1
|
Nuthalapati P, Thomas L, Donahue MA, Moura LMVR, DeStefano S, Simpson JR, Buchhalter J, Fureman BE, Pellinen J. Improving Seizure Frequency Documentation and Classification. Neurol Clin Pract 2023; 13:e200212. [PMID: 37873534 PMCID: PMC10586801 DOI: 10.1212/cpj.0000000000200212] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2023] [Accepted: 09/01/2023] [Indexed: 10/25/2023]
Abstract
Background and Objectives Accurate and reliable seizure data are essential for evaluating treatment strategies and tracking the quality of care in epilepsy clinics. This quality improvement project aimed to increase seizure documentation (i.e., documentation of seizure frequency from 80% to 100%, date of last seizure from 35% to 50%, and International League Against Epilepsy (ILAE) seizure classification from 35% to at least 50%) over 6 months. Methods We surveyed 7 epileptologists to determine their perceived seizure frequency, ILAE classification, and date of last seizure documentation habits. Baseline data were collected weekly from September to December 2021. Subsequently, we implemented a newly created flowsheet in our Electronic Health Record (EHR) based on the Epilepsy Learning Healthcare System (ELHS) Case Report Forms to increase seizure documentation in a standardized way. Two epileptologists tested this flowsheet tool in their epilepsy clinics between February 2022 and July 2022. Data were collected weekly and compared with documentation from other epileptologists within the same group. Results Epileptologists at our center believed they documented seizure frequency for 84%-87% of clinic visits, which aligned with baseline data collection, showing they recorded seizure frequency for 83% of clinic visits. Epileptologists believed they documented ILAE classification for 47%-52% of clinic visits, and baseline data showed this was documented in 33% of clinic visits. They also reported documenting the date of the last seizure for 52%-63% of clinic visits, but this occurred in only 35% of clinic visits. After implementing the new flowsheet, documentation increased to nearly 100% for all fields being completed by the providers who tested the flowsheet. Discussion We demonstrated that by implementing an easy-to-use standardized EHR documentation tool, our documentation of critical metrics, as defined by the ELHS, improved dramatically. This shows that simple and practical interventions can substantially improve clinically meaningful documentation.
Collapse
Affiliation(s)
- Poojith Nuthalapati
- Department of Neurology (PN, MAD, LMVRM), Massachusetts General Hospital, Harvard Medical School, Boston; Department of Neurology (LT, SD, JRS, JP), University of Colorado School of Medicine, Aurora; Department of Pediatrics (JB), Cumming School of Medicine, University of Calgary, AB, CA; and Mission Outcomes Team (BEF), Epilepsy Foundation, Landover, MD
| | - Lionel Thomas
- Department of Neurology (PN, MAD, LMVRM), Massachusetts General Hospital, Harvard Medical School, Boston; Department of Neurology (LT, SD, JRS, JP), University of Colorado School of Medicine, Aurora; Department of Pediatrics (JB), Cumming School of Medicine, University of Calgary, AB, CA; and Mission Outcomes Team (BEF), Epilepsy Foundation, Landover, MD
| | - Maria A Donahue
- Department of Neurology (PN, MAD, LMVRM), Massachusetts General Hospital, Harvard Medical School, Boston; Department of Neurology (LT, SD, JRS, JP), University of Colorado School of Medicine, Aurora; Department of Pediatrics (JB), Cumming School of Medicine, University of Calgary, AB, CA; and Mission Outcomes Team (BEF), Epilepsy Foundation, Landover, MD
| | - Lidia M V R Moura
- Department of Neurology (PN, MAD, LMVRM), Massachusetts General Hospital, Harvard Medical School, Boston; Department of Neurology (LT, SD, JRS, JP), University of Colorado School of Medicine, Aurora; Department of Pediatrics (JB), Cumming School of Medicine, University of Calgary, AB, CA; and Mission Outcomes Team (BEF), Epilepsy Foundation, Landover, MD
| | - Samuel DeStefano
- Department of Neurology (PN, MAD, LMVRM), Massachusetts General Hospital, Harvard Medical School, Boston; Department of Neurology (LT, SD, JRS, JP), University of Colorado School of Medicine, Aurora; Department of Pediatrics (JB), Cumming School of Medicine, University of Calgary, AB, CA; and Mission Outcomes Team (BEF), Epilepsy Foundation, Landover, MD
| | - Jennifer R Simpson
- Department of Neurology (PN, MAD, LMVRM), Massachusetts General Hospital, Harvard Medical School, Boston; Department of Neurology (LT, SD, JRS, JP), University of Colorado School of Medicine, Aurora; Department of Pediatrics (JB), Cumming School of Medicine, University of Calgary, AB, CA; and Mission Outcomes Team (BEF), Epilepsy Foundation, Landover, MD
| | - Jeffrey Buchhalter
- Department of Neurology (PN, MAD, LMVRM), Massachusetts General Hospital, Harvard Medical School, Boston; Department of Neurology (LT, SD, JRS, JP), University of Colorado School of Medicine, Aurora; Department of Pediatrics (JB), Cumming School of Medicine, University of Calgary, AB, CA; and Mission Outcomes Team (BEF), Epilepsy Foundation, Landover, MD
| | - Brandy E Fureman
- Department of Neurology (PN, MAD, LMVRM), Massachusetts General Hospital, Harvard Medical School, Boston; Department of Neurology (LT, SD, JRS, JP), University of Colorado School of Medicine, Aurora; Department of Pediatrics (JB), Cumming School of Medicine, University of Calgary, AB, CA; and Mission Outcomes Team (BEF), Epilepsy Foundation, Landover, MD
| | - Jacob Pellinen
- Department of Neurology (PN, MAD, LMVRM), Massachusetts General Hospital, Harvard Medical School, Boston; Department of Neurology (LT, SD, JRS, JP), University of Colorado School of Medicine, Aurora; Department of Pediatrics (JB), Cumming School of Medicine, University of Calgary, AB, CA; and Mission Outcomes Team (BEF), Epilepsy Foundation, Landover, MD
| |
Collapse
|
2
|
Zelano J, Nika O, Asztely F, Larsson D, Andersson K, Andrén K. Prevalence and nature of patient-reported antiseizure medication side effects in a Swedish regional multi-center study. Seizure 2023; 113:23-27. [PMID: 37931352 DOI: 10.1016/j.seizure.2023.10.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2023] [Revised: 10/23/2023] [Accepted: 10/31/2023] [Indexed: 11/08/2023] Open
Abstract
PURPOSE Side effects is one of the major clinical problems in epilepsy care. We assessed the prevalence of ASM side effects in participants in a large regional multicenter observational study in western Sweden and aimed to identify risk factors and inventory the nature of side effects with different ASM regimes. METHODS Cross-sectional analysis of survey answers and clinical characteristics of 406 adult participants recruited to a regional observational study between December 2020 and March 2023. Half of the participants had been seizure free for one year. Second-generation or newer ASMs were the most common. RESULTS A total of 164 (40 %, 95 %CI: 36-45) patients reported side effects. Patients reporting side effects were younger (median 41 vs 47 years, p = 0.015), had more frequently experienced a seizure in the last year (p = 0.02), and were more often on ASM polytherapy (p < 0.01). ASM polytherapy and age were significant risk factors in regression models, but the explanatory value was low. The most common side effect was tiredness followed by cognitive symptoms. CONCLUSIONS Our findings show that side effects are still common in epilepsy care and suggests that unnecessary polypharmacy should be avoided. Apart from number or ASMs, predicting who will experience side effects is difficult and more research on individual vulnerability is needed.
Collapse
Affiliation(s)
- Johan Zelano
- Department of clinical neuroscience, Institute of neuroscience and physiology, Sahlgrenska Academy, Gothenburg University, Blå stråket 7, 3v, Gothenburg 41345, Sweden; Department of Neurology, Sahlgrenska University Hospital, Gothenburg, Sweden; Wallenberg Center of Molecular and Translational Medicine, Gothenburg University, Sweden.
| | - Olha Nika
- Department of clinical neuroscience, Institute of neuroscience and physiology, Sahlgrenska Academy, Gothenburg University, Blå stråket 7, 3v, Gothenburg 41345, Sweden; Department of Neurology, Sahlgrenska University Hospital, Gothenburg, Sweden; Wallenberg Center of Molecular and Translational Medicine, Gothenburg University, Sweden
| | - Fredrik Asztely
- Department of clinical neuroscience, Institute of neuroscience and physiology, Sahlgrenska Academy, Gothenburg University, Blå stråket 7, 3v, Gothenburg 41345, Sweden; Angered hospital, SV hospital group, Gothenburg, Sweden
| | - David Larsson
- Department of clinical neuroscience, Institute of neuroscience and physiology, Sahlgrenska Academy, Gothenburg University, Blå stråket 7, 3v, Gothenburg 41345, Sweden; Department of Neurology, Sahlgrenska University Hospital, Gothenburg, Sweden; Wallenberg Center of Molecular and Translational Medicine, Gothenburg University, Sweden
| | - Klara Andersson
- Department of clinical neuroscience, Institute of neuroscience and physiology, Sahlgrenska Academy, Gothenburg University, Blå stråket 7, 3v, Gothenburg 41345, Sweden; Department of Neurology, Sahlgrenska University Hospital, Gothenburg, Sweden; Wallenberg Center of Molecular and Translational Medicine, Gothenburg University, Sweden
| | - Kerstin Andrén
- Department of clinical neuroscience, Institute of neuroscience and physiology, Sahlgrenska Academy, Gothenburg University, Blå stråket 7, 3v, Gothenburg 41345, Sweden; Angered hospital, SV hospital group, Gothenburg, Sweden
| |
Collapse
|
3
|
Abstract
Transition of care is the planned, coordinated movement from a child and family environment of pediatrics to a patient centered adult care setting. Epilepsy is a common neurological condition. While seizures remit in a proportion of children, in around 50% of children seizures persist into adulthood. Also, with advances in diagnostics and therapeutics, more children with epilepsy survive into adulthood, and need services of adult neurologists. Clinical guidelines from the American Academy of Pediatrics, American College of Family Physicians and American College of Physicians called for "supporting the healthcare transition from adolescence to adulthood", but this occurs in a minority of patients. There are several challenges to implementing transition of care at the level of the patient and family, pediatric and adult neurologist and with systems of care. Transition needs vary based on the type of epilepsy and epilepsy syndrome and presence of co-morbidities. Transition clinics are essential to effective transfer of care, but implementation remains extremely variable, with a variety of clinics or program structures in countries around the world. There is a need to develop multidisciplinary transition clinics, enhance physician education and establish national guidelines for this important process to be put into practice. Further studies are also needed to develop best practices and assess outcomes of well executed transition programs on epilepsy.
Collapse
Affiliation(s)
- Sujata Kanhere
- Division of Pediatric Neurology, Department of Pediatrics, K.J. Somaiya Medical College, Hospital & Research Centre, Mumbai, Maharashtra, India.
| | - Sucheta M Joshi
- Division of Pediatric Neurology, Department of Pediatrics, University of Michigan, Ann Arbor, USA
| |
Collapse
|
4
|
Fırat O, Dericioğlu N, Demirkan K. Adherence to epilepsy quality indicators in a tertiary referral center. Epilepsy Behav 2023; 146:109366. [PMID: 37531672 DOI: 10.1016/j.yebeh.2023.109366] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2023] [Revised: 07/05/2023] [Accepted: 07/20/2023] [Indexed: 08/04/2023]
Abstract
BACKGROUND Quality indicators play an important role in healthcare quality and patient safety. The aim of this study is to identify specific clinical pharmacy interventions to improve adherence to quality indicators and minimize risks among patients with epilepsy. MATERIAL AND METHODS A prospective, two-phase, observational study was conducted in a neurology outpatient clinic of a tertiary university hospital. In the first phase of the study, the rate of adherence to the quality indicators was evaluated with a checklist containing the quality indicators. In the second phase of the study, an expert panel meeting was convened to identify clinical pharmacist interventions to reduce the risks associated with non-adherence. The Fine-Kinney method was used to prioritize risks, and adherence rates with each quality improvement indicator (QI) were calculated. RESULTS The study found that adherence rates were highest for QIs involving estimating the number and type of seizures, providing medical treatment or referring patients with evidence of mood disorders to mental healthcare, and co-managing prenatal care for women with epilepsy. The most non-adherence rates were found in QIs involving quality-of-life assessment, daily folate supplementation, and addressing the decreased effectiveness of oral contraception. The annual review of information about educational issues was also poorly provided. An expert panel decided to integrate a clinical pharmacist into the outpatient clinic to improve medication adherence, side-effect assessment, drug interaction assessment, patient education, lifestyle-modification education, depression/suicide-related behavior screening, quality-of-life assessment, and effectiveness evaluation of oral contraceptives for female patients using enzyme-inducing ASM. CONCLUSION The study shows that medication adherence, assessment of side effects, drug interactions, and patient education are inadequately provided by neurologists in patients with epilepsy. Clinical pharmacists have a crucial role in reducing potential risks of non-adherence with quality indicators. By integrating clinical pharmacy services into routine epilepsy care processes, the quality of care can be improved. Future studies should focus on implementing these interventions and evaluating their impact on patient outcomes.
Collapse
Affiliation(s)
- Oğuzhan Fırat
- Hacettepe University, Faculty of Pharmacy, Department of Clinical Pharmacy, Ankara, Turkey.
| | - Neşe Dericioğlu
- Hacettepe University, Faculty of Medicine, Department of Neurology, Ankara, Turkey.
| | - Kutay Demirkan
- Hacettepe University, Faculty of Pharmacy, Department of Clinical Pharmacy, Ankara, Turkey.
| |
Collapse
|
5
|
Identifying Barriers to Care in the Pediatric Acute Seizure Care Pathway. Int J Integr Care 2022; 22:28. [PMID: 35431702 PMCID: PMC8973859 DOI: 10.5334/ijic.5598] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Accepted: 02/19/2022] [Indexed: 12/02/2022] Open
Abstract
Objective: We aimed to describe the acute seizure care pathway for pediatric patients and identify barriers encountered by those involved in seizure care management. We also proposed interventions to bridge these care gaps within this pathway. Methods: We constructed a process map that illustrates the acute seizure care pathway for pediatric patients at Boston Children’s Hospital (BCH). The map was designed from knowledge gathered from unstructured interviews with experts at BCH, direct observation of patient care management at BCH through a quality improvement implemented seizure diary and from findings through three studies conducted at BCH, including a prospective observational study by the pediatric Status Epilepticus Research Group, a multi-site international consortium. We also reviewed the literature highlighting gaps and strategies in seizure care management. Results: Within the process map, we identified twenty-nine care gaps encountered by caregivers, care teams, residential and educational institutions, and proposed interventions to address these challenges. The process map outlines clinical care of a patient through the following settings: 1) pre-hospitalization setting, defined as residential and educational settings before hospital admission, 2) BCH emergency department and inpatient settings, 3) post-hospitalization setting, defined as residential and educational settings following hospital discharge or clinic visit and 4) follow-up BCH outpatient settings, including neurology, epilepsy, and primary care provider clinics. The acute seizure care pathway for a pediatric patient who presents with seizures exhibits at least twenty-nine challenges in acute seizure care management. Significance: Identification of care barriers in the acute seizure care pathway provides a necessary first step for implementing interventions and strategies in acute seizure care management that could potentially impact patient outcomes.
Collapse
|
6
|
Samanta D, Elumalai V, Desai VC, Hoyt ML. Conceptualization and implementation of an interdisciplinary clinic for children with drug-resistant epilepsy during the COVID-19 pandemic. Epilepsy Behav 2021; 125:108403. [PMID: 34781061 PMCID: PMC8639664 DOI: 10.1016/j.yebeh.2021.108403] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2021] [Revised: 10/19/2021] [Accepted: 10/21/2021] [Indexed: 12/30/2022]
Abstract
OBJECTIVE To describe the rapid conceptualization and implementation of an interdisciplinary epilepsy clinic for children with drug-resistant epilepsy (DRE) at Arkansas Children's Hospital (ACH) during the COVID 19 pandemic. METHODS Focusing on care design and care coordination for children with DRE, multiple stakeholder groups decided to implement a clinic after the systematic rating of constructs present in a theoretical meta-analytic framework. Based on the projected success, the new interdisciplinary clinic (composed of an epileptologist, a neurosurgeon, and a neuropsychologist and coordinated by a full-time nurse) was established. Clinic operations were further refined through discussions with patients, families, and care providers. We collected data retrospectively (August 2020 to June 2021) to determine referral patterns, clinic scheduling metrics, patient characteristics, clinical recommendations, and epilepsy quality metrics. RESULTS Of the 32 Consolidated Framework for Implementation Research constructs assessed, 24 were positively rated to predict a high probability of successful implementation of the clinic. For approximately 100 patient visits, appearance and usage rates were >75%, yielding a clinic utilization rate of approximately 60%. Among 76 unique patients (average age of 12 years, 60% focal epilepsy), 39 patients (51.3%) were deemed eligible for epilepsy surgery evaluation. The majority of the patients (53.9%) were advised for additional diagnostic testing, and 31.6% of patients were scheduled for vagus nerve stimulation. More patients (33%) had changes in their existing anti-seizure medication (ASM) regimen rather than an addition of a new ASM (7.9%). Standardized epilepsy quality measures showed >80% to 90% adherence in 3 (reproductive counseling, depression and anxiety screening, documentation of seizure frequency) out of 4 metrics. SIGNIFICANCE This is the first study to show that an interdisciplinary clinic can be a valuable attribute of care models in high-need children with DRE by enabling comprehensive one-stop service for diagnostic evaluation, surgical consideration, and brief assessment of psychiatric comorbidities without compromising consensus-based best practices.
Collapse
Affiliation(s)
- Debopam Samanta
- Neurology Division, Department of Pediatrics, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA.
| | | | - Vidya C Desai
- College of Pharmacy, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | | |
Collapse
|
7
|
Patel AD. Measuring Quality of Epilepsy Care: The AAN Quality Measures. Pediatr Neurol 2021; 117:19-20. [PMID: 33647777 DOI: 10.1016/j.pediatrneurol.2020.01.020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2019] [Revised: 11/22/2019] [Accepted: 01/05/2020] [Indexed: 11/19/2022]
Affiliation(s)
- Anup D Patel
- Division of Neurology, Department of Pediatrics, Nationwide Children's Hospital, Columbus, Ohio.
| |
Collapse
|
8
|
Anand SK, Macki M, Culver LG, Wasade VS, Hendren S, Schwalb JM. Patient navigation in epilepsy care. Epilepsy Behav 2020; 113:107530. [PMID: 33232897 DOI: 10.1016/j.yebeh.2020.107530] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2020] [Accepted: 09/28/2020] [Indexed: 12/20/2022]
Abstract
The concept of patient navigation was first introduced in 1989 by the American Cancer Society and was first implemented in 1990 by Dr. Harold Freeman in Harlem, NY. The role of a patient navigator (PN) is to coordinate care between the care team, the patient, and their family while also providing social support. In the last 30 years, patient navigation in oncological care has expanded internationally and has been shown to significantly improve patient care experience, especially in the United States cancer care system. Like oncology care, patients who require epilepsy care face socioeconomic and healthcare system barriers and are at significant risk of morbidity and mortality if their care needs are not met. Although shortcomings in epilepsy care are longstanding, the COVID-19 pandemic has exacerbated these issues as both patients and providers have reported significant delays in care secondary to the pandemic. Prior to the pandemic, preliminary studies had shown the potential efficacy of patient navigation in improving epilepsy care. Considering the evidence that such programs are helpful for severely disadvantaged cancer patients and in enhancing epilepsy care, we believe that professional societies should support and encourage PN programs for coordinated and comprehensive care for patients with epilepsy.
Collapse
Affiliation(s)
- Sharath Kumar Anand
- Wayne State University School of Medicine, 540 E Canfield St., Detroit, MI, USA.
| | - Mohamed Macki
- Department of Neurosurgery, Henry Ford Hospital, 2799 W Grand Blvd, Detroit, MI, USA
| | - Lauren G Culver
- Wayne State University School of Medicine, 540 E Canfield St., Detroit, MI, USA
| | - Vibhangini S Wasade
- Department of Neurology, Henry Ford Hospital, 2799 W Grand Blvd, Detroit, MI, USA; Department of Neurology, Wayne State University School of Medicine, 540 E Canfield St., Detroit, MI, USA
| | - Samantha Hendren
- Division of Colorectal Surgery, Department of Surgery, University of Michigan, 1500 E Medical Center Dr., Ann Arbor, MI, USA
| | - Jason M Schwalb
- Department of Neurosurgery, Henry Ford Hospital, 2799 W Grand Blvd, Detroit, MI, USA; Center for Health Policy and Health Services Research, Henry Ford Health System, 2799 W Grand Blvd, Detroit MI 48202, USA
| |
Collapse
|
9
|
Dawes A, Attipoe S, Mittlesteadt J, Glynn P, Rust S, Debs A, Patel AD. Measuring the impact of epilepsy on families. Epilepsy Behav 2020; 111:107254. [PMID: 32610250 DOI: 10.1016/j.yebeh.2020.107254] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2020] [Accepted: 06/08/2020] [Indexed: 10/24/2022]
Abstract
OBJECTIVE Caring for a child with illness or a child with disability impacts family in various ways. The ability to assess the impact of this care on families is one way to proactively provide the necessary support and resources for impacted families. Accordingly, the goal of the current study was to assess the impact of pediatric epilepsy on individual families in a comprehensive epilepsy clinic using a slightly modified version of the Impact on Families Scale (IFS). METHODS Families of patients with epilepsy completed the IFS up to three times. The IFS score and the six categories (i.e., total impact, financial impact, general impact, family/social impact, coping, and sibling impact) were assessed using Student's two sample t-test to determine the differences between binary groups and Pearson's correlation to assess the associations with continuous variables. Linear regression modeling was used to develop a model to predict IFS score. RESULTS Three hundred and forty-one patients completed the scale at one time point, 314 at two time points, and 61 at three time points. The overall impact of epilepsy on families was 109 (95% confidence interval (CI): 106-112) at time point 1, 111 (95% CI: 108-114) at time point 2, and 112 (95% CI: 105-119) at time point 3. There was no statistical difference in IFS score among the three time points. There were no associations with age or gender. Multivariable modeling using stepwise regression indicated that treatment resistance and seizure-free status were associated with IFS score. No interaction effects were identified. CONCLUSIONS Findings from the current study suggest that the impact of epilepsy is highest for families that have children with active seizures at the time of their clinical visit and for those with children having treatment-resistant epilepsy. Although intuitive, this is the first study, to our knowledge, that has empirically verified these findings.
Collapse
Affiliation(s)
- Alex Dawes
- The Ohio State University, Columbus, OH 43210, United States; Nationwide Children's Hospital, Division of Neurology, 700 Children's Drive, Columbus, OH 43125, United States
| | - Selasi Attipoe
- The Ohio State University, Columbus, OH 43210, United States; Abigail Wexner Research Institute at Nationwide Children's Hospital, 575 Children's Crossroad, Columbus, OH 43215, United States
| | - Jackson Mittlesteadt
- University of Notre Dame, Notre Dame, IN 46556, United States; Nationwide Children's Hospital, Division of Neurology, 700 Children's Drive, Columbus, OH 43125, United States
| | - Peter Glynn
- Nationwide Children's Hospital, Division of Neurology, 700 Children's Drive, Columbus, OH 43125, United States
| | - Steve Rust
- Abigail Wexner Research Institute at Nationwide Children's Hospital, 575 Children's Crossroad, Columbus, OH 43215, United States
| | - Andrea Debs
- Nationwide Children's Hospital, Division of Neurology, 700 Children's Drive, Columbus, OH 43125, United States
| | - Anup D Patel
- Nationwide Children's Hospital, Division of Neurology, 700 Children's Drive, Columbus, OH 43125, United States.
| |
Collapse
|
10
|
Solli E, Colwell NA, Say I, Houston R, Johal AS, Pak J, Tomycz L. Deciphering the surgical treatment gap for drug-resistant epilepsy (DRE): A literature review. Epilepsia 2020; 61:1352-1364. [PMID: 32558937 DOI: 10.1111/epi.16572] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2020] [Revised: 04/28/2020] [Accepted: 05/14/2020] [Indexed: 12/18/2022]
Abstract
Patients with drug-resistant epilepsy (DRE) rarely achieve seizure freedom with medical therapy alone. Despite being safe and effective for select patients with DRE, epilepsy surgery remains heavily underutilized. Multiple studies have indicated that the overall rates of surgery in patients with DRE have stagnated in recent years and may be decreasing, even when hospitalizations for epilepsy-related problems are on the rise. Ultimately, many patients with DRE who might otherwise benefit from surgery continue to have intractable seizures, lacking access to the full spectrum of available treatment options. In this article, we review the various factors accounting for the persistent underutilization of epilepsy surgery and uncover several key themes, including the persistent knowledge gap among physicians in identifying potential surgical candidates, lack of coordinated patient care, patient misconceptions of surgery, and socioeconomic disparities impeding access to care. Moreover, factors such as the cost and complexity of the preoperative evaluation, a lack of federal resource allocation for the research of surgical therapies for epilepsy, and difficulties recruiting patients to clinical trials all contribute to this multifaceted dilemma.
Collapse
Affiliation(s)
- Elena Solli
- Department of Neurosurgery, Rutgers New Jersey Medical School, Newark, NJ, USA
| | - Nicole A Colwell
- Department of Neurosurgery, Rutgers New Jersey Medical School, Newark, NJ, USA
| | - Irene Say
- Department of Neurosurgery, Rutgers New Jersey Medical School, Newark, NJ, USA
| | - Rebecca Houston
- Department of Neurosurgery, Rutgers New Jersey Medical School, Newark, NJ, USA
| | - Anmol S Johal
- Department of Neurosurgery, Rutgers New Jersey Medical School, Newark, NJ, USA
| | - Jayoung Pak
- Department of Neurosurgery, Rutgers New Jersey Medical School, Newark, NJ, USA
| | - Luke Tomycz
- New Jersey Neuroscience Institute, Morristown, NJ, USA
| |
Collapse
|
11
|
Bone Health Screening Practices Among Neurologists in Patients on Antiepileptic Drugs: A Quality Improvement Project. Pediatr Neurol 2020; 102:49-55. [PMID: 31378440 DOI: 10.1016/j.pediatrneurol.2019.06.020] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2019] [Revised: 06/29/2019] [Accepted: 06/30/2019] [Indexed: 12/30/2022]
Abstract
BACKGROUND Pediatric patients with epilepsy are at risk for low vitamin D levels, increasing the risk for bone fractures, yet standardized bone health screening is not part of routine care. METHODS We surveyed pediatric neurologists (n = 68) at our center regarding screening practices, using an 11-item survey; constructed a bone health treatment algorithm; and developed a training intervention to improve screening rates. RESULTS The overall survey response rate was 47%. Among respondents, 64% estimated that they screened for bone health less than 25% of the time. Chart review before the intervention demonstrated an overall screening rate of 25.1% (n = 50/199). One year after implementation of a standardized algorithm, the overall screening rates increased to 53.8% (n = 100/186). The frequency of prescribing vitamin D for patients treated with antiepileptic medications increased among general neurologists (preintervention rate 16%, postintervention rate 51%, P < 0.01) as well as among epileptologists (preintervention rate 45%, postintervention rate 57%, P = 0.04). CONCLUSION In a relatively short follow-up period, there were significant changes in care patterns regarding screening for bone health in pediatric patients with epilepsy. Further implementation measures are underway to increase bone health screening and care in this population.
Collapse
|
12
|
Martello J, Shulman LM, Barr E, Gruber-Baldini A, Armstrong MJ. Assessment of Parkinson disease quality measures on 12-month patient outcomes. Neurol Clin Pract 2019; 10:58-64. [PMID: 32190421 DOI: 10.1212/cpj.0000000000000745] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2019] [Accepted: 08/15/2019] [Indexed: 11/15/2022]
Abstract
Background Quality measures (QMs) exist to operationalize guidelines by measuring adherence to guidelines through documentation, ultimately leading to improved patient outcomes. Studies are rare looking at the relationship between adherence to Parkinson disease (PD) QMs and patient outcomes. Methods We assessed adherence of our movement disorders specialists (MDSs) to the American Academy of Neurology's 2010 PD QM set through chart review using the measure set work group's criteria of documentation. We then evaluated patient outcomes to see whether there was a correlation with adherence to these QMs. Results Ninety-seven consecutive patients met the inclusion criteria. The mean disease duration was 9.3 (5.8) years. All patients were assessed by 1 of 4 MDSs. A total of 68% of QMs were documented across all patients. There was a small positive correlation between the number of documented QMs the year before the index visit and the number of calls/emails both the year before and after the index visit (r = 0.20, p = 0.04 and r = 0.26, p = 0.01, respectively.) There was a small negative correlation between the number of documented QMs and the number of PD follow-up visits the year after the index visit (r = -0.19, p = 0.05.) No other outcome showed a statistically significant correlation with the adherence to documented QMs. Conclusions We found no clinically important improvement in patient outcomes with higher adherence levels. It is important that QM developers validate QMs to ensure that they fulfill the intended goal of improved patient outcomes.
Collapse
Affiliation(s)
- Justin Martello
- Department of Neurosciences (JM), Christiana Care Health System, Newark, DE; Department of Neurology (LMS), University of Maryland School of Medicine, Baltimore, MD; Department of Epidemiology and Public Health (EB, AGB), University of Maryland School of Medicine, Baltimore, MD; and Department of Neurology (MJA), University of Florida College of Medicine, Gainesville, FL
| | - Lisa M Shulman
- Department of Neurosciences (JM), Christiana Care Health System, Newark, DE; Department of Neurology (LMS), University of Maryland School of Medicine, Baltimore, MD; Department of Epidemiology and Public Health (EB, AGB), University of Maryland School of Medicine, Baltimore, MD; and Department of Neurology (MJA), University of Florida College of Medicine, Gainesville, FL
| | - Erik Barr
- Department of Neurosciences (JM), Christiana Care Health System, Newark, DE; Department of Neurology (LMS), University of Maryland School of Medicine, Baltimore, MD; Department of Epidemiology and Public Health (EB, AGB), University of Maryland School of Medicine, Baltimore, MD; and Department of Neurology (MJA), University of Florida College of Medicine, Gainesville, FL
| | - Ann Gruber-Baldini
- Department of Neurosciences (JM), Christiana Care Health System, Newark, DE; Department of Neurology (LMS), University of Maryland School of Medicine, Baltimore, MD; Department of Epidemiology and Public Health (EB, AGB), University of Maryland School of Medicine, Baltimore, MD; and Department of Neurology (MJA), University of Florida College of Medicine, Gainesville, FL
| | - Melissa J Armstrong
- Department of Neurosciences (JM), Christiana Care Health System, Newark, DE; Department of Neurology (LMS), University of Maryland School of Medicine, Baltimore, MD; Department of Epidemiology and Public Health (EB, AGB), University of Maryland School of Medicine, Baltimore, MD; and Department of Neurology (MJA), University of Florida College of Medicine, Gainesville, FL
| |
Collapse
|
13
|
Kroner BL, Bumbut A, Berl MM, Goodkin HP, Gaillard WD. Parental perspectives on provider adherence to AAN epilepsy quality measures in rural and urban tertiary care centers. Epilepsy Behav 2019; 92:256-259. [PMID: 30731289 DOI: 10.1016/j.yebeh.2019.01.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2018] [Revised: 01/05/2019] [Accepted: 01/05/2019] [Indexed: 11/28/2022]
Abstract
Several American Academy of Neurology (AAN) epilepsy practice guidelines recommend conversations that neurologists should have with patients and their parents. We sought to determine whether parents of pediatric patients with epilepsy had knowledge of epilepsy quality measures (EQMs) and whether they recalled having discussions with their child's neurologist about each of the EQM. Surveys were distributed to parents at five clinic sites associated with epilepsy centers in Washington, DC and Charlottesville, Virginia. Key questions on the parent survey included whether neurologists had discussed, or parents had knowledge of, EQM topics which included medication side effects, safety, reproductive health, transition to adult care, learning and attention problems, bone health, sudden unexpected death in epilepsy (SUDEP), and risk of epilepsy-related death. No data were collected from the neurologist or the medical record about EQM discussions. Among 233 completed surveys, parental knowledge and neurologist discussion of EQM were highly correlated (p < .00001). Epilepsy quality measures most discussed with high parental knowledge were medication side effects, safety, learning and attention problems, and bone health. Sudden unexpected death in epilepsy was least discussed and known. We found consistent care practices in adherence to EQM across settings from urban to rural communities, with patients of all ages and epilepsy severities and staffed by neurologists with various levels of epilepsy expertise. Despite reported high rates of adherence on several measures, we identified opportunities for improvement. Querying and counseling about EQM should be an ongoing conversation which evolves with the child's age and epilepsy-associated risks.
Collapse
Affiliation(s)
- Barbara L Kroner
- RTI International, Division of Biostatistics and Epidemiology, 6110 Executive Boulevard, Rockville, MD 20852, USA.
| | - Adrian Bumbut
- Children's National Health System, Center for Neuroscience, 111 Michigan Avenue NW, Washington, DC 10010, USA.
| | - Madison M Berl
- Children's National Health System, Center for Neuroscience, 111 Michigan Avenue NW, Washington, DC 10010, USA.
| | - Howard P Goodkin
- University of Virginia Health System, Departments of Neurology and Pediatrics, 1221 Lee Street, Charlottesville, VA 22903, USA.
| | - William D Gaillard
- Children's National Health System, Center for Neuroscience, 111 Michigan Avenue NW, Washington, DC 10010, USA.
| |
Collapse
|
14
|
Owens S, Sirven JI, Shafer PO, Fishman J, Wild I, Findley M, Derry R, Walters J, Kopplin V, Kakacek J. Innovative approaches reaching underserved and rural communities to improve epilepsy care: A review of the methodology of the Connectors Project. Epilepsy Behav 2019; 90:273-283. [PMID: 30391149 DOI: 10.1016/j.yebeh.2018.09.029] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2018] [Accepted: 09/22/2018] [Indexed: 10/28/2022]
Abstract
OBJECTIVE The Connectors Project, a collaboration between the Epilepsy Foundation and UCB Pharma, was a multiyear project designed to improve epilepsy care in underserved communities. A core objective of the Connectors Project was to pilot new and innovative approaches to epilepsy awareness and education in rural and underserved areas, including standardized curricula for healthcare providers and patients. METHODS A series of consensus conferences explored opportunities and barriers to epilepsy care throughout the United States including access to local Epilepsy Foundations, neurologists, and epilepsy centers. Data from QuintilesIMS™ were examined for access to newer antiepileptic drugs (AEDs)-a proxy for quality of epilepsy care-in different regions. State factors (e.g., local epilepsy foundation office, access to newer vs. older AEDs, and geographic density and diversity) were used in selecting four states as examples of rural and underserved areas to pilot the awareness and educational programs. For each state, a work team assessed challenges and opportunities, tailored educational curricula, and developed strategies for effective delivery of the educational programs. Interventions were held between June 2016 and June 2017. Interventions consisted of outreach and awareness programs, in-person health education to healthcare providers and patients/families, and digital health education. RESULTS Michigan, Nevada, Oklahoma, and West Virginia were identified as pilot states representing geographically diverse areas, ranging from a state with a large high-density population center with several epilepsy centers and a local Epilepsy Foundation office (Michigan) to a state with predominately rural areas and a few small urban cores, two epilepsy centers, and no in-state Epilepsy Foundation office (West Virginia). State work teams tailored interventions and examined options for type, intent, ease of use, and impact. All states implemented outreach and awareness initiatives and in-person health education for patients and healthcare providers; use of digital health education was variable. Measurement of the interventions was agreed to be performed by the use of patient and physician surveys and reevaluation of data from QuintilesIMS for access to newer AEDs. CONCLUSION Local Epilepsy Foundation offices successfully connected healthcare providers in rural and underserved areas to epilepsy education designed to enhance quality care in epilepsy. Educational opportunities for people with epilepsy and their families addressed critical gaps in accessing quality epilepsy care and self-management. Tailored and innovative educational approaches can be used to increase awareness levels and to overcome geographic challenges in reaching underserved populations. Relationship building and repeated, consistent engagement with healthcare providers and patients can assist in improving communication and self-management skills among patients with epilepsy.
Collapse
Affiliation(s)
- Steven Owens
- Epilepsy Foundation, 8301 Professional Place-East, Suite 200, Landover, MD 20785, USA.
| | - Joseph I Sirven
- Department of Neurology, Mayo Clinic, 5777 East Mayo Boulevard, Phoenix, AZ 85054, USA.
| | - Patricia O Shafer
- Epilepsy Foundation, 8301 Professional Place-East, Suite 200, Landover, MD 20785, USA; Department of Neurology, Beth Israel Deaconess Medical Center, 330 Brookline Avenue, Boston, MA 02215, USA.
| | - Jesse Fishman
- UCB Pharma, 1950 Lake Park Drive SE, Smyrna, GA 30080, USA.
| | - Imane Wild
- UCB Pharma, 1950 Lake Park Drive SE, Smyrna, GA 30080, USA.
| | - Mark Findley
- Epilepsy Foundation of Greater Cincinnati, 895 Central Avenue, Suite 550, Cincinnati, OH 45202, USA.
| | - Russell Derry
- Epilepsy Foundation of Michigan, 25200 Telegraph Road, Suite 110, Southfield, MI 48033, USA.
| | - Jenniafer Walters
- Epilepsy Foundation of Oklahoma, 11212 North May Avenue Suite 108, Oklahoma City, OK 73120, USA.
| | - Vicki Kopplin
- Epilepsy Foundation of Minnesota, 8301 Professional Place East, Suite 200, St. Paul, MN 20785, USA.
| | - Jody Kakacek
- Epilepsy Foundation, 8301 Professional Place-East, Suite 200, Landover, MD 20785, USA.
| |
Collapse
|
15
|
Strzelczyk A, Griebel C, Lux W, Rosenow F, Reese JP. The Burden of Severely Drug-Refractory Epilepsy: A Comparative Longitudinal Evaluation of Mortality, Morbidity, Resource Use, and Cost Using German Health Insurance Data. Front Neurol 2017; 8:712. [PMID: 29312132 PMCID: PMC5743903 DOI: 10.3389/fneur.2017.00712] [Citation(s) in RCA: 83] [Impact Index Per Article: 11.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2017] [Accepted: 12/11/2017] [Indexed: 01/14/2023] Open
Abstract
Purpose To evaluate long-term outcome of three years and treatment patterns of patients suffering from severely drug-refractory epilepsy (SDRE). Methods This analysis was population-based and retrospective, with data collected from four million individuals insured by statutory German health insurance. ICD-10 codes for epilepsy (G40*) and intake of anticonvulsants were used to identify prevalent cases, which were then compared with a matched cohort drawn from the population at large. Insurance data were available from 2008 to 2013. Any patient who had been prescribed with at least four different antiepileptic drugs (AEDs) in an 18-month period was defined as an SDRE case. Results A total of 769 patients with SDRE were identified. Of these, 19% were children and adolescents; the overall mean age was 42.3 years, 45.4% were female and 54.6% male. An average of 2.7 AEDs per patient was prescribed during the first follow-up year. The AEDs most commonly prescribed were: levetiracetam (53.5%), lamotrigine (41.4%), valproate (41.3%), lacosamide (20.4%), and topiramate (17.8%). During 3-year follow-up, there was an annual rate of hospitalization in the range 42.7 to 55%, which was significantly higher than the 11.6–12.8% (p < 0.001) for the matched controls. Admissions to hospital because of epilepsy ranged between 1.7 and 1.9 per year, with an average duration for each epilepsy-caused hospitalization of 10–11.1 days. The number of comorbidities for SDRE patients was significantly increased compared with the matched controls: depression (28% against 10%), vascular disorders (22% against 5%), and injury rates were also higher (head 16% against 3%, trunk and limbs 16% against 8%). The 3-year mortality rate for SDRE patients was 14% against 2.1% in the matched cohort. Conclusion SDRE patients are treated with AED polytherapy for all of the 3-year follow-up period. They are hospitalized more frequently than the general population and show increased morbidity levels and a sevenfold increase in mortality rate over 3 years. Further examination is required of ways in which new approaches to treatment could lead to better outcomes in severely affected patients.
Collapse
Affiliation(s)
- Adam Strzelczyk
- Epilepsy Center Frankfurt Rhine-Main, Department of Neurology, Goethe University, Frankfurt am Main, Germany.,Epilepsy Center Hessen, Department of Neurology, Philipps-University Marburg, Marburg, Germany
| | | | - Wolfram Lux
- HGC GesundheitsConsult GmbH, Düsseldorf, Germany
| | - Felix Rosenow
- Epilepsy Center Frankfurt Rhine-Main, Department of Neurology, Goethe University, Frankfurt am Main, Germany.,Epilepsy Center Hessen, Department of Neurology, Philipps-University Marburg, Marburg, Germany
| | - Jens-Peter Reese
- Institute of Health Service Research and Clinical Epidemiology, Coordinating Center for Clinical Trials, Philipps-University Marburg, Marburg, Germany
| |
Collapse
|
16
|
Fishman J, Cohen G, Josephson C, Collier AM, Bharatham S, Zhang Y, Wild I. Patient emotions and perceptions of antiepileptic drug changes and titration during treatment for epilepsy. Epilepsy Behav 2017; 69:44-52. [PMID: 28222341 DOI: 10.1016/j.yebeh.2017.01.032] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2016] [Revised: 01/30/2017] [Accepted: 01/31/2017] [Indexed: 11/18/2022]
Abstract
OBJECTIVE To investigate the impact of antiepileptic drug (AED) change and dose titration on the emotional well-being of patients with epilepsy. METHODS Members of an online epilepsy community were invited to voluntarily participate in an online survey. The cross-sectional anonymous survey consisted of 31 multiple choice questions balanced in terms of variety and positivity/negativity of emotions concerning participants' most recent AED change. To substantiate survey results, spontaneous comments from epilepsy-related online forums and social media websites that mentioned participants' experiences with AED medication changes (termed passive listening statements) were analyzed and categorized by theme. RESULTS All 345 survey participants (270 [78.3%] female; 172 [49.9%] were 26-45years old) self-reported an epilepsy/seizure diagnosis and were currently taking seizure medication; 263 (76.2%) were taking ≥2 AEDs and 301 (87.2%) had ≥1 seizure in the previous 18months. All participants reported a medication change within the previous 12months (dose increased [153 participants (44.3%)], medication added [105 (30.4%)], dose decreased [49 (14.2%)], medication removed [38 (11.0%)]). Improving seizure control (247 [71.6%]) and adverse events (109 [31.6%]) were the most common reasons for medication change. Primary emotions most associated (≥10% of participants) with an AED regimen change were (before medication change; during/after medication change) hopefulness (50 [14.5%]; 43 [12.5%]), uncertainty (50 [14.5%]; 69 [20.0%]), and anxiety (35 [10.1%]; 45 [13.0%]), and were largely due to concerns whether the change would work (212/345 [61.4%]; 180/345 [52.2%]). In the text analysis segment aimed at validating the survey, 230 participants' passive listening statements about medication titration were analyzed; additional seizure activity during dose titration (93 [40.4%]), adverse events during titration (71 [30.9%]), higher medication dosages (33 [14.3%]), and drug costs (25 [10.9%]) were the most commonly noted concerns. CONCLUSION Although the emotional well-being of patients with epilepsy is complex, our study results suggest that participants report their emotional well-being as negatively affected by changes in AED regimen, with most patients reporting uncertainty regarding the outcome of such a change. Future research is warranted to explore approaches to alleviate patient concerns associated with AED medication changes.
Collapse
Affiliation(s)
- Jesse Fishman
- UCB Pharma, 1950 Lake Park Drive SE, Smyrna, GA 30080, USA.
| | - Greg Cohen
- UCB Pharma, 1950 Lake Park Drive SE, Smyrna, GA 30080, USA.
| | - Colin Josephson
- Department of Clinical Neurosciences, University of Calgary, Cummings School of Medicine, Foothills Medical Center, 1403 29th St NW, Calgary, Alberta T2N 2T9, Canada.
| | - Ann Marie Collier
- St Mary's Hospital, 750 Wellington Ave, Grand Junction, CO 81501, USA.
| | | | - Ying Zhang
- UCB Pharma, 1950 Lake Park Drive SE, Smyrna, GA 30080, USA.
| | - Imane Wild
- UCB Pharma, 1950 Lake Park Drive SE, Smyrna, GA 30080, USA.
| |
Collapse
|
17
|
Hill CE, Thomas B, Sansalone K, Davis KA, Shea JA, Litt B, Dahodwala N. Improved availability and quality of care with epilepsy nurse practitioners. Neurol Clin Pract 2017; 7:109-117. [PMID: 28409062 DOI: 10.1212/cpj.0000000000000337] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2016] [Accepted: 12/02/2016] [Indexed: 11/15/2022]
Abstract
BACKGROUND This study investigated the quality of care delivered by nurse practitioner (NP)-physician teams employed to expand clinic appointment availability for patients with epilepsy. METHODS We performed a retrospective observational cohort study of patients with epilepsy presenting to the Penn Epilepsy Center for a new patient appointment in 2014. During this time, patients were seen either by an NP-physician team care model or a more traditional physician-only care model. These care models were compared with regard to adherence to the 2014 American Academy of Neurology epilepsy quality measures at the initial visit. Clinical outcomes of seizure frequency, presentations to the Emergency Department, injury, and death were assessed over the subsequent year. RESULTS A total of 169 patients were identified by our inclusion and exclusion criteria: 65 patients in the NP-physician team care model cohort and 104 patients in the physician-only care model cohort. The NP-physician team care model saw, on average, 3 more patients per clinic session. There were no meaningful differences between these cohorts in baseline characteristics. The NP-physician team care model showed equivalent adherence to the physician-only care model for the epilepsy quality measures, with superior adherence to the counseling measures of querying for side effects, provision of personalized epilepsy safety education, and screening for behavioral health disorders. The 2 care models performed similarly in all clinical outcomes. CONCLUSIONS An NP-physician team care model employed to increase availability of care could also improve quality of care delivered.
Collapse
Affiliation(s)
- Chloe E Hill
- Departments of Neurology (CEH, BT, KS, KAD, BL, ND) and Medicine (JAS), University of Pennsylvania, Philadelphia
| | - Bethany Thomas
- Departments of Neurology (CEH, BT, KS, KAD, BL, ND) and Medicine (JAS), University of Pennsylvania, Philadelphia
| | - Kimberly Sansalone
- Departments of Neurology (CEH, BT, KS, KAD, BL, ND) and Medicine (JAS), University of Pennsylvania, Philadelphia
| | - Kathryn A Davis
- Departments of Neurology (CEH, BT, KS, KAD, BL, ND) and Medicine (JAS), University of Pennsylvania, Philadelphia
| | - Judy A Shea
- Departments of Neurology (CEH, BT, KS, KAD, BL, ND) and Medicine (JAS), University of Pennsylvania, Philadelphia
| | - Brian Litt
- Departments of Neurology (CEH, BT, KS, KAD, BL, ND) and Medicine (JAS), University of Pennsylvania, Philadelphia
| | - Nabila Dahodwala
- Departments of Neurology (CEH, BT, KS, KAD, BL, ND) and Medicine (JAS), University of Pennsylvania, Philadelphia
| |
Collapse
|
18
|
Moura LMVR, Schwamm E, Moura Junior V, Seitz MP, Hsu J, Cole AJ, Schwamm LH. Feasibility of the collection of patient-reported outcomes in an ambulatory neurology clinic. Neurology 2016; 87:2435-2442. [PMID: 27815405 PMCID: PMC5177682 DOI: 10.1212/wnl.0000000000003409] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2016] [Accepted: 09/08/2016] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To determine whether patients could self-report physical and mental health assessments in the waiting room and whether these assessments would be associated with modified Rankin Scale (mRS) and Quality of Life in Epilepsy (QOLIE-10) scores. METHODS We offered iPad-based surveys to consecutive adult neurology patients at check-in to collect patient-reported outcome measures (PROMs). We collected demographic and clinical data on 6,075 patients through survey or administrative claims and PROMs from participating patients. We compared demographic characteristics of participants and nonparticipants and tested associations between physical and mental health scores and mRS and QOLIE-10. RESULTS Of 6,075 patients seen by neurologists during the study period, 2,992 (49.3%) participated in the survey. Compared to nonparticipating patients, participating patients more often were privately insured (53.5% vs 42.7%, p < 0.01), married (51.5% vs 47.9%, p < 0.01), and seen in general neurology (nonsubspecialty) clinics (53.1% vs 46.6%, p < 0.01) and more likely to report English as their preferred language (50.1% vs 38.4%, p < 0.01). Participating patients had a mean physical health T score of 28.7 (SD 15) and mental health T score of 33 (SD 15), which were 3 and 2 SD worse than the average for the US general population, respectively. Mean T scores in every category of the mRS were different from every other category (n = 232, p < 0.01). Patient Reported Outcomes Measurement Information System-10 T scores were linearly associated with QOLIE-10 scores (n = 202, p < 0.01) CONCLUSIONS: Systematic digital collection of PROMs is feasible. Differences among survey participants and nonparticipants highlight the need to develop multilingual measurement tools that may improve collection from vulnerable populations.
Collapse
Affiliation(s)
- Lidia M V R Moura
- From the Department of Neurology (L.M.V.R.M., E.S., V.M.J., M.P.S., A.J.C., L.H.S.) and Mongan Institute for Health Policy (J.H.), Massachusetts General Hospital, Boston.
| | - Eli Schwamm
- From the Department of Neurology (L.M.V.R.M., E.S., V.M.J., M.P.S., A.J.C., L.H.S.) and Mongan Institute for Health Policy (J.H.), Massachusetts General Hospital, Boston
| | - Valdery Moura Junior
- From the Department of Neurology (L.M.V.R.M., E.S., V.M.J., M.P.S., A.J.C., L.H.S.) and Mongan Institute for Health Policy (J.H.), Massachusetts General Hospital, Boston
| | - Michael P Seitz
- From the Department of Neurology (L.M.V.R.M., E.S., V.M.J., M.P.S., A.J.C., L.H.S.) and Mongan Institute for Health Policy (J.H.), Massachusetts General Hospital, Boston
| | - John Hsu
- From the Department of Neurology (L.M.V.R.M., E.S., V.M.J., M.P.S., A.J.C., L.H.S.) and Mongan Institute for Health Policy (J.H.), Massachusetts General Hospital, Boston
| | - Andrew J Cole
- From the Department of Neurology (L.M.V.R.M., E.S., V.M.J., M.P.S., A.J.C., L.H.S.) and Mongan Institute for Health Policy (J.H.), Massachusetts General Hospital, Boston
| | - Lee H Schwamm
- From the Department of Neurology (L.M.V.R.M., E.S., V.M.J., M.P.S., A.J.C., L.H.S.) and Mongan Institute for Health Policy (J.H.), Massachusetts General Hospital, Boston
| |
Collapse
|
19
|
Strzelczyk A, Bergmann A, Biermann V, Braune S, Dieterle L, Forth B, Kortland LM, Lang M, Peckmann T, Schöffski O, Sigel KO, Rosenow F. Neurologist adherence to clinical practice guidelines and costs in patients with newly diagnosed and chronic epilepsy in Germany. Epilepsy Behav 2016; 64:75-82. [PMID: 27732920 DOI: 10.1016/j.yebeh.2016.07.037] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2016] [Revised: 07/08/2016] [Accepted: 07/25/2016] [Indexed: 12/01/2022]
Abstract
PURPOSE The aim of this study was to evaluate physician adherence to the German Neurological Society guidelines of 2008 regarding initial monotherapy and to determine the cost-of-illness in epilepsy. METHODS This was an observational cohort study using health data routinely collected at 55 outpatient neurology practices throughout Germany (NeuroTransData network). Data on socioeconomic status, course of epilepsy, anticonvulsive treatment, and direct and indirect costs were recorded using practice software-based questionnaires. RESULTS One thousand five hundred eighty-four patients with epilepsy (785 male (49.6%); mean age: 51.3±18.1years) were enrolled, of whom 507 were newly diagnosed. Initial monotherapy was started according to authorization status in 85.9%, with nonenzyme-inducing drugs in 94.3% of all AEDs. Drugs of first choice by guideline recommendations were used in 66.5%. Total annual direct costs in the first year amounted to €2194 (SD: €4273; range: €55-43,896) per patient, with hospitalization (59% of total direct costs) and anticonvulsants (30%) as the main cost factors. Annual total direct costs decreased by 29% to €1572 in the second year, mainly because of a 59% decrease in hospitalization costs. The use of first choice AEDs did not influence costs. Chronic epilepsy was present in 1077 patients, and total annual direct costs amounted to €1847 per patient, with anticonvulsants (51.0%) and hospitalization (41.0%) as the main cost factors. Potential cost-driving factors in these patients were active epilepsy and focal epilepsy syndrome. CONCLUSION This study shows excellent physician adherence to guidelines regarding initial monotherapy in adults with epilepsy. Newly diagnosed patients show higher total direct and hospital costs in the first year upon diagnosis, but these are not influenced by adherence to treatment guidelines.
Collapse
Affiliation(s)
- Adam Strzelczyk
- Epilepsy Center Frankfurt Rhine-Main and Department of Neurology, Goethe University, Frankfurt am Main, Germany; Epilepsy Center Hessen and Department of Neurology, Philipps-University, Marburg, Germany.
| | | | - Valeria Biermann
- Department of Health Management, Friedrich-Alexander-University (FAU), Erlangen-Nuremberg, Germany
| | | | | | | | - Lena-Marie Kortland
- Epilepsy Center Frankfurt Rhine-Main and Department of Neurology, Goethe University, Frankfurt am Main, Germany; Epilepsy Center Hessen and Department of Neurology, Philipps-University, Marburg, Germany
| | - Michael Lang
- NeuroTransData, NTD Study Group, Neuburg, Germany
| | | | - Oliver Schöffski
- Department of Health Management, Friedrich-Alexander-University (FAU), Erlangen-Nuremberg, Germany
| | | | - Felix Rosenow
- Epilepsy Center Frankfurt Rhine-Main and Department of Neurology, Goethe University, Frankfurt am Main, Germany; Epilepsy Center Hessen and Department of Neurology, Philipps-University, Marburg, Germany
| |
Collapse
|
20
|
Nelson GR, Filloux FM, Kerr LM. Educational Intervention Improves Compliance With AAN Guidelines for Return Epilepsy Visits: A Quality Improvement Project. J Child Neurol 2016; 31:1320-3. [PMID: 27306884 DOI: 10.1177/0883073816653200] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2015] [Accepted: 01/23/2016] [Indexed: 01/24/2023]
Abstract
In 2011, the American Academy of Neurology (AAN) released guidelines for return seizure visits detailing 8 points that should be addressed during such visits. These guidelines are designed to improve routine follow-up care for epilepsy patients. The authors performed a quality improvement project aimed at increasing compliance with these guidelines after educating providers about them. The authors performed a chart review before and after an intervention which included: education regarding the guidelines, providing materials to remind providers of the guidelines, and templates to facilitate compliance. The authors reviewed charts at 2 and 6 months after the intervention. Significant improvement in documentation of 4 of the 8 measures was observed after this educational intervention. This suggests that simple educational interventions may help providers change practice and can improve compliance with new guidelines while requiring minimal time and resources to implement.
Collapse
Affiliation(s)
- Gary R Nelson
- Department of Pediatric Neurology, University of Utah, Salt Lake City, UT, USA
| | - Francis M Filloux
- Department of Pediatric Neurology, University of Utah, Salt Lake City, UT, USA
| | - Lynne M Kerr
- Department of Pediatric Neurology, University of Utah, Salt Lake City, UT, USA
| |
Collapse
|
21
|
Moura LMVR, Carneiro TS, Thorn EL, Seitz MP, Hsu J, Cole AJ, Vickrey BG, Hoch DB. Patient perceptions of physician-documented quality care in epilepsy. Epilepsy Behav 2016; 62:90-6. [PMID: 27450312 DOI: 10.1016/j.yebeh.2016.06.024] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2016] [Revised: 06/20/2016] [Accepted: 06/21/2016] [Indexed: 10/21/2022]
Abstract
OBJECTIVE The aim of this study was to compare physician encounter documentation with patient perceptions of quality of epilepsy care and examine the association between quality and patient assessment of provider communication. METHODS We identified 505 adult patients with epilepsy aged 18years or older over a 3-year period in two large academic medical centers. We abstracted individual, clinical, and care measures from 2723 electronic clinical notes written by physicians. We then randomly selected 245 patients for a phone interview. We compared patient perceptions of care with the documented care for several established epilepsy quality measures. We also explored the association of patient's perception of provider communication with provider documentation of key encounter interventions. RESULTS There were 88 patients (36%) who completed the interviews. Fifty-seven (24%) refused to participate, and 100 (40%) could not be contacted. Participants and nonparticipants were comparable in their demographic and clinical characteristics; however, participants were more often seen by epilepsy specialists than nonparticipants (75% vs. 61.9%, p<0.01). Quality scores based on patient perceptions differed from those determined by assessing the documentation in the medical record for several quality measures, e.g., documentation of side effects of antiseizure therapy (p=0.05), safety counseling (p<0.01), and counseling for women of childbearing potential with epilepsy (McNemar's p=0.03; intraclass correlation coefficient, ICC=0.07). There was a significant, positive association between patient-reported counseling during the encounter (e.g., personalized safety counseling) and patient-reported scores of provider communication (p=0.05). CONCLUSIONS The association between the patient's recollection of counseling during the visit and his/her positive perception of the provider's communication skills highlights the importance of spending time counseling patients about their epilepsy and not just determining if seizures are controlled.
Collapse
Affiliation(s)
- Lidia M V R Moura
- Massachusetts General Hospital, Department of Neurology, Boston, United States.
| | - Thiago S Carneiro
- Massachusetts General Hospital, Department of Neurology, Boston, United States.
| | - Emily L Thorn
- Massachusetts General Hospital, Department of Neurology, Boston, United States.
| | - Michael P Seitz
- Massachusetts General Hospital, Department of Neurology, Boston, United States.
| | - John Hsu
- Massachusetts General Hospital, Department of Medicine, Mongan Institute, Boston, United States; Department of Health Care Policy, Harvard Medical School, Boston, United States.
| | - Andrew J Cole
- Massachusetts General Hospital, Department of Neurology, Boston, United States.
| | - Barbara G Vickrey
- Icahn School of Medicine at Mount Sinai, Department of Neurology, New York, United States.
| | - Daniel B Hoch
- Massachusetts General Hospital, Department of Neurology, Boston, United States.
| |
Collapse
|
22
|
Donner EJ, Waddell B, Osland K, Leach JP, Duncan S, Nashef L, Picot MC. After sudden unexpected death in epilepsy: Lessons learned and the road forward. Epilepsia 2016; 57 Suppl 1:46-53. [DOI: 10.1111/epi.13235] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/05/2015] [Indexed: 11/29/2022]
Affiliation(s)
- Elizabeth J. Donner
- Department of Paediatrics; Division of Neurology; The Hospital for Sick Children; University of Toronto; Toronto Ontario Canada
| | - Briony Waddell
- Department of Clinical Neurosciences; Western General Hospital; Edinburgh United Kingdom
| | | | - John P. Leach
- Queen Elizabeth University Hospital; University of Glasgow; Glasgow United Kingdom
| | - Susan Duncan
- Edinburgh and South East Scotland Epilepsy Service; Department of Clinical Neurosciences; Western General Hospital; Edinburgh United Kingdom
| | - Lina Nashef
- Department of Neurology; King's College Hospital; London United Kingdom
| | - Marie Christine Picot
- CHRU Montpellier; Clinical Investigation Center (CIC) & Clinical Research and Epidemiology Unit (URCE and INSERM); Montpellier France
| |
Collapse
|
23
|
Moura LMVR, Carneiro TS, Cole AJ, Hsu J, Vickrey BG, Hoch DB. Association between addressing antiseizure drug side effects and patient-reported medication adherence in epilepsy. Patient Prefer Adherence 2016; 10:2197-2207. [PMID: 27826186 PMCID: PMC5096772 DOI: 10.2147/ppa.s119973] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND AND AIM Adherence to treatment is a critical component of epilepsy management. This study examines whether addressing antiepileptic drug (AED) side effects at every visit is associated with increased patient-reported medication adherence. PATIENTS AND METHODS This study identified 243 adults with epilepsy who were seen at two academic outpatient neurology settings and had at least two visits over a 3-year period. Demographic and clinical characteristics were abstracted. Evidence that AED side effects were addressed was measured through 1) phone interview (patient-reported) and 2) medical records abstraction (physician-documented). Medication adherence was assessed using the validated Morisky Medication Adherence Scale-4. Complete adherence was determined as answering "no" to all questions. RESULTS Sixty-two (25%) patients completed the interviews. Participants and nonparticipants were comparable with respect to demographic and clinical characteristics; however, a smaller proportion of participants had a history of drug-resistant epilepsy than nonparticipants (17.7% vs 30.9%, P=0.04). Among the participants, evidence that AED side effects were addressed was present in 48 (77%) medical records and reported by 51 (82%) patients. Twenty-eight (45%) patients reported complete medication adherence. The most common reason for incomplete adherence was missed medication due to forgetfulness (n=31, 91%). There was no association between addressing AED side effects (neither physician-documented nor patient-reported) and complete medication adherence (P=0.22 and 0.20). DISCUSSION AND CONCLUSION Among patients with epilepsy, addressing medication side effects at every visit does not appear to increase patient-reported medication adherence.
Collapse
Affiliation(s)
- Lidia M V R Moura
- Department of Neurology
- Correspondence: Lidia M V R Moura, Department of Neurology, Massachusetts General Hospital, 55 Fruit Street, Wang 739D, Boston, MA 02114, USA, Tel +1 617 726 3311, Fax +1 617 726 9250, Email
| | | | | | - John Hsu
- Mongan Institute for Health Policy, Department of Medicine, Massachusetts General Hospital
- Department of Health Care Policy, Harvard Medical School, Boston, MA
| | - Barbara G Vickrey
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | | |
Collapse
|
24
|
Sigsbee B, Bever CT, Jones LK. Practice improvement requires more than guidelines and quality measures. Neurology 2015; 86:188-93. [DOI: 10.1212/wnl.0000000000002116] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2015] [Accepted: 08/19/2015] [Indexed: 11/15/2022] Open
|
25
|
Moura LMVR, Mendez DY, Jesus JD, Andrade RA, Weissman JS, Vickrey BG, Hoch DB. Association of adherence to epilepsy quality standards with seizure control. Epilepsy Res 2015; 117:35-41. [PMID: 26370916 DOI: 10.1016/j.eplepsyres.2015.08.008] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2015] [Revised: 07/24/2015] [Accepted: 08/08/2015] [Indexed: 11/24/2022]
Abstract
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.
Collapse
Affiliation(s)
- Lidia M V R Moura
- Department of Neurology, Massachusetts General Hospital, Boston, MA 02114, USA.
| | | | - Jonathan De Jesus
- Department of Neurology, Massachusetts General Hospital, Boston, MA 02114, USA.
| | - Rogger A Andrade
- Department of Neurology, Massachusetts General Hospital, Boston, MA 02114, USA.
| | - Joel S Weissman
- Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02120, USA; Department of Health Policy and Management, Harvard T Chan School of Public Health, Boston, MA 02115, USA.
| | - Barbara G Vickrey
- Department of Neurology, University of California, Los Angeles, CA 90095-1769, USA; VA Greater Los Angeles Healthcare System, Los Angeles, CA 90073, USA.
| | - Daniel B Hoch
- Department of Neurology, Massachusetts General Hospital, Boston, MA 02114, USA.
| |
Collapse
|
26
|
Fountain NB, Van Ness PC, Bennett A, Absher J, Patel AD, Sheth KN, Gloss DS, Morita DA, Stecker M. Quality improvement in neurology: Epilepsy Update Quality Measurement Set. Neurology 2015; 84:1483-7. [PMID: 25846995 DOI: 10.1212/wnl.0000000000001448] [Citation(s) in RCA: 73] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Affiliation(s)
- Nathan B Fountain
- From the Neurology Department (N.B.F.), Comprehensive Epilepsy Program, University of Virginia, Charlottesville; the Department of Neurology and Neurotherapeutics (P.C.V.N.), University of Texas Southwestern Medical Center, Dallas; the American Academy of Neurology (A.B.), Minneapolis, MN; Absher Neurology (J.A.), Greenville, SC; the Division of Neurology and Pediatrics (A.D.P.), Nationwide Children's Hospital and The Ohio State University College of Medicine, Columbus; the Division of Neurocritical Care & Emergency Neurology, Department of Neurology (K.N.S.), Yale University School of Medicine, New Haven, CT; the Department of Neurology (D.S.G.), Geisinger Health System, Danville, PA; the Department of Pediatrics, Division of Neurology (D.A.M.), Cincinnati Children's Hospital Medical Center, OH; and the Department of Patient Safety, Quality and Innovation (M.S.), Winthrop University Hospital, Mineola, NY
| | - Paul C Van Ness
- From the Neurology Department (N.B.F.), Comprehensive Epilepsy Program, University of Virginia, Charlottesville; the Department of Neurology and Neurotherapeutics (P.C.V.N.), University of Texas Southwestern Medical Center, Dallas; the American Academy of Neurology (A.B.), Minneapolis, MN; Absher Neurology (J.A.), Greenville, SC; the Division of Neurology and Pediatrics (A.D.P.), Nationwide Children's Hospital and The Ohio State University College of Medicine, Columbus; the Division of Neurocritical Care & Emergency Neurology, Department of Neurology (K.N.S.), Yale University School of Medicine, New Haven, CT; the Department of Neurology (D.S.G.), Geisinger Health System, Danville, PA; the Department of Pediatrics, Division of Neurology (D.A.M.), Cincinnati Children's Hospital Medical Center, OH; and the Department of Patient Safety, Quality and Innovation (M.S.), Winthrop University Hospital, Mineola, NY
| | - Amy Bennett
- From the Neurology Department (N.B.F.), Comprehensive Epilepsy Program, University of Virginia, Charlottesville; the Department of Neurology and Neurotherapeutics (P.C.V.N.), University of Texas Southwestern Medical Center, Dallas; the American Academy of Neurology (A.B.), Minneapolis, MN; Absher Neurology (J.A.), Greenville, SC; the Division of Neurology and Pediatrics (A.D.P.), Nationwide Children's Hospital and The Ohio State University College of Medicine, Columbus; the Division of Neurocritical Care & Emergency Neurology, Department of Neurology (K.N.S.), Yale University School of Medicine, New Haven, CT; the Department of Neurology (D.S.G.), Geisinger Health System, Danville, PA; the Department of Pediatrics, Division of Neurology (D.A.M.), Cincinnati Children's Hospital Medical Center, OH; and the Department of Patient Safety, Quality and Innovation (M.S.), Winthrop University Hospital, Mineola, NY
| | - John Absher
- From the Neurology Department (N.B.F.), Comprehensive Epilepsy Program, University of Virginia, Charlottesville; the Department of Neurology and Neurotherapeutics (P.C.V.N.), University of Texas Southwestern Medical Center, Dallas; the American Academy of Neurology (A.B.), Minneapolis, MN; Absher Neurology (J.A.), Greenville, SC; the Division of Neurology and Pediatrics (A.D.P.), Nationwide Children's Hospital and The Ohio State University College of Medicine, Columbus; the Division of Neurocritical Care & Emergency Neurology, Department of Neurology (K.N.S.), Yale University School of Medicine, New Haven, CT; the Department of Neurology (D.S.G.), Geisinger Health System, Danville, PA; the Department of Pediatrics, Division of Neurology (D.A.M.), Cincinnati Children's Hospital Medical Center, OH; and the Department of Patient Safety, Quality and Innovation (M.S.), Winthrop University Hospital, Mineola, NY
| | - Anup D Patel
- From the Neurology Department (N.B.F.), Comprehensive Epilepsy Program, University of Virginia, Charlottesville; the Department of Neurology and Neurotherapeutics (P.C.V.N.), University of Texas Southwestern Medical Center, Dallas; the American Academy of Neurology (A.B.), Minneapolis, MN; Absher Neurology (J.A.), Greenville, SC; the Division of Neurology and Pediatrics (A.D.P.), Nationwide Children's Hospital and The Ohio State University College of Medicine, Columbus; the Division of Neurocritical Care & Emergency Neurology, Department of Neurology (K.N.S.), Yale University School of Medicine, New Haven, CT; the Department of Neurology (D.S.G.), Geisinger Health System, Danville, PA; the Department of Pediatrics, Division of Neurology (D.A.M.), Cincinnati Children's Hospital Medical Center, OH; and the Department of Patient Safety, Quality and Innovation (M.S.), Winthrop University Hospital, Mineola, NY
| | - Kevin N Sheth
- From the Neurology Department (N.B.F.), Comprehensive Epilepsy Program, University of Virginia, Charlottesville; the Department of Neurology and Neurotherapeutics (P.C.V.N.), University of Texas Southwestern Medical Center, Dallas; the American Academy of Neurology (A.B.), Minneapolis, MN; Absher Neurology (J.A.), Greenville, SC; the Division of Neurology and Pediatrics (A.D.P.), Nationwide Children's Hospital and The Ohio State University College of Medicine, Columbus; the Division of Neurocritical Care & Emergency Neurology, Department of Neurology (K.N.S.), Yale University School of Medicine, New Haven, CT; the Department of Neurology (D.S.G.), Geisinger Health System, Danville, PA; the Department of Pediatrics, Division of Neurology (D.A.M.), Cincinnati Children's Hospital Medical Center, OH; and the Department of Patient Safety, Quality and Innovation (M.S.), Winthrop University Hospital, Mineola, NY
| | - David S Gloss
- From the Neurology Department (N.B.F.), Comprehensive Epilepsy Program, University of Virginia, Charlottesville; the Department of Neurology and Neurotherapeutics (P.C.V.N.), University of Texas Southwestern Medical Center, Dallas; the American Academy of Neurology (A.B.), Minneapolis, MN; Absher Neurology (J.A.), Greenville, SC; the Division of Neurology and Pediatrics (A.D.P.), Nationwide Children's Hospital and The Ohio State University College of Medicine, Columbus; the Division of Neurocritical Care & Emergency Neurology, Department of Neurology (K.N.S.), Yale University School of Medicine, New Haven, CT; the Department of Neurology (D.S.G.), Geisinger Health System, Danville, PA; the Department of Pediatrics, Division of Neurology (D.A.M.), Cincinnati Children's Hospital Medical Center, OH; and the Department of Patient Safety, Quality and Innovation (M.S.), Winthrop University Hospital, Mineola, NY
| | - Diego A Morita
- From the Neurology Department (N.B.F.), Comprehensive Epilepsy Program, University of Virginia, Charlottesville; the Department of Neurology and Neurotherapeutics (P.C.V.N.), University of Texas Southwestern Medical Center, Dallas; the American Academy of Neurology (A.B.), Minneapolis, MN; Absher Neurology (J.A.), Greenville, SC; the Division of Neurology and Pediatrics (A.D.P.), Nationwide Children's Hospital and The Ohio State University College of Medicine, Columbus; the Division of Neurocritical Care & Emergency Neurology, Department of Neurology (K.N.S.), Yale University School of Medicine, New Haven, CT; the Department of Neurology (D.S.G.), Geisinger Health System, Danville, PA; the Department of Pediatrics, Division of Neurology (D.A.M.), Cincinnati Children's Hospital Medical Center, OH; and the Department of Patient Safety, Quality and Innovation (M.S.), Winthrop University Hospital, Mineola, NY
| | - Mona Stecker
- From the Neurology Department (N.B.F.), Comprehensive Epilepsy Program, University of Virginia, Charlottesville; the Department of Neurology and Neurotherapeutics (P.C.V.N.), University of Texas Southwestern Medical Center, Dallas; the American Academy of Neurology (A.B.), Minneapolis, MN; Absher Neurology (J.A.), Greenville, SC; the Division of Neurology and Pediatrics (A.D.P.), Nationwide Children's Hospital and The Ohio State University College of Medicine, Columbus; the Division of Neurocritical Care & Emergency Neurology, Department of Neurology (K.N.S.), Yale University School of Medicine, New Haven, CT; the Department of Neurology (D.S.G.), Geisinger Health System, Danville, PA; the Department of Pediatrics, Division of Neurology (D.A.M.), Cincinnati Children's Hospital Medical Center, OH; and the Department of Patient Safety, Quality and Innovation (M.S.), Winthrop University Hospital, Mineola, NY
| |
Collapse
|
27
|
Ladner TR, Morgan CD, Pomerantz DJ, Kennedy VE, Azar N, Haas K, Lagrange A, Gallagher M, Singh P, Abou-Khalil BW, Arain AM. Does adherence to epilepsy quality measures correlate with reduced epilepsy-related adverse hospitalizations? A retrospective experience. Epilepsia 2015; 56:e63-7. [PMID: 25809720 DOI: 10.1111/epi.12965] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/11/2015] [Indexed: 03/10/2024]
Abstract
In 2011, the American Academy of Neurology (AAN) established eight epilepsy quality measures (EQMs) for chronic epilepsy treatment to address deficits in quality of care. This study assesses the relationship between adherence to these EQMs and epilepsy-related adverse hospitalizations (ERAHs). A retrospective chart review of 475 new epilepsy clinic patients with an ICD-9 code 345.1-9 between 2010 and 2012 was conducted. Patient demographics, adherence to AAN guidelines, and annual number of ERAHs were assessed. Fisher's exact test was used to assess the relationship between adherence to guidelines (as well as socioeconomic variables) and the presence of one or more ERAH per year. Of the eight measures, only documentation of seizure frequency, but not seizure type, correlated with ERAH (relative risk [RR] 0.343, 95% confidence interval [CI] 0.176-0.673, p = 0.010). Among patients in the intellectually disabled population (n = 70), only review/request of neuroimaging correlated with ERAH (RR 0.128, 95% CI 0.016-1.009, p = 0.004). ERAHs were more likely in African American patients (RR 2.451, 95% CI 1.377-4.348, p = 0.008), Hispanic/Latino patients (RR 4.016, 95% CI 1.721-9.346, p = 0.016), Medicaid patients (RR 2.217, 95% CI 1.258-3.712, p = 0.009), and uninsured patients (RR 2.667, 95% CI 1.332-5.348, p = 0.013). In this retrospective series, adherence to the eight AAN quality measures did not strongly correlate with annual ERAH.
Collapse
Affiliation(s)
- Travis R Ladner
- Department of Neurology, Vanderbilt University School of Medicine, Nashville, Tennessee, U.S.A
| | - Clinton D Morgan
- Department of Neurology, Vanderbilt University School of Medicine, Nashville, Tennessee, U.S.A
| | - Daniel J Pomerantz
- Department of Neurology, Vanderbilt University School of Medicine, Nashville, Tennessee, U.S.A
| | - Vanessa E Kennedy
- Department of Neurology, Vanderbilt University School of Medicine, Nashville, Tennessee, U.S.A
| | - Nabil Azar
- Department of Neurology, Vanderbilt University School of Medicine, Nashville, Tennessee, U.S.A
| | - Kevin Haas
- Department of Neurology, Vanderbilt University School of Medicine, Nashville, Tennessee, U.S.A
| | - Andre Lagrange
- Department of Neurology, Vanderbilt University School of Medicine, Nashville, Tennessee, U.S.A
| | - Martin Gallagher
- Department of Neurology, Vanderbilt University School of Medicine, Nashville, Tennessee, U.S.A
| | - Pradumna Singh
- Department of Neurology, Vanderbilt University School of Medicine, Nashville, Tennessee, U.S.A
| | - Bassel W Abou-Khalil
- Department of Neurology, Vanderbilt University School of Medicine, Nashville, Tennessee, U.S.A
| | - Amir M Arain
- Department of Neurology, Vanderbilt University School of Medicine, Nashville, Tennessee, U.S.A
| |
Collapse
|
28
|
Beran RG. SUDEP revisited - a decade on: have circumstances changed? Seizure 2015; 27:47-50. [PMID: 25891926 DOI: 10.1016/j.seizure.2015.02.009] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2014] [Revised: 02/11/2015] [Accepted: 02/12/2015] [Indexed: 02/08/2023] Open
Abstract
PURPOSE A paper, published a decade ago, endorsed doctors' right to avoid discussing Sudden Unexpected Death in Epilepsy (SUDEP). It did not negate discussion, advocating same where appropriate. This paper investigates the current situation to identify any changes. METHODS The tort of negligence includes a duty to discuss "material risks" and adhere to accepted practice. Within the last decade, "material risks" for SUDEP have not altered significantly and international practice discusses SUDEP with those patients who seek advice or in whom such discussion is designed to improve patient compliance. RESULTS Doctors are unlikely to be found negligent for not discussing SUDEP, acknowledging a push encouraging same, despite it being contrary to routine practice in the US, Italy, UK and elsewhere. Doctors should continue to practice the "art of medicine", discuss SUDEP when warranted and with patients seeking such advice. They must warn about risks, such as bathing alone, avoiding accident and injuries and possibly SUDEP in non-compliant patients and also consider the impact of such discussion. With no 'material' changes in the last decade, doctors must recognise when to discuss SUDEP, with which patients and in what context, accepting it may have a negative psychosocial impact on family dynamics unless discussed in a culturally competent fashion, to avoid causing additional stress for families where accepting the diagnosis of epilepsy may already prove difficult. CONCLUSION Having formed a therapeutic relationship with the patient, discussion of SUDEP should be considered within that context, acknowledging the "art of medicine" and the implications of such discussion, similar to the situation a decade ago.
Collapse
Affiliation(s)
- Roy G Beran
- Griffith University, School of Medicine, Queensland, Australia; University of New South Wales, South-Western Clinical School of Medicine, Sydney, Australia; Strategic Health Evaluators, 12 Thomas Street, Chatswood, NSW 2067, Australia.
| |
Collapse
|
29
|
Moura LMVR, Mendez DY, De Jesus J, Andrade RA, Hoch DB. Quality care in epilepsy: Women's counseling and its association with folic acid prescription or recommendation. Epilepsy Behav 2015; 44:151-4. [PMID: 25705826 DOI: 10.1016/j.yebeh.2014.12.039] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2014] [Revised: 11/29/2014] [Accepted: 12/26/2014] [Indexed: 10/24/2022]
Abstract
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.
Collapse
Affiliation(s)
- Lidia M V R Moura
- Department of Neurology, Massachusetts General Hospital, Boston, MA 02114, USA.
| | | | - Jonathan De Jesus
- Department of Neurology, Massachusetts General Hospital, Boston, MA 02114, USA.
| | - Rogger A Andrade
- Department of Neurology, Massachusetts General Hospital, Boston, MA 02114, USA.
| | - Daniel B Hoch
- Department of Neurology, Massachusetts General Hospital, Boston, MA 02114, USA.
| |
Collapse
|
30
|
Beran RG. Sudden unexpected death in epilepsy. Epilepsy Behav 2015; 44:251-2. [PMID: 25729003 DOI: 10.1016/j.yebeh.2014.12.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2014] [Accepted: 12/04/2014] [Indexed: 02/08/2023]
Affiliation(s)
- Roy G Beran
- School of Medicine, Griffith University, Australia; UNSW, Australia.
| |
Collapse
|
31
|
Sudden unexpected death in epilepsy (SUDEP): what do patients think? Epilepsy Behav 2015; 42:29-34. [PMID: 25499158 DOI: 10.1016/j.yebeh.2014.11.007] [Citation(s) in RCA: 49] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2014] [Revised: 11/06/2014] [Accepted: 11/08/2014] [Indexed: 11/20/2022]
Abstract
OBJECTIVES Sudden unexpected death in epilepsy (SUDEP) is a major cause of mortality in epilepsy. Despite its devastating consequences, SUDEP appears to be poorly discussed with patients by health professionals. The risk of causing psychological distress to the patient is highlighted as a reason for not discussing SUDEP. However, no studies have assessed the adult patients' views on this important question. We conducted this cross-sectional study to evaluate the awareness and perspectives on SUDEP among adult patients with epilepsy. METHODS One hundred five consecutive adult patients with epilepsy, referred to the Epilepsy Clinic of a tertiary hospital between October 2012 and November 2013, were surveyed to ascertain their views and understanding of SUDEP. The data were analyzed using logistic regression to explore the association between patients' awareness of SUDEP and characteristics such as age, gender, duration of epilepsy, level of education, and employment. RESULTS Awareness of SUDEP among adult patients with epilepsy was poor (14.3%). However, the vast majority (89.5%) wished to be informed about SUDEP, and 59% requested detailed information. The treating neurologist was considered to be the most appropriate source of SUDEP information by 85.6% of patients. Multivariable analysis of the data showed no association between characteristics of patients (age, gender, duration of epilepsy, level of education, and employment) and their awareness of SUDEP or desire to get SUDEP-related information. CONCLUSIONS Our study suggests that the majority of adult patients wish to be informed about SUDEP. This is in contrast to the general reluctance of medical professionals to inform all patients routinely about this condition.
Collapse
|
32
|
Roberts JI, Hrazdil C, Wiebe S, Sauro K, Vautour M, Wiebe N, Jetté N. Neurologists' knowledge of and attitudes toward epilepsy surgery: a national survey. Neurology 2014; 84:159-66. [PMID: 25503624 DOI: 10.1212/wnl.0000000000001127] [Citation(s) in RCA: 75] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVES In the current study, we aim to assess potential neurologist-related barriers to epilepsy surgery among Canadian neurologists. METHODS A 29-item, pilot-tested questionnaire was mailed to all neurologists registered to practice in Canada. Survey items included the following: (1) type of medical practice, (2) perceptions of surgical risks and benefits, (3) knowledge of existing practice guidelines, and (4) barriers to surgery for patients with epilepsy. Neurologists who did not complete the questionnaire after the initial mailing were contacted a second time by e-mail, fax, or telephone. After this reminder, the survey was mailed a second time to any remaining nonresponders. RESULTS In total, 425 of 796 neurologists returned the questionnaire (response rate 53.5%). Respondents included 327 neurologists who followed patients with epilepsy in their practice. More than half (56.6%) of neurologists required patients to be drug-resistant and to have at least one seizure per year before considering surgery, and nearly half (48.6%) failed to correctly define drug-resistant epilepsy. More than 75% of neurologists identified inadequate health care resources as the greatest barrier to surgery for patients with epilepsy. CONCLUSIONS A substantial proportion of Canadian neurologists are unaware of recommended standards of practice for epilepsy surgery. Access also appears to be a significant barrier to epilepsy surgery and surgical evaluation. As a result, we are concerned that patients with epilepsy are receiving inadequate care. A greater emphasis must be placed on knowledge dissemination and ensuring that the infrastructure and personnel are in place to allow patients to have timely access to this evidence-based treatment.
Collapse
Affiliation(s)
- Jodie I Roberts
- From the Department of Clinical Neurosciences and Hotchkiss Brain Institute (J.I.R., C.H., S.W., K.S., M.V., N.W., N.J.), and Department of Community Health Sciences and O'Brien Institute for Public Health (J.I.R., S.W., K.S., N.J.), University of Calgary; and Department of Medicine (C.H.), Division of Neurology, University of British Columbia, Vancouver, Canada
| | - Chantelle Hrazdil
- From the Department of Clinical Neurosciences and Hotchkiss Brain Institute (J.I.R., C.H., S.W., K.S., M.V., N.W., N.J.), and Department of Community Health Sciences and O'Brien Institute for Public Health (J.I.R., S.W., K.S., N.J.), University of Calgary; and Department of Medicine (C.H.), Division of Neurology, University of British Columbia, Vancouver, Canada
| | - Samuel Wiebe
- From the Department of Clinical Neurosciences and Hotchkiss Brain Institute (J.I.R., C.H., S.W., K.S., M.V., N.W., N.J.), and Department of Community Health Sciences and O'Brien Institute for Public Health (J.I.R., S.W., K.S., N.J.), University of Calgary; and Department of Medicine (C.H.), Division of Neurology, University of British Columbia, Vancouver, Canada
| | - Khara Sauro
- From the Department of Clinical Neurosciences and Hotchkiss Brain Institute (J.I.R., C.H., S.W., K.S., M.V., N.W., N.J.), and Department of Community Health Sciences and O'Brien Institute for Public Health (J.I.R., S.W., K.S., N.J.), University of Calgary; and Department of Medicine (C.H.), Division of Neurology, University of British Columbia, Vancouver, Canada
| | - Michelle Vautour
- From the Department of Clinical Neurosciences and Hotchkiss Brain Institute (J.I.R., C.H., S.W., K.S., M.V., N.W., N.J.), and Department of Community Health Sciences and O'Brien Institute for Public Health (J.I.R., S.W., K.S., N.J.), University of Calgary; and Department of Medicine (C.H.), Division of Neurology, University of British Columbia, Vancouver, Canada
| | - Natalie Wiebe
- From the Department of Clinical Neurosciences and Hotchkiss Brain Institute (J.I.R., C.H., S.W., K.S., M.V., N.W., N.J.), and Department of Community Health Sciences and O'Brien Institute for Public Health (J.I.R., S.W., K.S., N.J.), University of Calgary; and Department of Medicine (C.H.), Division of Neurology, University of British Columbia, Vancouver, Canada
| | - Nathalie Jetté
- From the Department of Clinical Neurosciences and Hotchkiss Brain Institute (J.I.R., C.H., S.W., K.S., M.V., N.W., N.J.), and Department of Community Health Sciences and O'Brien Institute for Public Health (J.I.R., S.W., K.S., N.J.), University of Calgary; and Department of Medicine (C.H.), Division of Neurology, University of British Columbia, Vancouver, Canada.
| |
Collapse
|
33
|
Mula M, Cock HR. More than seizures: improving the lives of people with refractory epilepsy. Eur J Neurol 2014; 22:24-30. [DOI: 10.1111/ene.12603] [Citation(s) in RCA: 53] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2014] [Accepted: 09/29/2014] [Indexed: 11/30/2022]
Affiliation(s)
- M. Mula
- Atkinson Morley Epilepsy Group; St Georges NHS Trust; London UK
- St George's University of London; London UK
| | - H. R. Cock
- Atkinson Morley Epilepsy Group; St Georges NHS Trust; London UK
- St George's University of London; London UK
| |
Collapse
|
34
|
de la Morena Vicente M, Ballesteros Plaza L, Martín García H, Vidal Díaz B, Anaya Caravaca B, Pérez Martínez D. Quality measures in neurology consult care for epileptic patients. NEUROLOGÍA (ENGLISH EDITION) 2014. [DOI: 10.1016/j.nrleng.2013.06.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
|
35
|
Fitzsimons M, Dunleavy B, O’Byrne P, Dunne M, Grimson J, Kalra D, Normand C, Delanty N. Assessing the quality of epilepsy care with an electronic patient record. Seizure 2013; 22:604-10. [DOI: 10.1016/j.seizure.2013.03.002] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2012] [Revised: 03/05/2013] [Accepted: 03/07/2013] [Indexed: 11/17/2022] Open
|
36
|
Berg AT, Baca CB, Loddenkemper T, Vickrey BG, Dlugos D. Priorities in pediatric epilepsy research: improving children's futures today. Neurology 2013; 81:1166-75. [PMID: 23966254 PMCID: PMC3795602 DOI: 10.1212/wnl.0b013e3182a55fb9] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2013] [Accepted: 06/26/2013] [Indexed: 11/15/2022] Open
Abstract
The Priorities in Pediatric Epilepsy Research workshop was held in the spirit of patient-centered and patient-driven mandates for developing best practices in care, particularly for epilepsy beginning under age 3 years. The workshop brought together parents, representatives of voluntary advocacy organizations, physicians, allied health professionals, researchers, and administrators to identify priority areas for pediatric epilepsy care and research including implementation and testing of interventions designed to improve care processes and outcomes. Priorities highlighted were 1) patient outcomes, especially seizure control but also behavioral, academic, and social functioning; 2) early and accurate diagnosis and optimal treatment; 3) role and involvement of parents (communication and shared decision-making); and 4) integration of school and community organizations with epilepsy care delivery. Key factors influencing pediatric epilepsy care included the child's impairments and seizure presentation, parents, providers, the health care system, and community systems. Care was represented as a sequential process from initial onset of seizures to referral for comprehensive evaluation when needed. We considered an alternative model in which comprehensive care would be utilized from onset, proactively, rather than reactively after pharmacoresistance became obvious. Barriers, including limited levels of evidence about many aspects of diagnosis and management, access to care--particularly epilepsy specialty and behavioral health care--and implementation, were identified. Progress hinges on coordinated research efforts that systematically address gaps in knowledge and overcoming barriers to access and implementation. The stakes are considerable, and the potential benefits for reduced burden of refractory epilepsy and lifelong disabilities may be enormous.
Collapse
Affiliation(s)
- Anne T Berg
- From the Ann & Robert H. Lurie Children's Hospital of Chicago (A.T.B.), Epilepsy Center, and Northwestern Memorial Feinberg School of Medicine, Department of Pediatrics, Chicago, IL; Department of Neurology (C.B.B., B.G.V.), University of California Los Angeles; Department of Neurology (C.B.B., B.G.V.), VA Greater Los Angeles Health Care System, Los Angeles, CA; Division of Epilepsy and Clinical Neurophysiology (T.L.), Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, MA; and Pediatric Regional Epilepsy Program (D.D.), The Children's Hospital of Philadelphia, Departments of Neurology and Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
| | | | | | | | | |
Collapse
|
37
|
de la Morena Vicente MA, Ballesteros Plaza L, Martín García H, Vidal Díaz B, Anaya Caravaca B, Pérez Martínez DA. Quality measures in neurology consult care for epileptic patients. Neurologia 2013; 29:267-70. [PMID: 24035296 DOI: 10.1016/j.nrl.2013.06.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2013] [Revised: 05/26/2013] [Accepted: 06/01/2013] [Indexed: 10/26/2022] Open
Abstract
INTRODUCTION Epilepsy is one of the most frequently observed diseases in neurology outpatient care. METHODS We analysed our hospital's implementation of the 8 epilepsy quality measures proposed by the American Academy of Neurology: documented seizure types and seizure frequency, aetiology of epilepsy or the epilepsy syndrome, review of EEG, MRI, or CT results, counselling about antiepileptic drug side effects, surgical therapy referral for intractable epilepsy, and counselling about epilepsy-specific safety issues and for women of childbearing age. RESULTS In most cases, the first four quality measures were documented correctly. In 66% of the cases, doctors had asked about any adverse drug effects during every visit. Almost all patients with intractable epilepsy had been informed about surgical options or referred to a surgical centre of reference for an evaluation at some point, although referrals usually took place more than 3 years after the initial proposal. Safety issues had been explained to 37% of the patients and less than half of women of childbearing age with epilepsy had received counselling regarding contraception and pregnancy at least once a year. CONCLUSIONS The care we provide is appropriate according to many of the quality measures, but we must deliver more counselling and information necessary for the care of epileptic patients in different stages of life.
Collapse
Affiliation(s)
| | - L Ballesteros Plaza
- Sección Neurología, Hospital Universitario Infanta Cristina, Comunidad de Madrid, España
| | - H Martín García
- Sección Neurología, Hospital Universitario Infanta Cristina, Comunidad de Madrid, España
| | - B Vidal Díaz
- Sección Neurología, Hospital Universitario Infanta Cristina, Comunidad de Madrid, España
| | - B Anaya Caravaca
- Sección Neurología, Hospital Universitario Infanta Cristina, Comunidad de Madrid, España
| | - D A Pérez Martínez
- Sección Neurología, Hospital Universitario Infanta Cristina, Comunidad de Madrid, España
| |
Collapse
|
38
|
Cisneros-Franco JM, Díaz-Torres MA, Rodríguez-Castañeda JB, Martínez-Silva A, Gutierrez-Herrera MA, San-Juan D. Impact of the implementation of the AAN epilepsy quality measures on the medical records in a university hospital. BMC Neurol 2013; 13:112. [PMID: 23984949 PMCID: PMC3765766 DOI: 10.1186/1471-2377-13-112] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2013] [Accepted: 07/30/2013] [Indexed: 11/17/2022] Open
Abstract
Background The American Academy of Neurology (AAN) suggested eight quality measures to be observed at every patient visit. The aim of this work is to compare the percentage of documentation of each measure before and after the implementation of a new worksheet in a third-level center. Methods Quasi-experimental study including medical records filled by medical school seniors and junior residents supervised by an epileptologist. The authors surveyed 80 consecutive charts of people with epilepsy who were seen in the outpatient clinic before and after the intervention. McNemar change test was used to compare the percentages of documentation of each quality measure–i.e., seizure type and frequency, etiology, EEG, MRI/CT head scans, AED side effects, surgical therapy referral, safety counseling, preconception counseling–and physical exam. Each quality measure was considered to be fulfilled only if it was assessed and properly recorded. Results Mean age was 35(±13) years, 55% women, mean epilepsy onset at age 18(±15), 82% presented with partial-onset seizures. The reporting rate improved for all quality measures (previous vs new), reaching statistical significance for: seizure type 80vs94% (p < 0.05), AED side effects 8vs24%, etiology 66vs88% (p < 0.01), safety counseling 5vs64%, preconception counseling 4vs20%, and physical exam 63vs94% (p < 0.001). Conclusion A quality-oriented epilepsy worksheet led to a better practice standardization and documentation of AAN standards for diagnostic and counseling purposes. Further evaluations should be undertaken to assess the impact on medical education and patient care.
Collapse
Affiliation(s)
- J Miguel Cisneros-Franco
- Neurophysiology Department, Instituto Nacional de Neurología y Neurocirugía, Insurgentes Sur 3877, Tlalpan, Mexico City 14269, Mexico.
| | | | | | | | | | | |
Collapse
|
39
|
LaFrance WC, de Marinis AJ, Webb AF, Machan JT, Rusch MD, Kanner AM. Comparing standard medical care for nonepileptic seizures in Chile and the United States. Epilepsy Behav 2012; 25:224-9. [PMID: 23032137 DOI: 10.1016/j.yebeh.2012.07.028] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2012] [Revised: 07/26/2012] [Accepted: 07/28/2012] [Indexed: 10/27/2022]
Abstract
OBJECTIVE We sought to compare the diagnostic and treatment practices for psychogenic nonepileptic seizures (PNES) in the United States (US) to Chile. METHODS A survey on the diagnostic and treatment practices for PNES was administered to practicing clinicians in Chile. Results from 96 Chilean respondents were compared to results from 307 US clinicians. Type I error (alpha) was set to 0.005 for multiple comparisons. DIAGNOSIS The diagnosis of PNES is made by inpatient video-EEG/LTM in 89% of the US respondents compared to 25% of the Chilean respondents (p<0.0001). The diagnosis of PNES is made by history and exam alone at twice the rate in Chile (38%) than in the US (16%; p<0.0001). TREATMENT A higher proportion of the Chilean respondents (65%) endorsed psychopharmacotherapy as potentially beneficial compared to the US respondents (31%; p<0.0001). DISCUSSION This cross-cultural multi-site survey reveals some differences in PNES evaluation and management between neurologists and other clinicians in the US and in Chile. Access to video EEG may improve PNES diagnosis and treatment.
Collapse
Affiliation(s)
- W Curt LaFrance
- Division of Neuropsychiatry and Behavioral Neurology, Rhode Island Hospital, Providence, RI, USA.
| | | | | | | | | | | |
Collapse
|