Delivering quality care in epilepsy.
TL;DR: Quality measurement will continue in epilepsy care, so a working knowledge of the topic is required by healthcare providers, and implementation of standardized quality measures can improve the care of people with epilepsy.
Abstract: PURPOSE OF REVIEW: The science of quality of care in medicine has been emerging for the past decade, but it has only recently addressed epilepsy care. Quality of care in this sense refers to implementation of policies in large populations to improve care. This can have a large impact on epilepsy patients, as much of their care is delivered by generalists who can improve their care through the explicit direct requirements of quality measures. RECENT FINDINGS: Eight epilepsy quality performance measures were recently approved by national organizations, but only three were adopted by Medicare and only one by the National Quality Forum. The main reason for not adopting them is the lack of high-level evidence. However, there is high-level evidence for the efficacy of epilepsy surgery and use of newer antiepileptic drugs for the treatment of intractable epilepsy. Other problems are the lack of information about gaps in care and the imprecision in epilepsy diagnosis coding. SUMMARY: Quality measurement will continue in epilepsy care, so a working knowledge of the topic is required by healthcare providers. Implementation of standardized quality measures can improve the care of people with epilepsy if the measures have demonstrated efficacy and can address gaps in care, and implementation is feasible.
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TL;DR: A quality-oriented epilepsy worksheet led to a better practice standardization and documentation of AAN standards for diagnostic and counseling purposes and should be undertaken to assess the impact on medical education and patient care.
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.
18 citations
Cites background from "Delivering quality care in epilepsy..."
...; licensee BioMed Creative Commons Attribution License (http:/ distribution, and reproduction in any medium care [3], has been difficult to assess, due to the lack of widespread quality measures specifically targeted to PWE....
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...This is of special importance, given that much of the care of PWE is delivered by primary care physicians [3]....
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TL;DR: The documentation of seizure frequency is a gap in care for patients with epilepsy, providers, and systems.
Abstract: Proper documentation during neurology clinic visits is essential. Medical providers that document precise and standardized findings aid other providers, nurses, and research personnel. The American Academy of Neurology (AAN) created standardized quality measures in order to improve delivery of care for patients with epilepsy, providers, and systems. We reviewed a total of 777 charts in order to find documentation on seizure frequency from the most recent clinical visit. Data was collected from electronic healthcare records. During initial chart review, the following information was noted: age, gender, seizure type(s), etiology type(s), provider (neurologist or epileptologist), whether seizure frequency was noted, and the reason for no documentation. The data review represented a sample of the epilepsy population seen at our institution. Of the 734 individuals, 475 patients had seizure frequency documented (65%). Two hundred and fifty-nine (259) people (35%) were missing seizure frequency data. For those individuals, we determined the reasoning behind why this data was not present in the chart note. Of those 259 charts, there were 65 (25%) charts missing seizure frequency, 161 (62%) charts that were vague, and 33 (13%) charts where seizure frequency could not be determined. Based on our findings, the documentation of seizure frequency is a gap in care.
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TL;DR: In 2009, the first epilepsy quality measure set was developed which was recently updated as discussed by the authors, which represents multiple areas in epilepsy care and contain the first outcome measure published in epilepsy, as well as a rigorous process using multiple workgroup members.
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TL;DR: Different guidelines and quality measures that have been used to identify best practices, types of best practices for use in clinical care developed using each of these approaches are described, and information on how to interpret the recommendations in specific guidelines andquality measures is described.
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TL;DR: In temporal-lobe epilepsy, surgery is superior to prolonged medical therapy, and Randomized trials of surgery for epilepsy are feasible and appear to yield precise estimates of treatment effects.
Abstract: Background Randomized trials of surgery for epilepsy have not been conducted, because of the difficulties involved in designing and implementing feasible studies. The lack of data supporting the therapeutic usefulness of surgery precludes making strong recommendations for patients with epilepsy. We conducted a randomized, controlled trial to assess the efficacy and safety of surgery for temporal-lobe epilepsy. Methods Eighty patients with temporal-lobe epilepsy were randomly assigned to surgery (40 patients) or treatment with antiepileptic drugs for one year (40 patients). Optimal medical therapy and primary outcomes were assessed by epileptologists who were unaware of the patients' treatment assignments. The primary outcome was freedom from seizures that impair awareness of self and surroundings. Secondary outcomes were the frequency and severity of seizures, the quality of life, disability, and death. Results At one year, the cumulative proportion of patients who were free of seizures impairing awarenes...
2,923 citations
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TL;DR: Whether surgery soon after failure of 2 antiepileptic drug (AED) trials is superior to continued medical management in controlling seizures and improving quality of life (QOL) is sought and among patients with newly intractable disabling MTLE, resective surgery plus AED treatment resulted in a lower probability of seizures during year 2 of follow-up than continued AEDtreatment alone.
Abstract: Context Despite reported success, surgery for pharmacoresistant seizures is often seen as a last resort. Patients are typically referred for surgery after 20 years of seizures, often too late to avoid significant disability and premature death. Objective We sought to determine whether surgery soon after failure of 2 antiepileptic drug (AED) trials is superior to continued medical management in controlling seizures and improving quality of life (QOL). Design, Setting, and Participants The Early Randomized Surgical Epilepsy Trial (ERSET) is a multicenter, controlled, parallel-group clinical trial performed at 16 US epilepsy surgery centers. The 38 participants (18 men and 20 women; aged ≥12 years) had mesial temporal lobe epilepsy (MTLE) and disabling seizues for no more than 2 consecutive years following adequate trials of 2 brand-name AEDs. Eligibility for anteromesial temporal resection (AMTR) was based on a standardized presurgical evaluation protocol. Participants were randomized to continued AED treatment or AMTR 2003-2007, and observed for 2 years. Planned enrollment was 200, but the trial was halted prematurely due to slow accrual. Intervention Receipt of continued AED treatment (n = 23) or a standardized AMTR plus AED treatment (n = 15). In the medical group, 7 participants underwent AMTR prior to the end of follow-up and 1 participant in the surgical group never received surgery. Main Outcome Measures The primary outcome variable was freedom from disabling seizures during year 2 of follow-up. Secondary outcome variables were health-related QOL (measured primarily by the 2-year change in the Quality of Life in Epilepsy 89 [QOLIE-89] overall T-score), cognitive function, and social adaptation. Results Zero of 23 participants in the medical group and 11 of 15 in the surgical group were seizure free during year 2 of follow-up (odds ratio = ∞; 95% CI, 11.8 to ∞; P Conclusions Among patients with newly intractable disabling MTLE, resective surgery plus AED treatment resulted in a lower probability of seizures during year 2 of follow-up than continued AED treatment alone. Given the premature termination of the trial, the results should be interpreted with appropriate caution. Trial Registration clinicaltrials.gov Identifier: NCT00040326
902 citations
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University of Pennsylvania1, Rush University Medical Center2, Cleveland Clinic3, Vanderbilt University4, Boston University5, Cornell University6, National Institutes of Health7, Columbia University8, Harvard University9, Boston Children's Hospital10, University of Wisconsin-Madison11, University of California, San Francisco12, Nemours Foundation13, University of Illinois at Chicago14, University of Alabama at Birmingham15, Rutgers University16, University of Michigan17, Cincinnati Children's Hospital Medical Center18
TL;DR: The results of this evidence-based assessment provide guidelines for the prescription of AEDs for patients with newly diagnosed epilepsy and identify those seizure types and syndromes where more evidence is necessary.
Abstract: Objective: To assess the evidence demonstrating efficacy, tolerability, and safety of seven new antiepileptic drugs (AEDs) (gabapentin, lamotrigine, topiramate, tiagabine, oxcarbazepine, levetiracetam, and zonisamide—reviewed in the order in which these agents received approval by the US Food and Drug Administration) in the treatment of children and adults with newly diagnosed partial and generalized epilepsies. Methods: A 23-member committee, including general neurologists, pediatric neurologists, epileptologists, and doctors in pharmacy, evaluated the available evidence based on a structured literature review including MEDLINE, Current Contents, and Cochrane library for relevant articles from 1987 until September 2002, with selected manual searches up until 2003. Results: There is evidence either from comparative or dose-controlled trials that gabapentin, lamotrigine, topiramate, and oxcarbazepine have efficacy as monotherapy in newly diagnosed adolescents and adults with either partial or mixed seizure disorders. There is also evidence that lamotrigine is effective for newly diagnosed absence seizures in children. Evidence for effectiveness of the new AEDs in newly diagnosed patients with other generalized epilepsy syndromes is lacking. Conclusions: The results of this evidence-based assessment provide guidelines for the prescription of AEDs for patients with newly diagnosed epilepsy and identify those seizure types and syndromes where more evidence is necessary.
632 citations
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American Academy of Neurology1, University of Miami2, Emory University3, Columbia University4, University of Kansas5, New York University6, University of Calgary7, Centers for Disease Control and Prevention8, New York Medical College9, Johns Hopkins University10, Harvard University11, University of Maryland, Baltimore12, University of Wisconsin-Madison13, University of Tennessee Health Science Center14, Texas A&M University15, National Institutes of Health16, University of Pennsylvania17
TL;DR: A committee assembled by the AAN reassessed the evidence related to the care of women with epilepsy (WWE) during pregnancy, including antiepileptic drug (AED) teratogenicity and adverse perinatal outcomes.
Abstract: A committee assembled by the American Academy of Neurology (AAN) reassessed the evidence related to the care of women with epilepsy (WWE) during pregnancy, including antiepileptic drug (AED) teratogenicity and adverse perinatal outcomes. It is highly probable that intrauterine first-trimester valproate (VPA) exposure has higher risk of major congenital malformations (MCMs) compared to carbamazepine (CBZ), and possibly compared to phenytoin (PHT) or lamotrigine (LTG). It is probable that VPA as part of polytherapy and possible that VPA as monotherapy contribute to the development of MCMs. AED polytherapy probably contributes to the development of MCMs and reduced cognitive outcomes compared to monotherapy. Intrauterine exposure to VPA monotherapy probably reduces cognitive outcomes and monotherapy exposure to PHT or phenobarbital (PB) possibly reduces cognitive outcomes. Neonates of WWE taking AEDs probably have an increased risk of being small for gestational age and possibly have an increased risk of a 1-minute Apgar score of <7. If possible, avoidance of VPA and AED polytherapy during the first trimester of pregnancy should be considered to decrease the risk of MCMs. If possible, avoidance of VPA and AED polytherapy throughout pregnancy should be considered and avoidance of PHT and PB throughout pregnancy may be considered to prevent reduced cognitive outcomes.
221 citations
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TL;DR: Morbidity, socioeconomic characteristics, and secondary care supply are important confounding factors that explain between a third and a half of the variation in admission rates across health authority areas Performance indicators should relate to aspects of care that can be controlled by decision makers.
Abstract: Objective To investigate the impact of factors outside the control of primary care on performance indicators proposed as measures of the quality of primary care. Design Multiple regression analysis relating admission rates standardised for age and sex for asthma, diabetes, and epilepsy to socioeconomic population characteristics and to the supply of secondary care resources. Setting 90 family health services authorities in England, 1989-90 to 1994-5. Results At health authority level socioeconomic characteristics, health status, and secondary care supply factors explained 45% of the variation in admission rates for asthma, 33% for diabetes, and 55% for epilepsy. When health authorities were ranked, only four of the 10 with the highest age-sex standardised admission rates for asthma in 1994-5 remained in the top 10 when allowance was made for socioeconomic characteristics, health status, and secondary care supply factors. There was also substantial year to year variation in the rates. Conclusion Health outcomes should relate to crude rates of adverse events in the population. These give the best indication of the size of a health problem. Performance indicators, however, should relate to those aspects of care which can be altered by the staff whose performance is being measured.
202 citations