Management and attitudes of epilepsy by a group of Sydney general practitioners

Management and attitudes toward patients with epilepsy in general practice: How far have we come in three decades?

BACKGROUND

Previous surveys of Australian primary care physicians' attitudes regarding epilepsy and persons with epilepsy (PWE), conducted 20-30 years ago, identified the need for further education in epilepsy care for frontline clinicians. This follow-up study of general practitioners (GPs) in Sydney was conducted to determine the degree of changes in knowledge, attitudes, and management of PWE, with the purpose of evaluating if there had been significant improvement during this period.

METHODS

A questionnaire, evaluating various aspects of epilepsy care, including investigations, preferred healthcare provider (HCP), and attitudes toward epilepsy was developed, largely based on the previous work, piloted, and completed by a representative sample of Sydney GPs.

RESULTS

A total of 52 completed responses were received. Thirty-six out of 47 GPs (77%) chose neurologists as the most important HCP followed by the GP (9/47; 18.7%). Almost half of the GPs (25/51; 49%) mentioned that they never initiated antiepileptic medication (AEM) therapy by themselves yet half of these GPs would alter the neurologist's regimen, without necessitating referral back to that neurologist. Another 27% (14/51 GPs) rarely commenced AEM therapy. Six out of 50 GPs did not mention an electroencephalogram (EEG) as a routine investigation, and 21/50 did not mention magnetic resonance imaging (MRI) as routine for PWE. The five most commonly used AEMs, identified by at least 10% of respondents, were sodium valproate (42), carbamazepine (37), levetiracetam (31), lamotrigine (16), and phenytoin (15). Emotional, behavioral, and psychosocial issues were perceived to be more common among PWE; however, they could contribute equally well to society as people without epilepsy.

CONCLUSION

The results of the study indicate a perceptual shift regarding GP's attitudes to epilepsy; however, there remain deficiencies in knowledge, particularly with regard to investigations and management. The study highlights the need for more formal training of GPs in caring for PWE.

First-aid management of tonic-clonic seizures among healthcare personnel: A survey by the Apulian section of the Italian League Against Epilepsy

INTRODUCTION

To evaluate the knowledge of healthcare workers about first-aid measures to be performed during and after a tonic-clonic seizure.

METHODS

One hundred and fifty-four healthcare workers (86 physicians) working at 8 tertiary hospitals in the Apulia region, Italy, responded to a questionnaire comprising of 28 questions based on available Italian and international recommendations about what to do during a tonic-clonic seizure.

RESULTS

One hundred and fifty-four healthcare workers completed and returned surveys with a response rate of 96.25%. There were 55 nurses (35.7%), 86 physicians (55.8%), and 13 healthcare workers with different roles (Electroencephalograph technicians, psychologists, social workers). Among physicians, there were 7 cardiologists, 3 surgeons, 12 infectious-disease specialists, 11 internal medicine specialists, 2 psychiatrists, 2 gynecologists, 27 specialists working in the emergency department, and 22 physicians with different specializations. Nearly 90% of the respondents identified head protection as important first aid, while 100% responded to not keep the legs elevated. To avoid tongue bite, both physicians and other healthcare workers would put something in the mouth (54.0%), like a Guedel cannula (71.0%) fingers (29.5%). Grabbing arms and legs, trying to stop the seizure, would be potentially performed by 11.6% of our sample. Physicians would administer a benzodiazepine during the seizure (65.7%) and during the postictal phase (29.2%), even if the patient is known to have epilepsy (23.7%), and in this case, 11.3% of respondents would administer the usual antiepileptic medications. More than half of respondents would call the emergency telephone number, because of necessary hospitalization in case of tonic-clonic seizure, even if it is experienced by a patient known to have epilepsy.

CONCLUSION

Our survey suggests the need for epilepsy educational programs on first-aid management of seizures among healthcare workers.

Epilepsy: What do health-care professionals in Riyadh know?

PURPOSE

The objective of this study was to report on the knowledge of epilepsy, as well as attitudes and practices toward individuals with epilepsy, among health-care professionals in Riyadh, the capital city of Saudi Arabia.

METHODS

A survey consisting of 23 questions pertaining to epilepsy awareness was distributed to health education workers (n=51), nutritionists (n=56), physicians (n=265), dentists (n=58), pharmacists (n=41), nurses (n=224), physiotherapists (n=65), and fifth-year medical students (n=62) in three tertiary hospitals in Riyadh.

RESULTS

Of the 822 respondents who completed the questionnaire, 100% had heard about epilepsy, and 92.6% would allow their children to interact with an individual who has epilepsy. However, 67% of respondents would not want their children to marry an individual with epilepsy, 97.9% of respondents believed that individuals with epilepsy should have the same employment opportunities as the general population, 10.5% believe that supernatural power is the cause of epilepsy, 67.2% did not know how to deal with an individual experiencing an epileptic episode, and 56% did not know that surgery was a treatment option for individuals with epilepsy in Saudi Arabia. Of the 822 respondents, 39% would not abide by a physician's advice not to operate a motor vehicle because of their illness, 91% of whom cited problems with the public transportation system as a reason for disregarding the doctor's advice. When asked if the participants had access to any information on how to deal with epilepsy during their professional training, 60.3% had access to such information during their graduate studies. Ninety-eight percent of those with access to this information were physicians and health-care educators (p<0.001). Physicians and health-care educators were significantly more aware of epilepsy than any of the other groups.

CONCLUSION

The level of epilepsy awareness among health-care professionals in Riyadh needs improvement.

Primary care doctors' management behavior with respect to epilepsy in Kerala, southern India

Although a majority of persons with epilepsy in developing countries are diagnosed, treated, and followed up by primary care doctors, few efforts have been made to examine their understanding with respect to epilepsy management. Through a questionnaire survey, we gathered information about the epilepsy management behavior of 500 primary care doctors distributed across the south Indian state of Kerala. Very few of them ever had diagnosed focal seizures, and the majority of them overutilize EEGs, prescribe continuous antiepileptic drug (AED) prophylaxis for febrile convulsions, use relatively expensive AEDs often in combination and in suboptimal doses, and did not know about alternate management options for AED-resistant epilepsies. A substantial proportion of the current large treatment gap in epilepsy in developing countries could be minimized by educating the primary care physicians about the diagnosis of epileptic seizures, cost-effective AED treatment, and need-based referral for specialized care.

Dealing with epilepsy: parents speak up

In this study, focus groups were used to examine parents' attitudes toward mental health services, use of mental health and other services, as well as service-related and other challenges encountered by parents of children with epilepsy. Both quantitative and qualitative analytic approaches were used to analyze the transcripts of 36 parents grouped into six focus groups by socioeconomic status (SES) (high, low) and ethnicity (African-American, Caucasian, Hispanic). The quantitative analyses demonstrated that, irrespective of SES and ethnicity, the parents were highly aware of their children's behavioral, emotional, and cognitive difficulties and the lack of knowledge about epilepsy among medical, educational, and mental health professionals. The higher-SES parents were significantly more concerned about inadequate educational services and the need for medical services, but less concerned about mental health and medical service use than the lower-SES parents. Insufficient knowledge about epilepsy and about services, parent emotional difficulties, and use of educational services differed significantly by ethnicity. The qualitative analyses highlighted the parents' concerns regarding misconceptions about epilepsy and the stigma toward mental health care among the African-American and Hispanic parents. These findings suggest the need for accessible and better-quality mental health, educational, and medical services for children with epilepsy irrespective of SES and ethnicity. They also underscore the importance of educating parents, service providers, and the general public about epilepsy.

Patient, caregiver, and health care practitioner knowledge of, beliefs about, and attitudes toward epilepsy

The medical literature related to knowledge of, beliefs about, and attitudes toward epilepsy was reviewed from the perspective of patients, caregivers, and health care providers. The literature points to a desire for enhanced epilepsy education by patients and caregivers; however, these needs have not been met by primary or specialty care. Surveys of general practitioners (GPs) point to limitations in knowledge and negative attitudes. GPs view their role in epilepsy care as primarily educational and tend to acknowledge their limitations by referring difficult cases. Ongoing education for GPs is important, as is an improved partnership in defining roles for care and education. Health care professionals specialized in epilepsy care acknowledge their own set of barriers to optimal care. Epilepsy education programs have been able to improve knowledge; however, long-term improvements in behavioral outcomes or quality of life are less documented. Suggestions for improvements are provided.

Unmet mental health needs in pediatric epilepsy: insights from providers

Eighteen pediatric neurologists and 18 pediatricians completed a 5-point Likert scale questionnaire on their knowledge of, attitudes toward, and management of the behavioral, cognitive, and psychosocial aspects of pediatric epilepsy, before and after a lecture on this topic. They also responded to questions about possible barriers to mental health care of children with epilepsy. The brief educational intervention modified the knowledge/attitudes of pediatricians compared with pediatric neurologists on the impact of epilepsy on behavior and cognition in children with epilepsy. However, there were no between-group differences in how providers perceived their competence to assess behavioral and cognitive comorbid conditions in pediatric epilepsy. Responses to open-ended questions suggested insufficient mental health coverage for and expertise on pediatric epilepsy, resistance of mental health clinicians to treat children with epilepsy, and the stigma of mental health as possible barriers to mental health care in children with epilepsy. In addition to the need for provider education about the behavioral and cognitive comorbid conditions of pediatric epilepsy, these findings emphasize the importance of examining alternative routes to increasing mental health care for children with epilepsy.

Initial Perspectives from Midwestern Neurologists: Epilepsy Patients' Barriers and Motivators for Seeking Treatment

PURPOSE

Epilepsy is a chronic neurological illness that affects 2.7 million people in the United States, but remains poorly understood. Care providers may not recognize their patients' need for epilepsy information, contributing to treatment barriers, such as stigmatization and poor patient-provider communication.

METHODS

The current study piloted a survey of epilepsy-related attitudes and perceptions of 33 Midwestern neurologists. The survey included questions about perceived barriers to and motivators for treatment, thoughts on misperceptions of epilepsy in the community and in the patient population, and potential interventions to address misperceptions.

RESULTS

Respondents perceived misinformation and lack of knowledge in patients and the general public that could be contributing to the barriers that exist to treat patients adequately. Respondents suggested potential methods for addressing misperceptions effectively.

DISCUSSION

This study of neurologists' perceptions about epilepsy barriers and needs provides an important perspective for the development of interventions to address misperceptions and barriers among patients and the public.

The general practice management of epilepsy in Perth, Western Australia

Ninety randomly selected general practitioners from the Perth metropolitan area completed a self-administered postal questionnaire aiming to examine the extent of their involvement with epilepsy and how closely their management mirrored best practice guidelines. GPs saw a median of 6 patients with epilepsy, mainly adults. They perceived complementary roles for GPs and neurologists: the GP providing ongoing support and education, monitoring treatment and making dosage adjustments; with the neurologist largely making the formal diagnosis and other management decisions. Only 42% regarded their knowledge of epilepsy as adequate for their practice. About half advised patients on the existence of the Epilepsy Association. Some respondents overestimated the usefulness of EEG. Plasma antiepileptic drug (AED) measurements were overvalued, with 69% of respondents performing plasma levels without regard to symptoms, and 20% would alter AED doses solely on the basis of plasma levels. GPs may tolerate very frequent seizures before referring their patients for more specialised evaluation.

Psychosocial aspects of epilepsy in Oman: attitude of health personnel

PURPOSE

To assess with a questionnaire the awareness and attitudes of the doctors in Oman toward epilepsy. Attitudes of society toward epilepsy have a wide-ranging influence, affecting issues as diverse as compliance with treatment and doctor--patient communication. Recent studies in both developing and developed countries suggest that within the medical profession, there is a lack of knowledge and negative attitudes toward people with epilepsy (PWE). There are no equivalent studies for Oman or the Arab world.

METHODS

The questionnaire included queries on the backgrounds of the physicians, including their training and qualifications, the main sources of their knowledge of epilepsy, as well as their perceptions of the attributes and care requirements of PWE.

RESULTS

Sixty-two percent (n=121) of those questioned, who were medical personnel working in different regions of Oman, responded. The results suggest that, despite coming from diverse cultural backgrounds and nationalities, the practicing doctors in Oman gained knowledge of epilepsy much earlier than did their counterparts in developed countries. The majority of the respondents thought that PWE have more propensities toward dysfunctional personality and behavioral characteristics than do "normal" people. On questions relating to public image, our respondents opined that, although the general public is negative toward PWE, the realities regarding PWE should be publicized because PWE are capable of having a normal family life and being an integral part of society.

CONCLUSIONS

In spite of having an earlier exposure to seizures and sympathetic acceptance of PWE, negative views still persist on matters related to cognitive and behavior domains. It is concluded that a developing country such as Oman must inculcate more realistic perceptions and attitudes among their doctors toward PWE.

Doctors' perspectives and practices regarding epilepsy

OBJECTIVE

The main aim of this study was to evaluate the knowledge, management practices and attitudes towards people with epilepsy (PWE) by a group of general practitioners (GP) and pediatrician (PD) residents.

METHODS

A cross-sectional study was carried out in three training hospitals, and had been selected 31 GP and 47 PD who agreed with the study. The collection of data was made by self-applied structured questionnaire.

RESULTS

Many respondents have positive values about PWE, and recognize prejudice in the population against them. The residents recognize in themselves and in the colleagues lack of knowledge about PWE, and that Medical School do not give enough importance to the study of PWE. The reference of PWE to the neurologist is a common practice among the doctors. Half of them are favorable to the idea of assuming the patients clinical management after an initial clientele appraisal by the neurologist.

CONCLUSIONS

The non-neurologist doctors do not feel comfortable in managing PWE due to barriers. Our doctors complain about the undergraduate medical training related to the epilepsy. Although, there is not a clear relationship between the undergraduate medical training, referral practices and satisfaction about the management of PWE. The patients care is influenced not only by knowledge, but also by doctors' attitudes. In this way, there are other barriers, perceived or not, to providing care to PWE by the generalists, and they need to be approached in the medical undergraduate curriculum and medical continuing education.

Referral characteristics of primary care physicians for seizure patients

PURPOSE

To investigate primary care physicians' behavior with respect to referral patterns, antiepileptic drug (AED) initiation, and level of comfort in managing seizure patients.

METHODS

A cross-sectional descriptive study design was used for collecting and analyzing data. A 20-item survey was developed and mailed to 8,195 primary care physicians including family practitioners, internal medicine physicians, and obstetrics-gynecologists throughout the state of Ohio; 504 primary care physicians that interact regularly with epilepsy patients responded to the survey.

RESULTS

Two patterns of referral emerged. Data showed that the majority (n = 382) of physicians refer >/=50% of their patients, but a minority of physicians (n = 122) refer <50% of their patients. Differences between the two groups existed in three of the four research questions asked: who initiates AED therapy, comfort level, and percentage of patients referred to a neurologist. Influence of managed care on decision making was not different between the two groups.

CONCLUSIONS

A minority of primary care physicians rate themselves very comfortable with seizure patients. These same physicians refer a minority of their patients to a neurologist. As a whole, however, primary care physicians refer a majority of their seizure patients to a neurologist. Neurologists evaluate most seizure patients because most primary care physicians claim not to be extremely comfortable with evaluation and treatment of seizures. We conclude that neurologists play an essential role in the treatment of most seizure patients.

Assessing the needs of pharmacists and physicians in caring for patients with epilepsy

OBJECTIVE

To obtain primary care physicians' and community pharmacists' opinions of the Pharmacist Note, a model epilepsy patient profile maintained by the pharmacist and transmitted to the physician as needed, and the information it contains.

DESIGN

A cross-sectional descriptive study design was used for collecting and analyzing data. Separate surveys were developed and mailed to physicians and pharmacists.

PARTICIPANTS

554 primary care physicians and 114 community pharmacists in Ohio who interact regularly with epilepsy patients.

MAIN OUTCOME MEASURES

Pharmacist and physician opinions on the Pharmacist Note program.

RESULTS

Physicians ranked seizure frequency as their most useful piece of information, followed by medication compliance and drug interaction screening. For medication profile and drug interaction screening, most physicians currently use themselves as their primary source of information, although a significant number would prefer to use pharmacists as information sources in these areas (p < .05). A majority (62%) would like to have pharmacists more involved in the care of their patients. Pharmacists identified lack of time and lack of appointments with patients, inadequate pharmacy staff, and insufficient reimbursement as barriers to implementing the Pharmacist Note program.

CONCLUSION

Physicians desire pharmacist involvement in specific areas of care for patients with epilepsy, and the feasibility of implementing the Pharmacist Note and similar programs appears promising. However, pharmacists identified barriers to implementation, and these barriers need to be addressed if this type of program is to be successful.

Epilepsy management: the general practitioner's perspective

The opinions of general practitioners are considered important in the management of people with epilepsy. As part of an evaluation of the Comprehensive Epilepsy Service at The Queen Elizabeth Hospital in South Australia, 120 general practitioners were surveyed about their opinions of the Service and epilepsy issues using self-administered questionnaires. This enabled their opinions about the Service and epilepsy management to be elicited for future planning of effective service provision. The results of the evaluation showed that the Service needed to have a higher profile in the community regarding its existence and role. GPs considered they should manage the care of patients with epilepsy but a cooperative approach between GPs and the Service was important for successful management of difficult cases. Education about epilepsy for the patient and GP was also considered to be important for successful service provision. The GP's involvement in evaluation is essential for influencing the way in which health care services are delivered with regard to availability and accessibility for both themselves and their patients and should be encouraged to ensure effective epilepsy patient management.