Are You Providing Adequate Baseline Epilepsy Care?

Andrew N. Wilner, MD; Nathan B. Fountain, MD


July 08, 2015

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Dr Wilner: Welcome to Medscape. I am Dr Andrew Wilner, and I have the pleasure today of speaking with Dr Nathan Fountain. Dr Fountain is professor of neurology at the University of Virginia in Charlottesville and an epilepsy expert.

Dr Fountain, you are the lead author of a recent paper on quality improvement in neurology,[1] which specifies how to improve treatment of patients with epilepsy. Tell us: Why do we need these guidelines?

Dr Fountain: These are actually quality measures so they are a bit different from guidelines. Guidelines suggest exactly how to act or behave in a certain situation; quality measures are different because they aim to define the minimum thing that you should do during an encounter, for example, or in taking care of a patient who would need a minimum standard. Guidelines tend to be ideal care, and quality measures tend to be conceptually minimal care.

Of course, if everybody already did the minimum, then we would not have quality measures. The second component of quality measures is that they address behaviors or things that we should do in taking care of patients that we don't necessarily do universally. So, quality measures represent a gap or address a gap in care.

Dr Wilner: What are some of these quality measures?

Dr Fountain: There are seven quality measures in this paper and they build on previous quality measures from 2009.[2] The 2009 quality measures asked whether or not you collected seizure frequency at each clinic visit; whether or not you determined the etiology or decided if it was unknown at each clinic visit; whether or not you had performed an MRI and an EEG in patients at some time during the course of their epilepsy evaluation; whether or not you asked about safety issues; whether or not you referred them for epilepsy surgery if they had intractable epilepsy; and, finally, whether or not women with reproductive potential were counseled appropriately (eg, about teratogenic effects of antiepileptic drugs). These are examples of things that everybody agreed were a good idea to include, and in general, the emphasis was on performance measures (ie, if you did these things, you got credit for doing them, if appropriate).

The new measures build on this and take it one step further by asking clinicians to actually act on what they find. The idea is to move closer and closer to outcome measures so that, eventually, you could measure seizure frequency or the proportion of people who are seizure free to see whether the actions you are doing result in more seizure freedom—which is, of course, the goal for everybody.

We started with some general things that we ask people to do (eg, collecting seizure frequency at each visit). The new quality measures build directly on this and ask whether or not you acted on what you found. For example, you not only have to collect the frequency of each seizure type; so if the patient is not seizure free, then you have to either act on it or say why you didn't act on it. The new quality measures relate directly to outcomes, so in this case, the outcome is seizure freedom.

Dr Wilner: You and I both did epilepsy fellowships, and if we didn't do all of these things in our fellowship, I think they would have thrown us out. So who are these measures for?

Dr Fountain: At the beginning of using these measures, we decided that it was for all clinicians taking care of patients with epilepsy (eg, general neurologists, primary care physicians). I think your point is well taken that we would have said, during the course of training, of course, that we are doing these things. But, in fact, there have been prospective studies to determine whether clinicians do these things. And even epileptologists do not do these things universally. There are good reasons for this in some cases, but if we decided that it is the minimum care, it should be applied to everyone, including epileptologists. There are studies from epilepsy centers, from general neurology practices, and from other sources, and they include interviewing patients to ask whether their doctor actually did this. All of these sources suggest a gap for the kind of things that are in the new quality measures.

Dr Wilner: Are there ongoing studies to see whether quality improvement really happens?

Dr Fountain: There are several ongoing studies. The first question to ask is whether the old measures are being implemented. Are people doing the measures? Does it make a difference in care? For the 2009 measures, there have been studies from epilepsy centers, from general neurologists, and from other sources that clearly demonstrate that even among epileptologists, we really aren't pursuing these quality measures. If we think that these are the minimum standards, then we really should be following them.

Dr Wilner: In my practice, I am going to have to pay attention to your paper and write all of these standards down to make sure that I am not one of the guilty ones. I want to thank you very much for spending this time with Medscape and explaining these new quality measures. It will be interesting to see the next paper, which I think is going to tell us how well we are doing.


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