Tackling the indicators in the nGMS contract is an important step towards providing structured care for patients with epilepsy, says Dr Andrew Orr


   

Epilepsy is acknowledged as the most common serious neurological condition,1 with around half a million sufferers from active disease in the UK. However, it has until recently been something of a ‘Cinderella subject’. Thanks largely to the recent development of national guidance by the Scottish Intercollegiate Guidelines Network (SIGN)2,3 and the National Institute for Clinical Excellence,4 the condition was included in the quality and outcomes framework (QOF) of the nGMS contract.1

The recognition of epilepsy in the contract is also a reflection of the considerable efforts of the major epilepsy patient organisations to raise the profile of this distressing and debilitating illness.

Epilepsy indicators an incentive for GPs?

It is not yet clear whether allocating only 16 points to epilepsy in the contract (Table 1, below) has acted as an incentive for practices to introduce epilepsy management systems.

Table 1: Clinical indicators for epilepsy
Disease/ Indicator no Clinical indicator Points Qualifier Preferred Read code Payment stages
Records
Epilepsy 1 The practice can produce a register of patients receiving drug treatment for epilepsy 2   F25%  
Ongoing management
Epilepsy 2 The percentage of patients age 16 years and over on drug treatment for epilepsy who have a record of seizure frequency 4 Recorded in past 15 months 6675 25-90%
Epilepsy 3 The percentage of patients age 16 years and over on drug treatment for epilepsy who have a record of medication review 4 Recorded in past 15 months 8BIF 25-90%
Epilepsy 4 The percentage of patients age 16 years and over on drug treatment for epilepsy who have been convulsion-free for the past 12 months 6 Recorded in past 15 months None available 25-70%

A few practices will have had a system in place already, and will have found it relatively easy to achieve maximum points. Most practices will have tackled the epilepsy indicators as part of the greater challenge of the QOF, and may have found the effort required greater than anticipated.

Regrettably, some practices will have considered the rewards not sufficient for the effort required, and will have passed the subject by. What is evident, however, is that patients do stand to benefit from this exercise. So what have we learned at the end of the first year?

Patient register - Epilepsy 1

On the face of it, setting up a patient register looked to be a straightforward task, involving computer searches on diagnosis and anti-epileptic drug (AED) use. In reality, we have all found that this is complicated because of the number and invalidity of many of the recorded diagnoses.

In addition, around a third of all patients are on AEDs for other reasons (pain relief and psychiatric). We found that case by case scrutiny of the validity of the diagnosis and compliance with medication was needed. However, this is a one-off task and these four points will be easily attained in subsequent years.

The practice prevalence should be in the range 0.5-1.0%. A low prevalence might indicate that not all cases in the practice have been identified,and it might be worth checking this again during the current year. A high prevalence is quite likely to indicate that some of the cases are invalid, and that further ‘tidying up’ is required.

Awarding QOF points to specific diagnostic criteria, such as EEG, brain imaging or specialist referral, would have aided more accurate validation.

Seizure frequency - Epilepsy 2

This is the only indicator based on evidence. The Commission on Outcome Measurement in Epilepsy report 5 states that "seizure frequency is by far the most sensitive measure of efficacy and should be used whenever possible”.

It is essential to have this information when considering a proper medication review (see below). It can be recorded as part of a structured review programme or opportunistically during a consultation, or gleaned from hospital correspondence.

For a variety of reasons (work, driving, acceptance) patients often play down their seizure frequency, and direct questioning must be done with sensitivity.

A single seizure will invalidate a driving licence, which cannot be re-applied for until a seizure-free year has passed. This can have devastating social, economic and psychological effects for patients.

Medication review - Epilepsy 3

This indicator is vested in good clinical practice and is an essential component of a structured management programme. As with other diseases, the review should include sideeffects, interactions and compliance issues. There are, however, particular issues to consider for patients with epilepsy (Box 1, below): just ticking the box is not enough.

Box 1: Questions to ask at medication reviews
  •  

    Has maximum seizure control been achieved? Patients are often very accepting of the status quo and seizure frequency needs to be established accurately. Given the wider range of AEDs now available, a change of medication and possibly a re-referral to secondary care might be indicated
  • Are side-effects at an acceptable level? Again, patients often feel that they must accept side-effects as the price for avoiding seizures. Side-effects can be alleviated by a careful change of medication (agreed by the patient)
  • Is a hepatic enzyme inducing AED compromising contraception in a female patient? Is pregnancy being planned and, if so, has consideration been given to appropriate AED management? These issues are dealt with in detail in the SIGN 70 2 and NICE 20 4 guidelines, and also in the Royal Society of Medicine (RSM) guideline on management of epilepsy in women 6
  • Is medication needed at all? Many patients languish on AEDs long after they are clinically needed, and thus suffer unnecessarily from their side-effects.This is particularly true of those in institutional care. Both the SIGN 70 2 and the NICE 20 4 guidelines give advice on how to manage withdrawal of treatment (with patient agreement). Of course, some patients will elect to continue taking medications because of the worry about seizure recurrence with consequent loss of their driving licence, and this has to be accepted

In our practice we found that we were able to withdraw medication from 9% of patients in the initial registration process, and from a further 8% subsequently. Ironically, this means that we have a lower prevalence rate than might be expected regionally or nationally.

Given its potentially significant consequences, it is regrettable that medication review is confined to one tick box, and is awarded only four points.

Patients seizure-free for 12 months - Epilepsy 4

This indicator has no apparent evidence base; it is strange, therefore, that it attracts the greatest number of points (six). All the GP can do is to comply with making a record of the date of the last seizure, keeping this up to date within 15 months.

Other limitations of the QOF indicators

Giving high quality information to patients and considering non-clinical interventions (social and learning support) are not recognised by the QOF. This is regrettable, as these measures are strongly recommended in all the national guidelines, because they have a great influence on the wellbeing of patients.

Opportunities arising from the indicators

The inclusion of epilepsy in the QOF is a major step forward in the recognition of this significant neurological condition.

Practices will have learned much about the numbers, nature and needs of their patients who have epilepsy. I hope they will not simply ‘tick the boxes’ but will establish proper structured management programmes, as recommended by the guidelines.

Such programmes have been shown to achieve real clinical gains for patients.7 They provide opportunities to identify patients for whom seizure control can be improved and medication side-effects reduced, and some whose medication can be withdrawn altogether. The benefits experienced by patients, and the professional satisfaction felt by the primary care team, will be far more rewarding than the mere 16 points allocated.

Reference

  1. Investing in General Practice:The New General Medical Services Contract. www.bma.org.uk
  2. Scottish Intercollegiate Guidelines Network. SIGN 70. Diagnosis and management of epilepsy in adults. Edinburgh: SIGN, 2003.
  3. Scottish Intercollegiate Guidelines Network. SIGN 81. Diagnosis and management of epilepsies in children and young people. Edinburgh: SIGN, 2005.
  4. National Institute for Clinical Excellence. Guideline 20.The diagnosis and management of the epilepsies in adults and children in primary and secondary care. London: NICE, 2004.
  5. Baker GA, Camfield C, Camfield P et al. Commission on Outcome Measurement in Epilepsy, 1994-1997: final report. Epilepsia 1998; 39: 213-31.
  6. Royal Society of Medicine. Primary care guidelines for the management of females with epilepsy. London: RSM, 2004.
  7. Orr A, MacKenzie A. Practice’s structured approach improves management of epilepsy. Guidelines in Practice 2003; 6(9), 35-42.

Guidelines in Practice, August 2005, Volume 8(8)
© 2005MGP Ltd
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