Dr. Zuckerman expresses his objections to the new epilepsy quality measures.
The epilepsy quality measures, previously mentioned in the “Measure for Measure” post, are being published in the January 4 issue of Neurology. I have expressed my misgivings regarding the proposed measures, but incredibly, somehow my observations were not incorporated into the final measures. Since these are now the “official” measures that will determine whether you are treating patients with epilepsy in a manner that our specialty society deems to be in accordance with “expert” standards, I would like to go into further detail regarding these measures.
First, some general objectionsThe make up of the committee to determine these standards is overly weighted by “epilepsy specialists” (14). I think the views of general, practicing neurologists should have been taken into account when a document of this nature was developed. Despite the inclusion of various imaging specialists, a family physician, a pediatrician, a neuropsychologist, and a neurosurgeon, no general neurologists sat on this committee. Sure, epileptologists study the best means of evaluating and treating patients with seizures, but several of the measures have no empiric basis for their recommendation. For example, in measure #5 even, the committee reports, “This measure may increase the burden of documentation, but it is anticipated that the improvement in quality of care will outweigh the increase in documentation burden.”
Several of the measures are ambiguous in the article published in Neurology, but no fear—those desirous of actually understanding the measures are referred to appendix 1e, available on the AAN website. Unfortunately, this appendix only contains the members of the quality measure developers of the AAN and no information regarding the epilepsy measure specifics.
My reactions to the eight specific measures
The following focuses on the practicality of each measure in regards to the likelihood that conformance with that measure will indeed lead to an improved quality of care (which ultimately is the point of all this).
1. All visits list the seizure type(s) and frequency of each type. I have no objection to this measure—certainly the minimum that would be expected in any encounter with a patient with epilepsy. It would have been nice to specify the classification scheme used, presumably the International Classification of Seizure Type (1981), but this should be made explicit.
2. Documenting etiology of Epilepsy or Epilepsy Syndrome. The problem I have with this measure is that it is required at eachvisit. So, if you have been following the patient for fifteen years, each and every visit must contain documentation of the epilepsy etiology. After the initial evaluation and follow up, how often does this information change? It seems like superfluous documentation without improving care.
3. Initial epilepsy evaluations document the results of an EEG, or if not yet performed, requesting of an EEG. I have no objection to this measure.
4. Initial epilepsy evaluations document the results of an imaging study (CT or MRI), or if not yet performed, requesting of an appropriate study. I have no objection to this measure. Numbers 3 and 4 are reasonable, since they specify performance only at the initial epilepsy evaluation.
5. Querying and counseling about side effects of antiepileptic medications. Certainly, asking the patient about any possible side effects and informing the patient about the common potential side effects is good medical practice. The objectionable portion of this measure relates to the requirement to “Documenting this discussion in the medical record.” The devil is in the details, and the requisite amount of documentation is not specified. The requirement to repeat this exercise with each visit seems more likely to create more clinically meaningless verbiage in the medical record than it does improving patient care.
6. Patients with intractable epilepsy have been considered for referral for surgery. Maybe I missed the lecture, but I do not know of a specific definition of “intractable.” Does this measure imply that for the 99.9% of patients who do not have “intractable” epilepsy that there needs to be documentation of that fact in order to satisfy this measure?
7. Counseling about epilepsy safety issues. This measure is also vague; it specifies that the issues are individualized to the patient age, frequency of seizures, occupation, and leisure activities, and that the information must be provided at least once a year for epilepsy patients. Does this mean that if my patient has gone five years without a seizure that I still have to document providing this information or document that it is not necessary? More clarification is needed.
8. Counseling for women of childbearing potential regarding the risks of AEDs in the use of contraceptives and in pregnancy. All female patients age 12-44 years who have epilepsy are to be included in the denominator. Females in this age group who are not of childbearing potential presumably must be identified as such to avoid being judged as non-compliant with this measure. How these excluded patients are to be denoted is not defined. In addition, the extent of counseling detail and how this is to be documented is not spelled out.
In addition to the above objections to the implemented measures, there may be other “errors of omission.” For example, it seems puzzling that the quality of care of an epilepsy patient is completely independent of the success of seizure prevention or the rationality of the medical regimen. These measures would also not penalize physicians who over utilize resources by ordering unnecessary EEGs, imaging studies, or blood tests, such as chemistries or blood levels. Of course, all of the above represent only my opinions, but I appreciate the opportunity to “rage against the storm.”