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 co-managed 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 neurologists. However, more attention and work need to be dedicated on implementing and documenting education and counseling people with epilepsy in the clinical setting.

中文翻译：

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全国神经科医生和初级保健提供者样本的癫痫质量表现：急性和慢性护理管理的特征化趋势

介绍

癫痫特定的质量指标和绩效衡量标准已多次发布和修订。癫痫特定质量措施的应用已在一些医疗保健系统中得到证明。然而，迄今为止，还没有关于全国样本中癫痫表现指标随时间和跨环境变化的信息。退伍军人事务部 (VA) 医疗保健系统提供了一个机会来研究癫痫特定表现随时间的变化，在急性与慢性癫痫护理中，以及初级与专业护理中。

方法

执行了 VA 系统内新诊断的癫痫和癫痫退伍军人慢性护理的图表提取。确定了 2007-2014 年 ICD-9-CM 诊断为 345.XX 和 780.39 的退伍军人。为每位患有癫痫的退伍军人确定了基于癫痫治疗质量指标 (QUIET) VA 测量的癫痫特定性能测量。分析了不同时间（2009 年、2012 年和 2014 年）、癫痫护理来源（仅限初级保健、仅限神经病学以及神经病学和初级保健之间的共享护理）的护理差异。使用卡方统计比较了变量间护理措施比例的差异。

结果

对 2386 名患有癫痫症的退伍军人的图表审查包括 297 名女性 (11.2%)、281 名 (10.5%) 接受急性护理和 2105 (89.5%) 名接受慢性护理。在所有年份中，203 人 (72.5%) 订购/执行了脑电图检查，225 (80.4%) 人订购/执行了神经影像学检查，106 (37.9%) 人接受了驾驶注意事项的指导，71 (25.4%) 人接受了安全和伤害预防教育，以及251 人（89.6%）开始使用抗癫痫药物单一疗法。接受过癫痫诊断和癫痫类型教育的新发癫痫患者的比例随着时间的推移而增加，2008 年为 30 (34.9%)，2012 年为 42 (43.8%)，2012 年为 52 (53.1%)。在接受长期护理的 2105 名退伍军人中，864 名 (41.1%) 遇到记录在案的抗癫痫药物依从性，361 名 (17.15%) 遇到了驾驶限制问题，1345 (63. 9%) 的遭遇记录了一般教育和咨询，250 (11.9%) 次遭遇记录了安全和伤害预防，488 (23.2%) 次遭遇记录了药物副作用，463 (22.0%) 次遭遇记录了治疗方案的讨论。对于慢性癫痫护理，质量措施的记录不会随着时间而改变。与单独的神经病学或初级保健相比，由初级保健和神经病学共同管理的退伍军人具有更高的驾驶指导和安全指导比例。

讨论

一般而言，文档诊断程序（如 EEG 和神经影像学）的癫痫表现指标较高（>70% 的新发癫痫），而关键教育和咨询指标的较低（<50%）。尽管通过宣传工作和专业会议在学术文献中强调社会心理教育和整体管理的重要性，但随着时间的推移，教育和咨询并没有显着改善。与神经科医生相比，初级保健提供者在心理社会教育的某些方面表现得更好。然而，需要更多的关注和工作专注于在临床环境中实施和记录癫痫患者的教育和咨询。