Dr Nigel Watson explains how the results of an audit convinced all the GPs in his practice of the need to improve epilepsy care


   

Epilepsy is defined as recurrent (two or more) epileptic seizures unprovoked by any immediate cause. For some time the practice has wanted to look at the management of our patients with epilepsy.

The perception was that many patients with epilepsy are initially diagnosed and briefly followed up by secondary care. They are then discharged back to primary care, where they receive their repeat prescription and seldom see their GP.

Questions that needed answering were:

  • Are their seizures well controlled?
  • Do the patients need to stop their medication if they are seizure free?

A working party established in Southampton had produced a document Guidelines for the Management of Epilepsy.1 This excellent document is full of information and suggested quality criteria. This was the catalyst for us to commence a review of patients with epilepsy in the practice.

 

Our practice has 12200 patients, 30% of whom are >65 years of age and 17% are >75 years of age (Figure 1, below). The practice looks after two residential homes for patients with learning difficulties with a total of 40–50 residents. At least 40% of the residents also have epilepsy.

Figure 1: Age distribution expressed as a percentage of each sub-group
bar chart

Epilepsy is the most common serious neurological disorder in the UK. The prevalence of active epilepsy (defined as a patient with epilepsy currently receiving treatment) is about 5/1000 population in the UK,1 with an annual incidence of new cases of 5/10000. A practice with 12200 patients would expect to have approximately 60 patients with active epilepsy. Our practice currently has 75 patients with active epilepsy on anti-epileptic drugs (AEDs).

Approximately 70% of patients will achieve 5-year remission from seizures within 9 years of diagnosis. About 25% of patients will continue to have seizures despite adequate medical treatment. Poorly controlled epileptic seizures carry an annual mortality of about 1/200.

Previous studies2 have shown great potential for improving the care of patients with epilepsy, particularly with therapeutic intervention, and well-documented, careful, ongoing support.

Despite recommendations in a number of reports, significant inconsistencies in epilepsy care exist in both primary and secondary care.3

 

In February 1999 the Arnewood practice identified, by means of a computer search, 150 patients with a diagnosis of epilepsy within the practice.

A subgroup of 75 patients (50%) who had received at least one AED in the last 12 months was then identified. Of these, 25 patients (33%) were taking more than one AED.

 

  • The aim of treatment is to keep the patient seizure free.
  • 70–80% of patients should be controlled on one AED; a second 3rug to be administered only if seizures continue.
  • Medication should be given only once or twice a day to aid compliance.
  • Patients with poor control should be referred back to the specialist promptly.
  • Patients on anti-epileptic medication should be reviewed annually and the results recorded.
  • Patients should be asked about the date of the last seizure and the information recorded.
  • Patients should be asked about the frequency of seizures and the information recorded.

Standards

  • 75% of patients with epilepsy and controlled on an AED should be reviewed annually.
  • 75% of patients should have the date of their last seizure documented.
  • 75% of patients should have the frequency of their seizures documented.
  • 50% of patients should have their weight documented in the previous year.1 A significant change in weight may require a change in dose of AED.

Patients should be classified according to seizure frequency as follows:

  • Poor control – one or more seizures per month in last 12 months. Some of these patients are brittle epileptics and under hospital care. Some patients have accepted that they will have seizures and it is part of their life and do not consult their GP. With modern treatments, I believe that a significant number can have their seizures better controlled.
  • Moderate control – less than one seizure per month on average in the last 12 months. Few of these patients will be under hospital care. Minor adjustments in treatment may decrease the frequency of seizures.
  • Good control – no seizures in the last 12 months. The implications for driving are significant; we needed to establish whether these patients should be referred back to the neurology clinic to consider withdrawing their AEDs.

The results of the first audit cycle are summarised in Figure 2, below.

Figure 2: Results of the first audit cycle

Details
First cycle 01/02/99
Total number of registered patients
12 200
Total number of patients with a diagnosis of epilepsy
150
Total number of patients with epilepsy currently taking AEDs
75
Prevalence of patients with epilepsy per 1000

12.3

Prevalence of patients with epilepsy on AEDs per 1000
6.2
% of patients reviewed in last 12 months
51%
% of patients with a record of last seizure
40%
% of patients with a record of seizure frequency in last 12 months
40%
% of patients with recorded weight in last 12 months
16%
bar chart

 

  1. The list of patients with active epilepsy was circulated to all GPs and a responsible GP was identified for each patient. (The practice does not have personal lists, so the responsible GP may not be the patient's registered GP.)
  2. A standard letter was produced to send to patients who had not had their epilepsy management reviewed in the last 12 months. This letter explains that the practice has reviewed the care of patients with epilepsy as a result of new, locally produced guidelines. It then lists the standards the practice is trying to achieve in their management. Finally, it invites them to make an appointment to attend the surgery for a review.
  3. The practice has entered all clinical notes on the computer for more than 10 years. A computer program has been written that allows a number of questions to be answered, which results in details of the agreed criteria being entered on the computer notes, under the heading of epilepsy. These entries are all Read coded and can thus be found on computer searches.
  4. The audit will be repeated in 12 months, i.e. February 2000.

 

Patients with epilepsy comprise a relatively small group for study. About 50% of patients with a diagnosis of epilepsy can be excluded because they no longer require medication. This would mean that each GP will be looking after between 5 and 15 patients with epilepsy on one or more AEDs. The group is easily identified by computer search or through repeat prescriptions.

There is good evidence that the quality of life for these patients can be improved with better care in general practice.

It can be difficult to achieve change in general practice, especially if it involves an increased workload. The audit convinced all GPs in the practice that there was a need to improve our care for this group of patients.

The proposals for action were broadly accepted by the practice. Some GPs are not keen on sending letters to patients but prefer to monitor them either opportunistically or through repeat prescriptions. When the audit is repeated in 12 months' time, this area will be reviewed.

 

Much of the information requested could be provided by the patients in written form, and care targeted at those with poorly controlled seizures.

In secondary care, epilepsy liaison nurses have expanded their role over the last few years. A suitably trained nurse could monitor and advise these patients in primary care.

 

  1. Southampton Multi-disciplinary Audit Advisory Group (MAAG). Epilepsy Guidelines 1999.
  2. Cooper GL, Huitson A. An audit of the management of patients with epilepsy in general practice. J R Coll Gen Pract 1986; 36: 204-8.
  3. Jackoby A, Graham-Jones S et al. A general practice records audit of the process of care for people with epilepsy. Br J Gen Pract 1996; 46: 595-9.

Guidelines in Practice, June 1999, Volume 2
© 1999 MGP Ltd
further information | subscribe