A total of 33 practices across Leicestershire have been involved in this interface audit project. This involved the review of 777 sets of patient notes. Members of the Clinical Audit Team at the University Hospitals of Leicester collected the data. A full report of the audit has been produced and circulated to participating practices; the information below however provides a summary of the project.
· To identify areas in which improvements need to be made to the care of adult epilepsy patients in Leicestershire.
· A coordinated epilepsy service can reduce morbidity and improve quality of life for patients and need not necessarily require extra investment. By prioritising epilepsy and setting clear objectives and targets for providers, purchasers can expect to realise significant health gains in terms of better seizure control and improved function.
· It has been reported that approximately 3 patients per GP will have poor seizure control and poor quality of life. They may also have side effects of medication. These patients should either be referred to secondary care neurologists or be under shared care between primary and secondary care.
·
Various audits in the UK have highlighted the following
problems with care, lack of systematic follow-up, failure of GP-patient
communication, low levels of patient knowledge and poor communication
between primary /secondary care.
· Report on the profile of current prescribing practices by both primary and secondary care.
· Identify arrangements for review, referral and monitoring of patients.
· Identify the completeness for documentation (e.g. history of seizures) in both primary and secondary care.
· Report on the quality of communication between healthcare professionals/ primary and secondary care.
· Report on patients views about the care they receive for their epilepsy.
The following statements indicate the measurable
criteria identified for this project.
1. Patients should be seen at the neurology or epilepsy clinic within 4 weeks of referral from primary care.
2. Patients should have their diagnosis confirmed by a neurologist, epileptologist or physician with a special interest in epilepsy.
3. Patients should be taking one anti-epileptic drug.
4. Patients should be prescribed recommended first-line anti-epileptic drugs (AEDs).
5. Patients with epilepsy will be reviewed annually.
6. 80% of secondary care referrals should be discharged back to their GP within 12 months.
7. Patient’s notes should contain a record of seizures – this should include: medication review, date of seizure, frequency of seizures and number of seizures over the last 12 months.
8. 70% of patients should be seizure free 2 years from initial diagnosis.
9.
Patients with epilepsy should be recorded on a practice register in
primary care.
Approval and funding was obtained from the Leicestershire Interface Audit Group. A Pilot audit was carried out at 3 GP practices to check that the audit was feasible. All GP practices in Leicestershire were then invited to participate by the Primary Care Audit Group (PCAG).
The audit data was collected in 3 phases.
1. GP practices were asked to identify all their adult patients with epilepsy who were currently taking AEDs. A casenote and /or computer records review was carried out. For practices with 50 or less patients with epilepsy all records were looked at. For larger practices with 50+ patients a sample size was taken (sample size calculated to be 95% confident +/-5%). Members of the Interface Audit Project Team, based at the Leicester Royal Infirmary, collected data.
2. The case notes of patients who had epilepsy related admissions /outpatients visits at the Leicester Royal Infirmary (LRI) were then reviewed as were any appropriate Accident & Emergency records.
3.
Finally an anonymous questionnaire was sent out to the patients
from their GP practice.
The data was collected using a scannable ‘formic’ questionnaire and scanned into a database. Analysis was carried out using Excel and SPSS software packages.
33 GP Practices were
visited between 22 August 2000 and 4 July 2001, 777 sets of patient notes
were audited.
Patient questionnaires were sent out to each patient if they were considered suitable by the GP. Patients with learning difficulties were not sent questionnaires. GP practices were given the choice as to whether or not they would like to utilise this part of the audit methodology. A total of 531 patient questionnaires were distributed with 239 forms being returned.
The following recommendations are currently under discussion:
Primary
care trusts need to encourage general practices to set up epilepsy
registers (like other disease registers for chronic diseases management),
and fund initiatives actively recalling patients for annual review of
their epilepsy.
Leicestershire
needs a specialist epileptologist to increase the number of appointments
available to assess and review patients with suspected epilepsy &
co-ordinate care pathways.
Additional
epilepsy specialist nurses need to be recruited and trained in
Leicestershire to educate patients and forge links between GPS,
neurologists and patients.
There
needs to be standardisation in recording epilepsy care to enable
communication between professionals and allow easy audit. The date of the
last fit should be recorded. The number of fits in the last 12 months
should be recorded (0-10). If there are more than 10 fits in the preceding
year these should be expressed as fits per day or week or month as
appropriate. Computerisation allows common templates to be used
facilitating annual audit at a general practice level. Neurology clinics
need to use computer systems that integrate with general practice allowing
seamless transfer of clinic information facilitating joint care.
Future audits should liase with general practices and set up working practice epilepsy registers while undertaking data collection. This would provide lasting benefits to practices if the registers are accepted and used as part of a structured approach to epilepsy care.