American Academy of Neurology Epilepsy Measures

As we struggle to improve the treatment of epilepsy, we often focus on finding a cure for the disease. Although this is always our hope and our goal, we should remind ourselves that we should implement the best up-to-date treatment as we continue our journey to find a cure. As clinical research and basic science try to reach this goal, the treatment and the management of epilepsy should reach every epileptic who is interested in the treatment and is able to afford it.

An army of healthcare providers and multispecialty teams are needed to do the job. To ensure quality care from the bench to the patient, quality measures are needed. While physicians and healthcare providers have different skills and different approaches to a particular medical disease, like epilepsy, quality measures will help standardize and improve the care at their practices. This might raise the bar for the accepted standard of care of epilepsy. These measures will be an incentive for medical care facilities, healthcare providers, and payers to constantly strive to achieve better care.

Several effective treatment options are available for epilepsy, but some are underutilized. For example, the effectiveness of epilepsy surgery and its positive impact on the quality of life of the candidate patients is undisputed. Yet, there is still a significant delay in referral for evaluation for epilepsy surgery5. Prolonged preoperative illness of more than 20 years was associated with increased risk of recurrent seizures6. Again, epilepsy measures might facilitate the early detection of the patient with medically refractory epilepsy who may be an appropriate candidate for epilepsy surgery.

The American Academy of Neurology recently published epilepsy measures to help improve epilepsy care1. Members are encouraged to use the measures in their practices. This is the first set of epilepsy measures that were developed and approved by a medical society. No set of measures will be perfect, so these will be revised periodically and reviewed every three years.

Following an extensive literature search, 160 relevant recommendations from 19 guidelines were reviewed by the American Academy of Neurology
(AAN) Quality Measurement and Reporting Subcommittee. The AAN panel agreed on 8 final epilepsy measures which were later approved by the Physician Consortium for Performance Improvement, PCPI. The AMA-convened PCPI is comprised of more than 170 national medical specialty societies and other medical organizations that are interested in improving the quality of patient care.

This is a brief description of the final 8 measures.1 Full description was published on Neurology website (www.neurology.org. January 2011; 76: 94-96 Data Supplement)3:

No. 1: Seizure type and current seizure frequency.

All visits with the type(s) of seizure(s) and current
seizure frequency for each seizure type documented in
the medical record.

No. 2: Documentation of etiology of epilepsy or epilepsy syndrome.

All visits with the etiology of epilepsy or epilepsy
syndrome reviewed and documented if known, or
documented as unknown or cryptogenic.

No. 3: EEG results reviewed, requested, or test ordered.

All initial evaluations with the results of at least one
EEG reviewed or requested, or if EEG was not
performed previously, then an EEG ordered.

No. 4: MRI/CT scan reviewed, requested, or scan ordered.

All initial evaluations with the results of at least one MRI
or CT scan reviewed or requested or, if a MRI or CT scan
was not obtained previously, then a MRI or CT scan
ordered (MRI preferred).

No. 5: Querying and counseling about antiepileptic drug side effects.

All visits where patients were queried and counseled
about antiepileptic drug side effects and the querying
and counseling was documented in the medical record.

No. 6: Surgical therapy referral consideration for intractable Epilepsy.

All patients with a diagnosis of intractable epilepsy who
were considered for referral for a neurologic evaluation
of appropriateness for surgical therapy and the
consideration was documented in the medical record
within the past 3 years.

No. 7: Counseling about epilepsy specific safety issues.

All patients who were counseled about context-specific
safety issues, appropriate to the patient’s age, seizure
type(s) and frequency(ies), occupation and leisure
activities, etc. (e.g., injury prevention, burns,
appropriate driving restrictions, or bathing) at least
once per year.

No. 8: Counseling for women of childbearing potential with Epilepsy.

All female patients of childbearing potential (12–44
years old) diagnosed with epilepsy who were counseled
about epilepsy and how its treatment may affect
contraception and pregnancy at least once per year.

Measure Exclusions:

In certain circumstances, a particular patient who otherwise meets the denominator criteria needs to be excluded from the denominator of a specific measure due to one of three reasons, medical, patient, or system reasons. There should be a clear and well documented reason to permit exclusion:

1- Medical Reason: Not indicated or contraindicated
2- Patient Reason:
    a. Patient declined
    b. Social or religious reasons
    c. Other patient reasons
3- System Reason:
    a. Services not available
    b. Financial reason (no insurance coverage/payer –related limitations)
    c. Other system reasons


Most physicians are familiar with clinical outcome measures and clinical guidelines. However, these new epilepsy measures are not intended to be clinical guidelines or standard medical care; rather they are intended to help physicians’ quality improvement. They are useful to calculate individual physician performance. Physicians might also find the measures useful to identify a particular patient population in their practices for clinical trials or other research.

These measures can be useful for reporting to the payers. Currently, Centers of Medicare and Medicaid Services (CMS) Physician Quality Reporting Initiative (PQRI) are considering paying incentives (about 1%) to physicians who participate in the Physician Quality Reporting (Previously known as Physician Quality Reporting Initiative (PQRI). In 2011, the program name was changed to Physician Quality Reporting System (Physician Quality Reporting)2.


How to calculate a performance measure3:

Performance measure is a fraction created by three components:

1-Numerator (A): Patients who meet numerator inclusion criteria

2- Denominator (PD): patient who meet the denominator inclusion criteria

3- Denominator Exclusion (C): patients who have valid medical, patient, or system exclusions.


Numerator (A)
Performance = ----------------------------------------------------------------------
Denominator (PD) – Denominator Exclusions (C)

For example, to calculate performance measure No. 3:

Performance Numerator (A) Includes:
Patients who had the results of at least one electroencephalogram (EEG) reviewed or requested, or if an EEG was not performed previously, then an EEG ordered.

Performance Denominator (PD) Includes:
All patients with a diagnosis of epilepsy seen for an initial evaluation.

Denominator Exclusions (C) Include:
• Documentation of medical reason for not ordering an EEG if an EEG was not performed previously
• Documentation of patient reason for not reviewing or requesting EEG results or, if an EEG was not performed previously, for not ordering an EEG
• Documentation of system reason for not reviewing or requesting EEG results or, if an EEG was not performed previously, for not ordering an EEG

Then the above formula can be used to calculate the fraction.


Conclusion:

These measures will be a useful tool to many neurologists and other physicians who are caring for people with epilepsy. The hope is to optimize the current treatment options and standardize care. Further education regarding the classification of epilepsy and the appropriate use of the ICD codes will help implement the measures.

References:

1- Neurology 2011;76: 94-99
2- www.cms.gov . Accessed January 18, 2011
3- www.neurology.org . Neurology 2011; Appendix e-1
4- Trevathan E, Gilliam F. Neurology. 2003;61:432-433
5- Benbadis SR, et al, Seizure. 2003 Apr;12(3): 167-70
6- Yoon H.H, et al, Neurology 2003;61:445-4