The growing number of Veterans with epilepsy and the resultant need to improve access while more effectively managing care led to the creation of four geographic Epilepsy Centers of Excellence (ECOEs) in FY09, with implementation of the ECOE network in 2010. This COE approach arose out of the need to improve delivery care but has not been studied for its effectiveness as a model of care. We examined the impact of the ECOE model on access to care for Veterans with epilepsy (VWE) using the relational coordination (RC) framework.
Objective 1: Describe changes in quality and access in epilepsy care before and after ECOE initiative implementation.
Objective 2: Describe the associations between changes in the structure and processes of care implemented by the four ECOE regions and RC among epilepsy care team members in each ECOE.
Objective 3: Determine whether variations in access to and quality of VA epilepsy care between ECOE regions are associated with variations in RC.
This four-year comparative case study used VA inpatient, outpatient, and pharmacy data to identify VWE. Access to neurology specialty care and quality of care were assessed using national administrative data and using medical chart abstraction from a random sample stratified within ECOE by epilepsy chronicity and seizure control. Access and quality were assessed each year (FY09-14) using administrative data, and in FY09, FY12, and FY14 using medical chart abstraction. Access to care examined receipt of neurology care and use of emergency care for seizures. Quality was assessed using Quality in Epilepsy Treatment (QUIET) measures (developed by our team) identified as important by ECOE clinicians and VA Neurology leadership (e.g., use of teratogenic antiepileptic drugs (AED) in women of childbearing age; use of suboptimal AED in older VWE; AED monotherapy for Veterans newly diagnosed with epilepsy; neurology care for Veterans newly diagnosed with epilepsy and those with medication resistant seizures; treatment of depression in VWE). We assessed RC using the Relational Coordination survey distributed to neurologists and primary care clinicians via email in February 2013 and February 2015. Interviews of survey participants identified changes in structure and processes of care/research/education (2013, 2015). Quantitative analysis examining differences in access and quality over time included descriptive statistics, generalized estimating equations (GEE) and mixed effects models controlling for patient characteristics, facility characteristics, and the effect of patients nested within facilities. Qualitative analyses evaluated interview data, and information from annual reports and meeting minutes.
We found stable rates of neurology specialty care access (~37.5% 2009-2014) and a 30% reduction in emergency care with a diagnosis of seizures in both hubs and spokes. GEE models found that that patients were significantly more likely to receive emergency care for seizures BEFORE implementation than in 2014 (OR: 1.37; 95% CI 1.31-1.43). Quality of care ranged from ~19% for women of child-bearing age on teratogenic medications receiving birth control, to 96% for newly diagnosed VWE receiving monotherapy in 2009. VWE were significantly more likely to receive high quality epilepsy care after ECOE implementation as evidenced by lower probability of having a drug-drug interaction (OR: 0.55; 95% CI 0.51-0.59) and higher likelihood of those with drug-resistant epilepsy receiving neurology specialty care (OR: 1.06; 95% CI 1.02-1.11). Newly diagnosed VWE were also significantly more likely to have a neurology visit within a year of diagnosis (OR: 1.62; 95% CI 1.51-1.74) and receive brain imaging (OR: 1.43; 95% CI 1.33-1.54) after ECOE implementation.
For Aim 2 we focused on innovations in care, education, and research missions as there was minimal variation on the organization and delivery of care across ECOE hubs. There was significant variation in innovation across hub (0-10); hubs with higher patient care workload pressure were equally as innovative as those with lower workload pressure. Hubs with more innovation activity reported more activities related to communication and coordination of work suggesting enhanced RC within the qualitative data, but the relationship between innovations and RC based on survey scores was not significant.
Furthermore, we found that RC was not associated with measures of access, which may be due to limitations of system capacity despite a growing epilepsy population. RC was associated with improved quality on measures related to sub-optimal prescribing for older Veterans and women, and processes of care (electroencephalogram and imaging) recommended for Veterans newly diagnosed with epilepsy. Regions with higher scores on RC were significantly more likely to have high quality of care based on these metrics than regions with lower scores.
We found extremely high concordance on quality measures for treatment of Veterans with depression, and use of monotherapy for newly diagnosed epilepsy, and some gaps in quality that have been fed back to the ECOEs to target specific quality improvement initiatives. To date, our clinical partner has identified the lack of improvement in the proportion of women of childbearing potential who received teratogenic seizure medications (valproate, topiramate) without evidence of birth control as a priority to address with quality improvement initiatives. Our project was instrumental to the development of a clinical work group focused on women with epilepsy, and which is led by an epileptologist from a spoke facility. This group is developing quality improvement projects for women with epilepsy with a goal of improving the quality of care and patient outcomes.
An incidental finding of lower rates of treatment for depression among older VWE led to development of a work group focused on integrated mental health and psychogenic nonepileptic seizures that is also focused on developing quality improvement projects and research projects for comorbid mental health and epilepsy.
While we found some variation in RC across facilities and regions, and that RC was associated with several measures of quality, we found that using RC in a national system was difficult without champions assisting the team at each facility in which surveys were administered. There was good survey representation at most hubs, but data from spokes was more sparse.
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