The impact of an educational intervention, the New GP Contract and NICE guidelines on anti-epilepsy therapeutic drug monitoring

The management of people with epilepsy in a city wide care home service, the impact of a GP with Special Interest in epilepsy, and Enhanced Health in Care Homes Framework

BACKGROUND

The incidence of epilepsy increases with age, especially in people diagnosed with dementia. Seizures in an elderly population are likely to have a focal onset, for which sodium channel blockers are the drug of choice. This study reviews the clinical needs and care of people with epilepsy (PWE) in a city wide care home service and assessing the impact of a GP with Special Interest in epilepsy (GPwSIe).

METHOD

The clinical notes of PWE, or with a documented single seizure, who had at any time been under the care of the service, which included a GPwSIe, providing care to all nursing and residential homes in Chester were reviewed from June 2020 to December 2022.

RESULTS

In the 102 people in the study, thirty eight (37%) had clinical input from a GPwSIe with 82% having positive outcomes. No referrals were required to secondary care.

CONCLUSION

This first comprehensive study of epilepsy in UK care homes has revealed a significant workload. A dedicated care home service, which included a GPwSIe, can meet that clinical need, prevent secondary care referral, and facilitate education for colleagues and carers. National Institute of Health and Care Excellence (NICE) guidelines for management of seizures, likely to have a focal onset, and in a population who might not be suitable for standard investigation, could be simplified for this group of people. The service is a good example of how the Enhanced Care Home Framework can facilitate improved care.

The impact of a clinical review of people with active epilepsy not under shared care by a GP with special interest

PURPOSE

To review clinical outcomes of a single face-to-face review of people with epilepsy (PWE) not under shared care, and any recommendations following a notes review of non-attendees and those under shared care, by a GP with Special Interest in epilepsy (GPwSIe).

METHOD

One hundred and eighty one PWE, not under shared care were invited for a review. In addition, fifty six people under shared care had a notes review. Interventional outcomes were reviewed after 12 months.

RESULTS

There had been ten deaths (all non-attributable to epilepsy), and six people had left the area, leaving 221 people who completed the audit. Fifty one percent attended for review, and were more likely to be in documented remission (p = 0.01). The frequency of annual GP epilepsy reviews in the following year did not rise significantly. There was a significant rise in vitamin D prescriptions (p < 0.001). Thirty seven DEXA scans were arranged, 76% were abnormal. There was reluctance by patients to withdraw medication, change multi dose, or subtherapeutic anti-seizure medication (ASM) regimes, even in the context of long-term seizure remission or inadequate seizure control. Three people achieved remission from changes made to ASM as a result of the review.

CONCLUSION

Review of PWE in primary care remains poor. Attitudes from both GPs and PWE to their condition needs evaluation in order to plan future care. Bone health is an issue easily addressed in primary care and should be promoted through education or the re-introduction of a specific QOF (Quality and Outcomes Framework) target. Guidance on bone health for ASM needs clarification. This study adds to the evidence of the effectiveness of a GPwSIe.

Educational intervention to improve appropriate digoxin therapeutic drug monitoring: a quasi-experimental study

OBJECTIVES

Our previous retrospecive study evaluating the appropriateness of serum digoxin concentration (SDC) measurements revealed errors in the timing of blood specimen collection in 98% of the tests. The aim of this study is to evaluate the appropriateness of the SDC measurements and the factors involved in inappropriate test-ordering, after training health personnel in digoxin therapeutic drug monitoring.

METHODS

This is a training-based quasi-experimental study. The residents and nurses of the Cardiology Clinic were trained first in December 2017, and refresher training courses were carried out every month throughout the study. The medical data of the inpatients receiving digoxin therapy were recorded prospectively, between January and December 2018. The appropriateness of the physicians' orders for SDC measurement was evaluated according to the criteria of the right indication and right timing of blood collection. The results are presented by descriptive statistics, Student's t-test and χ² analysis.

RESULTS

A total of 232 SDC tests were ordered for 121 patients (age: 71.0±12.6 years, 56.2% women). Of these orders,129 (55.6%) were considered appropriate: 205 (88.4%) for indication and 129 (62.9%) for blood collection timing. There was a significant correlation between inappropriate order for SDC test and the age of the patient, female gender, impairment of renal function tests, high levels of serum BNP and the number of medications used (P<0.005).

CONCLUSIONS

Approximately a one-half decrease in inappropriate tests compared with our previous study results imply that education has a positive effect on physician behaviour. However, physicians' concerns due to increased risk factors for the patient still play a role in inappropriate test-ordering.

Factors Associated with Good Seizure Control in Patients on Valproic Acid

Objective

This study aims to generate a reference range for valproic acid (VPA) in this cohort and determine the factors associated with good seizure control in patients taking this drug.

Materials and Methods

We conducted a prospective, cohort, observational study among patients with epilepsy who received VPA treatment at Hospital Kuala Lumpur. The patients were considered to have good control if they had a 50% or higher seizure reduction in the one-year study period compared with the previous year. The VPA reference range was generated from those patients who had good control and whose drug concentration values were available. Multiple logistic regression analysis with a backward likelihood ratio method was applied to assess the predicting factors for good seizure control.

Results

A total of 242 patients were recruited and followed up for one year. The VPA reference range was determined to be 40-85 mg/L. After multivariate analysis, significant predictive variables for good control were monotherapy [adjusted OR 4.74, 95% CI: 2.258, 9.947, p<0.001], non-smoking [adjusted OR 3.23, 95% CI: 1.099, 9.473, p=0.033], normal brain imaging results [adjusted OR 5.83, 95% CI: 2.507, 13.552, p<0.001], and the absence of stress [adjusted OR 19.98, 95% CI: 9.255, 42.764, p<0.001].

Conclusion

Monotherapy, non-smoking, normal brain imaging results, and the absence of stress are predictive of good seizure control in patients on VPA. However, a serum concentration of VPA in the reference range failed to predict good seizure control.

The contribution of British general practice to our knowledge of epilepsy and its effects on people

INTRODUCTION

British general practice is a good base for epidemiological research which is evidenced by the study of epilepsy.

SOURCES OF DATA

A comprehensive search of PubMed using various keywords for articles on epilepsy research performed in British general practice.

AREAS OF AGREEMENT

Studies in the setting of general practice have contributed significantly to knowledge in the field of epilepsy, especially in relation to epidemiology, studies of prognosis and treatment patterns and psychosocial aspects.

AREAS OF CONTROVERSY

The extent to which epilepsy can be managed in general practice.

GROWING POINTS

The importance of primary care research and the importance of collaborative studies between general practice, hospital and university departments.

AREAS TIMELY FOR DEVELOPING RESEARCH

The effects of interventions at general practice level on seizure control, morbidity and mortality.