of patients with epilepsy at a primary care level is imperative. In South Africa, most uninsured patients suffering from epilepsy and other chronic illnesses are managed by general practitioners in state-provided primary care settings. We conducted a qualitative pilot study to explore perceptions of doctors working in primary care settings in Cape Town regarding the quality of epilepsy management. Our analysis revealed that these clinicians believe that epilepsy is poorly managed. Attributing factors were consistent with those found in literature. Although study findings cannot be generalized, we conclude that lack of attention to factors impacting on management of epilepsy is a serious concern and may lead to violations of health rights. Urgent prioritization, advocacy, collaboration, and empowerment of healthcare professionals, patients, lay carers, and the general public are needed to improve the management and quality of care of PWE.

A Dutch and American commentary on IT in health care: roundtable discussions on IT and innovations in health care

PURPOSE

This chapter reports on experts' perspectives on health information technology (HIT) and how it may be used to improve health care quality and to lower health care costs.

DESIGN/METHODOLOGY/APPROACH

Two roundtables were convened that focused on how to best use HIT to improve the quality of health care while ensuring it is accessible and affordable. Participants drew upon lessons learned in the Netherlands, the United States, and other countries.

FINDINGS

The first roundtable focused on the use of (1) electronic health records (EHRs) by health care providers, (2) cloud computing for EHRs and health portals for consumers, and (3) data registries and networks for public health surveillance. The second roundtable highlighted (1) the rapid growth of personalized medicine, (2) the corresponding growth and sophistication of bioinformatics and analytics, (3) the increasing presence of mobile HIT, and (4) the disruptive changes in the institutional structures of biomedical research and development.

PRACTICAL IMPLICATIONS

Governmental sponsorship of small pilot projects to solve practicable health system problems would encourage HIT innovation among key stakeholders. However, large-scale HIT solutions developed through small pilot projects--should be pursued through public-private partnerships. At the same time, governments should speed up legislative and regulatory procedures to encourage adoption of cost-effective HIT innovations.

SOCIAL IMPLICATIONS

Mobile HIT and social media are capable of fostering disease prevention and encouraging personal responsibility for improving or stabilizing chronic diseases.

ORIGINALITY/VALUE

Both health services researchers and policy makers should find this chapter of value since it highlights trends in HIT and addresses how health care quality may be improved while costs are contained.