The new GMS contract will encourage GPs to take a systematised approach to epilepsy care, which should benefit patients and practices, says Dr Andrew Orr
Epilepsy is a welcome inclusion among the clinical indicators of the quality and outcomes framework of the new GP contract, which acknowledges that it is "the most common serious neurological condition”.1
It is regrettable that a maximum of only 16 points has been allotted to this condition which has such profound effects on both sufferers and their carers, but this should not act as a disincentive to paying due attention to this important and rewarding task.
The recent SIGN guideline on the diagnosis and management of epilepsy in adults has clearly indicated aspirations for the care of patients with epilepsy within general practice.2
Tackling the epilepsy indicators
Simply ‘ticking the boxes’ will do little to advance the care of patients with epilepsy, but if we use the stimulus of the indicators to establish a robust epilepsy management system we will do these patients a service.
Already, new contract software is being developed, for example the Scottish GPASS SPICE system.3 This will satisfy the point-counting aspect of the contract while encouraging good quality clinical care, in line with the SIGN guideline.2
The epilepsy indicators are summarised in Table 1 (below).
Clinical indicator Points Qualifier Preferred
|Table 1: Clinical indicators for epilepsy|
|Disease/ Indicator no||Clinical indicator||Points||Qualifier||Preferred Read code||Payment stages|
|Epilepsy 1||The practice can produce a register of patients receiving drug treatment for epilepsy||2||F25%|
|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%|
Patient register – Epilepsy 1
This should be the easiest indicator to achieve, but because of the practical difficulties in case finding and validation it will also be the most labour intensive. However, once a register is in place the other indicators will follow easily.
Establishing a valid register will involve the following steps:
- Find all the patients aged 16 and over in the practice who have any sort of diagnosis relating to epilepsy. This will cover a wide range of conditions, for example epilepsy, grand mal, petit mal, seizures, status epilepticus, convulsions and fits. In many cases the diagnosis may be out of date or inaccurate, or the condition may be inactive.
- Search prescription records for all patients currently taking antiepileptic drugs (AEDs). About a third of these will be taking AEDs for other reasons, such as chronic pain or a psychiatric illness.
- Match up the results of steps 1 and 2 to find out which patients have a relevant diagnosis and appear to be taking AEDs. Check compliance carefully, as some patients will be found to have defaulted from treatment.
- Consolidate a valid diagnosis of any type of epilepsy in which the patient is complying with AEDs into a single computer coding: ‘epilepsy’ - F25%.
- It is advisable to tidy away all out of date diagnoses and all patients not on treatment into another single coding: ‘h/o epilepsy’ - 1743.
- Calculate the practice prevalence of the condition as a percentage of the list size, or by cases per thousand. Typically this should lie between 0.5 and 1%, (5-10 cases per 1000) - the new contract software should do this simple calculation for you. This figure will be required for verification purposes, to be compared with national or local prevalence.
Seizure frequency – Epilepsy 2
A record of seizure frequency, made within the previous 15 months, is entered as Read code 6675.
The only outcome measure given credence by the SIGN guideline is seizure frequency. It quotes the Commission on the Outcome Measurement in Epilepsy (COME) report, which states that "seizure frequency is by far the most sensitive measure of efficacy and should be used whenever possible”.4
The new contract recommends certain information be recorded in the patient’s notes at each review. This is probably best accomplished by designing a simple recording sheet, but new contract software may manage the task for us.
The data to be recorded are:
- Seizure type and frequency, including date of last seizure
- AED therapy and dosage
- Adverse drug reactions resulting from AED therapy
- Key indicators of quality of care (topics discussed and plans for future review).1
The new contract states that "no recommendation has been made by SIGN on the frequency of the review”. This is now corrected by the publication of SIGN 70, which states that "an annual review is desirable”.2 Certainly an annual review programme will help practices to achieve the indicators.
Medication review – Epilepsy 3
By any standards this indicator represents good clinical practice, and it is particularly relevant for this group of patients. The preferred Read code for ‘epilepsy medication review’ is 8BIF.
Patients seizure-free for 12 months – Epilepsy 4
There is no clear evidence regarding the appropriateness of seizure-free status as an indicator of good epilepsy care. It is therefore ironic that the greatest number of contract points (six) has been allotted to this indicator.
Moreover, it is awkward that as yet there is no Read code that covers this. Practices will have to invent a suitable marker code to cover the concept ‘seizure free for past 12 months, recorded in the past 15 months’. It is to be hoped that the new contract computer software will include a code for this.
Reconciling the indicators with good clinical care
Not all the indicators set by the new contract are firmly based on evidence, and viewed in isolation they will not greatly enhance epilepsy care. However, they represent an important step in the right direction.
|Box 1: Recommended epilepsy management model|
A structured management system for epilepsy should be established in primary care. As with other chronic diseases, an annual review is desirable
The shared care management system adopted should seek to:
Reproduced with kind permission from SIGN 70. Diagnosis and Management of Epilepsy in Adults. Edinburgh, SIGN 2003.
The framework will lead GPs to create a valid disease register and establish an annual review programme. These are the essential components of a structured management system for patients with epilepsy, recommended by the SIGN 70 guideline (Box 1 above).
The development of good new contract software, which incorporates the SIGN guidelines, will help the translation of the epilepsy indicators into sound clinical practice.
In the literature there are few descriptions of how epilepsy care may be delivered in general practice, but it is possible to set up a practice epilepsy management system and achieve real clinical gains.5 These will bring greater benefits to patients and prove more rewarding than merely gaining points under the new contract.
- Investing in General Practice: The New General Medical Services Contract. http://www.bma.org.uk
- Scottish Intercollegiate Guidelines Network. SIGN 70. Diagnosis and Management of Epilepsy in Adults. Edinburgh: SIGN, 2003.
- Scottish Programme for Improving Clinical Effectiveness. GPASS (General Practice Administration System for Scotland). Crown Office 2003. www.show.scot.nhs.uk/gpass
- Baker GA, Camfield C, Camfield P et al. Commission on Outcome Measurement in Epilepsy, 1994-1997: final report. Epilepsia 1998; 39: 213-31.
- Orr A, MacKenzie A. Practice’s structured approach improves management of epilepsy. Guidelines in Practice 2003; Vol 6(9), 35-42.