Adherence to outpatient epilepsy quality indicators at a tertiary epilepsy center

Adherence to epilepsy quality indicators in a tertiary referral center

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.

Construction of nursing-sensitive quality indicators for epilepsy in China: A Delphi consensus study

OBJECTIVE

The quality and safety of epilepsy care are of great importance because seizures are unpredictable. The aim of this study was to develop a set of nursing-sensitive quality indicators (NSQIs) for assessing and improving the quality of epilepsy nursing care in China.

METHODS

An international literature review, a cross-sectional survey and a qualitative study were conducted to identify candidate NSQIs for epilepsy care and compile a questionnaire. Then, two rounds of electronic Delphi studies were conducted with a panel of 27 independent experts to identify the final NSQIs for epilepsy.

RESULTS

Thirty-nine candidate NSQIs were extracted for the Delphi process. The recovery rates in the first and second rounds of expert consultations were 92.6% and 96.2%, respectively. The experts' authority coefficients of the two rounds were 0.876 and 0.878, respectively. The Kendall W value of the two rounds ranged between 0.094 and 0.200 (p<0.001). Eight structure indicators, 9 process indicators and 7 outcome indicators that represented the following three domains were included in the set of NSQIs for epilepsy: nursing resource allocation, implementation of nursing care, and outcomes of patients with epilepsy.

CONCLUSION

These NSQIs for epilepsy provide a primary foundation for monitoring and improving the quality of epilepsy nursing care in China. However, the effects of these indicators on improvements in epilepsy care and outcomes in patients need to be verified in clinical practice.

Assessment of Parkinson disease quality measures on 12-month patient outcomes

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.

Improving knowledge translation of clinical practice guidelines for epilepsy

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Parental perspectives on provider adherence to AAN epilepsy quality measures in rural and urban tertiary care centers

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.

Quality Indicator for Epilepsy Treatment 15 (QUIET-15): Intervening after recurrent seizures in the elderly

In this study, we examined the provision of care to older adults with epilepsy and compliance with the "Quality Indicator for Epilepsy Treatment 15" (QUIET-15) measure. We analyzed 2008-2010, 5% random sample of Medicare beneficiaries augmented with data from all beneficiaries who identified as a minority with claims related to seizures (780.3x) or epilepsy (345.xx). Of 36,912 identified epilepsy cases, 12.6% had ≥1 emergency room (ER) visit for seizure(s). For those who presented to ER, among those taking anti-epileptic drugs (AEDs), AED was changed in 15.4%, dose adjusted in 19.7%, and stopped in 14.9%; among those not taking AED, therapy was initiated in 68.5%. In adjusted logistic regressions, African-Americans were more likely to have recurrent seizures than Whites (OR 1.41, 95%CI 1.27-1.56), while Asians were less likely to have recurrent seizures (OR 0.71, 95%CI 0.57-0.89). There were no significant racial/ethnic differences in the likelihood of a post-seizure intervention. The chance of seizure recurrence leading to ER visit decreased with age and increased with the number of comorbidities. Patients with seizure recurrence were more likely to be taking an enzyme-inducing AED (OR 1.69, 95%CI 1.57-1.82) and receiving Part D Low Income Subsidy (OR 1.36, 95%CI 1.22-1.51). The probability of AED change after a seizure was higher for patients with ≥4 comorbidities (OR 1.69, 95%CI 1.25-2.27), patients who saw a neurologist (OR 1.49, 95%CI 1.30-1.70), and patients who were taking an enzyme-inducing AED (OR 1.47, 95%CI 1.27-1.71). Overall, a minority of Medicare beneficiaries experienced seizure recurrence that resulted in an ER visit. However, only half of them received treatment concordant with QUIET-15. Though racial differences were observed in occurrence of seizures, none were noted in the provision of care.

Improved availability and quality of care with epilepsy nurse practitioners

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.

Patient perceptions of physician-documented quality care in epilepsy

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.

Guidelines and Quality Standards for Adults with Epilepsy

Guidelines and quality measures for epilepsy care have the potential to improve the quality of epilepsy care. Quality measures are increasingly used for pay-for-performance. This article describes 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, and information on how to interpret the recommendations in specific guidelines and quality measures described elsewhere in this issue.

Association between addressing antiseizure drug side effects and patient-reported medication adherence in epilepsy

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.

Association of adherence to epilepsy quality standards with seizure control

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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