The road to quality: Paved with more than good intentions

Implementing Guidelines and Measures in Epilepsy Care

ABSTRACT

People with epilepsy must receive up-to-date, high-quality care that aligns with current understanding of basic disease mechanisms, improved diagnostic testing, and evolving medical and surgical treatments. Varying progress has been made in identifying, measuring, and mitigating epilepsy care gaps. Epilepsy guidelines and quality measures should be developed using rigorous processes informed by systematic reviews of best evidence in conjunction with prioritization of need. Epilepsy measures help operationalize guidelines and practice parameters. Most epilepsy quality indicators are process-based metrics defined by delivering care to the patient. Systematic and reliable tracking and documentation of seizure frequency using consistent language is required as a patient-reported outcome within individuals over time and across populations. Emerging literature has demonstrated gaps in epilepsy care, perhaps highlighting limitations in the dissemination and implementation of guidelines and quality measures in clinical practice. Quality improvement methods applied to clinical data registries and learning health systems may afford new opportunities to iteratively, collaboratively, and feasibly disseminate guidelines and quality measures, measure epilepsy care quality, allow for the testing of interventions to mitigate identified care gaps, and, ultimately, improve care for patients with epilepsy.

A Shortage of Neurologists - We Must Act Now: A Report From the AAN 2019 Transforming Leaders Program

In nearly every US state, a large mismatch exists between the need for neurologists and neurologic services and the availability of neurologists to provide these services. Patients with neurologic disorders are rising in prevalence and require access to high-level care to reduce disability. The current neurology mismatch reduces access to care, worsens patient outcomes, and erodes career satisfaction and quality of life for neurologists as they face increasingly insurmountable demands. As a community, we must address this mismatch in the demand and supply of neurologic care in an aggressive and sustained manner to ensure the future health of our patients and our specialty. The American Academy of Neurology has multiple ongoing initiatives to help reduce and resolve the existing mismatch. With the intent of raising awareness and widening the debate nationally, we present a strategic plan that the Academy could implement to coordinate and expand existing efforts. We characterize the suggested strategies as shaping the demand, enhancing the workforce, and advocating for neurologist value. The proposed framework is based on available data and expert opinion when data were lacking. Prioritization of strategies will vary by geography, practice setting, and local resources. The time to act is now to allow concerted effort and targeted interventions to avert this looming public health crisis.

Accuracy of ICD-10-CM claims-based definitions for epilepsy and seizure type

OBJECTIVE

To evaluate the accuracy of ICD-10-CM claims-based definitions for epilepsy and classifying seizure types in the outpatient setting.

METHODS

We reviewed electronic health records (EHR) for a cohort of adults aged 18+ years seen by six neurologists who had an outpatient visit at a level 4 epilepsy center between 01/2019-09/2019. The neurologists used a standardized documentation template to capture the diagnosis of epilepsy (yes/no/unsure), seizure type (focal/generalized/unknown), and seizure frequency in the EHR. Using linked ICD-10-CM codes assigned by the provider, we assessed the accuracy of claims-based definitions for epilepsy, focal seizure type, and generalized seizure type against the reference-standard EHR documentation by estimating sensitivity (Sn), specificity (Sp), positive predictive value (PPV), and negative predictive value (NPV).

RESULTS

There were 673 eligible outpatient encounters. After review of EHRs for standardized documentation, an analytic sample consisted of 520 encounters representing 402 unique patients. In the EHR documentation, 93.5 % (n = 486/520) of encounters were with patients with a diagnosis of epilepsy. Of those, 66.0 % (n = 321/486) had ≥1 focal seizure, 41.6 % (n = 202/486) had ≥1 generalized seizure, and 7% (n = 34/486) had ≥1 unknown seizure. An ICD-10-CM definition for epilepsy (i.e., ICD-10 G40.X) achieved Sn = 84.4 % (95 % CI 80.8-87.5%), Sp = 79.4 % (95 % CI 62.1-91.3%), PPV = 98.3 % (95 % CI 96.6-99.3%), and NPV = 26.2 % (95 % CI 18.0-35.8%). The classification of focal vs generalized/unknown seizures achieved Sn = 69.8 % (95 % CI 64.4-74.8%), Sp = 79.4 % (95 % CI 72.4-85.3%), PPV = 86.8 % (95 % CI 82.1-90.7%), and NPV = 57.5 % (95 % CI 50.8-64.0%).

CONCLUSIONS

Claims-based definitions using groups of ICD-10-CM codes assigned by neurologists in routine outpatient clinic visits at a level 4 epilepsy center performed well in discriminating between patients with and without a diagnosis of epilepsy and between seizure types.