I was interested to read Dr Andrew Orr’s article on the epilepsy indicators (‘Have QOF indicators improved epilepsy management?’ Guidelines in Practice August 2005).
The inclusion of epilepsy in the Quality and Outcomes Framework (QOF) is one of the more laudable features of the nGMS contract. However, it was not the meagre 16 points on offer that induced our practice to aspire to achieving these indicators, but rather a long-recognised need to improve the care we provide. Did our QOF-inspired annual reviews result in improved care?
We have 50 patients on our register, giving a prevalence of 0.65%, which is within the predicted range. In the 15 months prior to 1 April 2005, 40 patients attended for an annual review. Of these, 28 were recorded as seizure-free over the previous 12 months. Six of the 12 patients who were not seizure-free had their medication adjusted and six did not.
As the purpose of the exercise is, or should be,to improve epilepsy control, and not tick boxes, it is perhaps surprising that improved control was attempted in only 50% of our patients with continuing seizures. This may reflect the attitudes of doctors or patients or a lack of confidence on the part of the doctor.
Dr Orr points out that “patients are often very accepting of the status quo”. In two of our cases it is documented that the GP advised an increase in medication, which the patient declined. In two cases, the doctor and patient agreed that the patient was on maximal tolerated anticonvulsant therapy. One of the remaining two patients is under secondary care and considered by the specialist to be “reasonably well controlled”; the other has subsequently been referred to secondary care.
One of the problems of epilepsy care is that GPs gain very little experience in epilepsy management. We have identified 12 patients with suboptimal control. Shared between four full-time equivalent GPs that is three patients each. Even if one GP in the practice undertook all the reviews,he or she would be unlikely to gain enough experience to be confident about changing anti-epileptic medication. I believe there is a case for appointing GP specialists to provide epilepsy care for a number of practices in a locality.
The contract rewards practices for carrying out annual reviews but does not encourage us to target poorly controlled patients. I believe we should produce a register of high-risk epilepsy patients and put in place systems to identify and call in patients who do not adhere to treatment or who present to hospital following a seizure.1
Dr Orr’s practice was able to withdraw medication “from 9% of patients in the initial registration process, and from a further 8% subsequently”.We attempted to withdraw medication in only one of our patients, with the unfortunate result that the patient had his first seizure for several years. I note that the NICE guideline on epilepsy recommends that “withdrawal of AEDs must be managed by, or be under the guidance of, the specialist.”2
I do not believe that the QOF indicators alone will improve epilepsy management. We will also need further education to change doctors’ and patients’ attitudes, GP specialists, and improved liaison between primary and secondary care.
Dr Phillip Bland, GP,
Dalton in Furness
- Smithson WH, Hanna NJ. Deaths from epilepsy: what next? Br J Gen Pract 2002; 52: 795-6.
- 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.