Epilepsy quality performance in a national sample of neurologists and primary care providers: Characterizing trends in acute and chronic care management

Introduction: Epilepsy-specific quality indicators and performance measures have been published and revised multiple times. The application of epilepsy-specific quality measures has been demonstrated in a few healthcare systems. However, there is no information to date on changes in epilepsy performance measures over time, and across settings, in a national sample. The Department of Veterans Affairs (VA) healthcare system provides an opportunity to study the changes in epilepsy-specific performance over time, in acute versus chronic epilepsy care, as well as in primary versus specialty care. Methods: Chart extractions of newly diagnosed epilepsy and chronic care of Veterans with epilepsy within the VA system were performed. Veterans with ICD-9-CM diagnosis 345.XX and 780.39 from 2007-2014 were identified. Epilepsy-specific performance measures based on the Quality Indicators in Epilepsy Treatment (QUIET) VA measurement were ascertained for each Veteran with epilepsy. Difference in care across time (2009, 2012, and 2014), source of epilepsy care (primary care only, neurology only, and shared care between neurology and primary care) was analyzed. Differences in proportion of care measures across variables were compared using chi-square statistics. Results: Chart reviews of 2386 Veterans with epilepsy included 297 women (11.2%), 281 (10.5%) receiving acute care and 2105 (89.5%) receiving chronic care. Across all years 203 (72.5%) had electroencephalograph ordered/performed, 225 (80.4%) had neuroimaging ordered/performed, 106 (37.9%) were instructed about driving precautions, 71 (25.4%) were educated about safety and injury prevention, and 251 (89.6%) had anti-seizure medication monotherapy initiated. The proportion of people with new-onset seizures educated about diagnosis and type of seizure increased over time 30 (34.9%) in 2008, 42 (43.8%) in 2012, and 52 (53.1%). Of the 2105 Veterans receiving chronic care 864 (41.1%) encounters documented compliance of anti-seizure medication, 361 (17.15%) encounters addressed driving restrictions, 1345 (63.9%) encounters documented general education and counseling, 250 (11.9%) of encounters documented safety and injury prevention, 488 (23.2%) of encounters documented medication side effects, and 463 (22.0%) of encounters documented discussion of treatment options. With chronic epilepsy care, documentation of quality measures did not change with time. Veterans who were comanaged by primary care and neurology had a higher proportion of driving instruction and safety instructions compared to neurology or primary care alone. Discussion: In general, the epilepsy performance measures were high (>70% of new-onset epilepsy) for documentation diagnostic procedures (such as EEG and neuroimaging) and low across key educational and counseling measures (<50%). Despite the emphasis on the importance of psychosocial education and holistic management in the academic literature, through advocacy work, and during professional meetings, there was not a significant improvement in education and counseling over time. Some aspects of psychosocial education were performed better among primary care providers compared to neurolo-gists. However, more attention and work need to be dedicated on implementing and documenting education and counseling people with epilepsy in the clinical setting. Published by Elsevier Inc.