While epilepsy is one of the most common neurological conditions in the United States, and the Veterans Health Administration (VA) anticipates an increase in its epilepsy population due to traumatic brain injury in veterans with combat service in Afghanistan and Iraq (hereafter OEF-OIF veterans), little is known about the quality of care provided to veterans with epilepsy. This lack of knowledge is due to the fact that, until recently, no validated measures of quality for the care of adults with epilepsy existed. The recent development of the QUality Indicators for Epilepsy Treatment (QUIET) by this research team provides a foundation for examining the quality of epilepsy care with the VA. However, the CDC funding used to develop these indicators was restricted to examining quality for patients receiving care within the context of primary or general neurology care. Moreover, their limited scope does not address issues that may be relevant to the VA, where significant numbers of epilepsy patients are elderly or have post-traumatic epilepsy as a result of OEF-OIF combat service.
The objective of the proposed study was to build upon our prior work by addressing the limitations of the existing quality measure. Specific objectives included:
1) Expand the scope of the QUIET indicators to individuals who also receive epilepsy specialty care.
2) Adapt the existing QUIET indicators to the VA population including issues that may be more relevant to veterans epilepsy (e.g., geriatric and post-traumatic epilepsy).
This project built upon our previous work by engaging an expert panel of VA and DoD clinicians to examine the existing QUIET indicators. We first conducted a focus group (N=8), at the American Epilepsy Society meeting, to identify important aspects of care quality within epilepsy specialty care (e.g., timely referral for surgery consultation) and aspects of epilepsy care that may be particularly relevant to the VA population. We followed up that focus group with a series of conference calls to more clearly define issues of concern to the clinicians. After there was consensus by the clinician panel regarding the specific areas of concern, we conducted a systematic literature review to examine the evidence base for items identified by the expert panel. After the literature review we developed initial quality indicator (QI) statements that were piloted to a second group of epilepsy clinicians and health services researchers (N=5) who examined the QI statements for clarity, structure, and ease of understanding regarding the meaning of each quality indicator. We then used a modified Delphi process to identify statements that were considered by the panel to be valid and reliable measures of quality for epilepsy care in all epilepsy care settings. Quality Indicator statements were rated by 9 panel members (1 DoD and 8 VA clinicians) for validity/appropriateness as a quality measure, and feasibility (can be reliably measured) using a 9-point Likert scale as recommended by the RAND appropriateness method. After the initial rating, the group participated in a series of conference calls to discuss the initial ratings and concerns regarding each indicator. After those discussions, wording of several items was adapted based on panel member suggestions, and the panel members re-rated each item. Items that reached consensus (defined by the RAND-UCLA Appropriateness Method) were accepted as QUIET-VA indicators. A third round of ratings was conducted for items which did not reach consensus in round two. Items that reached consensus after the third round were added to the QUIET-VA measure. Those that did not reach consensus on the third round of ratings were dropped from consideration.
The major areas of concern identified by clinicians included specific criteria for referral to a comprehensive epilepsy center for monitoring, and a variety of issues associated with antiepileptic drug (AED) treatment: drug-drug interactions, teratogenic effects of antiepileptic drugs, potential for suicidality related to antiepileptic drug exposure, and bone health. Eleven QIs were presented to the clinician panel for the first round of ratings. During that round two QIs met criteria for appropriateness and feasibility. These items recommended referral to a neurologist if the patient continues to have seizures after three months of treatment, and referral to an epileptologist for further evaluation if seizures persist after 12 months of appropriate treatment by a neurologist. On the second round of ratings, recommendations for assessment of Vitamin D levels and bone density measurements for those on AED treatment over two years were approved. Additional measures were not approved on the third round.
The development of VA-DoD specific quality indicators will allow benchmarking of epilepsy care quality within the VA. We hope to use these QIs to examine the changes in epilepsy care that may occur before, during, and after the implementation of VA Epilepsy Centers of Excellence (2008-2014). Such a study will allow us to identify variation in quality across facilities or regions, identify characteristics of care organization that are associated with that variation, and develop interventions to improve the quality of VA epilepsy care. Since the VA is on the leading edge of epilepsy quality of care assessment, this approach will also provide an exemplar to non-VA facilities to develop programs to benchmark care and develop interventions to improve epilepsy care quality in other healthcare systems.
External Links for this Project
Grant Number: I01HX000321-01
None at this time.