Improving quality of care for epilepsy patients using a pharmacist review service

Transcription

1 Improving quality of care for epilepsy patients using a pharmacist review service Carole Brown MSc (Clin Pharm), PIP, PwSI Epilepsy, MRPharmS A structured review process for epilepsy in primary care has been advocated as best practice. In Calderdale Primary Care Trust, a prescribing clinical pharmacist practitioner with a special interest in epilepsy (PwSI epilepsy) has been conducting annual reviews for epilepsy patients in GP practices. This service has improved patient care over and above the Quality and Outcomes Framework (QOF) indicators for epilepsy and has been shown to be sustainable. Various publications have demonstrated that epilepsy is the Cinderella of long-term conditions. The All Parliamentary Group on Epilepsy 2007 report Wasted money, wasted lives showed that epilepsy patients were poorly managed in primary care, 189milllion was wasted per year in unnecessary medication, there were 400 unnecessary deaths per annum from epilepsy and also that the epilepsy review process was unstructured and lacking in detail. 1 We set out to address these concerns by providing an in-depth structured review process led by a specialist health practitioner. The charity Epilepsy Action has developed a Primary Care Epilepsy review pack, which provides an informative and practical resource for running an epilepsy clinic in primary care. 2 This pack has recently been updated. The NICE clinical guideline (CG137) for the epilepsies and the SIGN guideline for epilepsy (No. 70, 2005) 4 also provide frameworks for epilepsy management. Most GPs see so few cases of epilepsy they have traditionally reported difficulties with diagnosis, counselling and prescribing of antiepileptic drugs. An association has been made between the quality of epilepsy management in primary care and epilepsy-related hospital admissions; 5 furthermore, Adherence to antiepileptic drugs and other medicines Concordance and understanding of the patient s long-term condition Frequency of seizures recorded Date of last seizure recorded History and description of seizure event Discussion of seizure type, duration, trigger factors, auras, postictal recovery Epilepsy care plan given Therapeutic drug monitoring if indicated Routine monitoring Antiepileptic drug and other drug interactions assessed, both pharmacokinetic and pharmacodynamic Effect of non-antiepileptic drugs on seizure threshold Antiepileptic drug side-effects, doses titrated where appropriate to minimise adverse effects Balance between treatment and quality of life addressed Women s issues (contraception, preconception, pregnancy, menopause) addressed Review of over-the-counter medicines, herbal remedies and aromatherapy Bone health advice and monitoring for relevant antiepileptic drugs BMI, height, weight, diet, exercise, blood pressure, smoking status, alcohol intake recorded First aid and safety information given Epilepsy ID card issued Lifestyle advice and non-clinical interventions given where appropriate For patients with learning disability, Cardiff Health Check used Withdrawal of antiepileptic drugs where appropriate Rescue medication, protocol and training for carers given Table 1. Epilepsy review protocol checklist used in Calderdale increased costs of up to 50 per cent have been shown to be associated with frequent seizures. 6 The involvement of a pharmacist practitioner with a special interest in epilepsy (PwSI epilepsy) within the neurology team in Calderdale maximises the skill mix. Diagnosis of epilepsy is made in secondary care; however, the ongoing management of epilepsy is pharmacologically driven. The pharmacology training of a pharmacist practitioner provides an ideal background for reviewing and optimising treatment in these patients. Rogers and Thomas have described the potential of seamless care by practitioners cultivating an interest in epilepsy. 7 The PwSI epilepsy in Calderdale has a specialist epilepsy role two days per week with a general role within a GP practice for the remainder. She is 12 Progress in Neurology and Psychiatry September/October

2 Epilepsy z Multidisciplinary care a professional member of Epilepsy Action and the International League Against Epilepsy. Objective The objective of our project was to improve the quality of care for epilepsy patients, reduce hospital admissions and increase access to an epilepsy specialist health professional closer to home. The core review was a holistic, structured process adapted to patients individual circumstances, reviewing anti convulsant medication, other medication and lifestyle issues. This review process and the information given to patients enabled them to self-manage and take control of their epilepsy. Procedure This was a project funded by Calderdale Primary Care Trust (PCT). The project commenced in 2010 when a prescribing clinical pharmacist PwSI epilepsy was asked to conduct the annual review of epilepsy patients in GP practices within Calderdale PCT. A total of 360 patients were reviewed in eight GP practices and in a community hospital over a 12- month period. The practice register of epilepsy patients was used to invite patients in for their annual review. GPs prioritised patients where appropriate. The letter of invitation explained the review process, what to expect from the review and how to prepare for it. Each patient was allocated a 30- minute appointment, with shorter appointments for follow-ups. Various clinical systems were used throughout Calderdale. All reviews were documented in shared clinical notes using an epilepsy template designed to incorporate all relevant data. A formic sheet was designed to record outcome data from the review. All practices signed up to the review process. The core review was a holistic, structured process adapted to individual circumstances depending on age, sex, type of epilepsy, other medication and lifestyle issues. Treatment took into account personal preferences and the patient fully participated in all treatment decisions. The review protocol checklist is shown in Table 1. Joint clinics were held with GPs to review patients with learning disabilities and epilepsy using the Cardiff Health Check for People with a Learning Disability as a framework to improve their care. Vulnerable In Patient (VIP) cards and information folders were given to these patients Written information, obtained from Epilepsy Action and the National Society for Epilepsy in the form of booklets, leaflets and epilepsy ID cards, including first aid instructions, were given to patients to back up the verbal information. Leaflets were available in many other languages for non- English speaking patients; interpreters were also used for these patients, often family members. Results The PwSI epilepsy reviewed patients with epilepsy taking into account comorbidities and effects of AEDs and other medication. In total, 23 per cent of patients had an alteration to their AED regimen. Care was taken to avoid combining medication with similar adverse effect profiles, ie additive neurotoxicity. Advice was given to reduce risk factors for seizures. To reduce seizure frequency, appropriate adjustments were made to medication, titrating AEDs up and down, altering timing of medication, changing medication that affected the seizure threshold, and commencing or switching AEDs, where indicated. Advice was given to patients with vagal nerve stimulator devices. Where necessary, medication was prescribed for osteoporosis following local protocols. In the case of complex patients, we liaised with community matrons involved in their care plans. An epilepsy record designed by Epilepsy Action was piloted in some complex patients. This contained an overview of their medical history, tests, medication, appointments, a seizure diary and space to enter notes and comments. Patients found this a useful aide memoir and communication channel between primary and secondary care. Neurologists letters were acted upon and outcomes relayed back. Good links with the neurology department and epilepsy nurses in the two local hospitals helped to resolve any medication issues quickly and to clarify information in hospital letters. This improved patient safety by monitoring medicines reconciliation and reduced potential medication errors. Some patients were discharged from follow-up once regular review had been established in primary care. This helped secondary care to achieve their target for seeing new patients. Regular clinical meetings with the neurologist and epilepsy nurses were established to discuss the management of patients and epilepsy protocols and to review epilepsy patient information leaflets. Quality measures Quality measures included patient questionnaires. These showed that 82 per cent of the 86 patients responding felt that the PwSI epilepsy review was good and had improved their understanding of their condition. Overall, patients and carers found their review informative and reassuring. The service was evaluated for 180 patients. Figures 1 to 3 show the proportion of patients receiving various interventions and Progress in Neurology and Psychiatry September/October

3 review of epilepsy medication review of medication side-effects review of medication interactions verbal advice given patient care plan safety advice given written information given bone health assessment blood pressure review blood tests requested SUDEP discussed therapeutic drug monitoring Figure 1. Activities undertaken at patient review in Calderdale s epilepsy service (n=180) AED compliance checked AED information provided Chronic AED effect reviewed idiosyncratic AED effect reviewed non-aed information provided interaction identified between non-aeds chronic AED effect identified interaction identified between AEDs idiosyncratic AED effect identified barbiturate prescribing reviewed therapeutic drug monitoring normal therapeutic drug monitoring abnormal barbituate stopped advice and Figure 4 shows the proportion of patients referred to another healthcare professional Figure 2. Medication intervention or issues raised at patient review in Calderdale s epilepsy service (n=180) Outcomes This service improved patient care over and above the Quality and Outcomes Framework (QOF) indicators for epilepsy. The PwSI epilepsy interventions led to a reduction in seizure frequency and improved compliance with AEDs as a result of better concordance. Reduction in emergency hospital admissions was measured in terms of patients having no admission in the six months following the PwSI epilepsy intervention but emergency hospital admissions prior to the review. Reductions in neurology appointments were confirmed by GPs where the intervention by the PwSI epilepsy had prevented a referral to the neurologist or a follow-up appointment. Medication changes together with lifestyle advice and avoidance of trigger factors resulted in a 6.4 per cent reduction in emergency hospital admissions and a 5.3 per cent reduction in neurology appointments. Discussion PwSI epilepsy interventions resulted in reductions in emergency hospital admissions and neurology admissions, representing significant cost savings. Historically, the standard of care for epilepsy patients has been low compared with other long-term conditions, despite it being associated with a high mortality rate: people with epilepsy are two to three times more likely to die prematurely than those without epilepsy; moreover, epilepsy patients show a higher incidence of depression and suicide than the general population Our service was developed to address these issues by providing patients with a structured review by a PwSI epilepsy. For example, issues such as sudden unexpected death in epilepsy (SUDEP) are discussed with patients and preliminary questions to screen for depression are asked, followed up using a questionnaire, eg PHQ 9 or GAD 7, following which anti - depressant treatment or counselling are initiated if necessary. Impact on patient management This work has been important in transforming the way in which epilepsy patients are managed in our trust. It has improved their quality of life by decreasing seizure frequency, reducing side-effects and optimising medication. The PwSI epilepsy is an independent prescriber, which has been an advantage in terms of managing dose titrations. The project has involved interaction and team working with a num- 14 Progress in Neurology and Psychiatry September/October

4 Epilepsy z Multidisciplinary care ber of health professionals both in primary and secondary care. For example, community pharmacists have been informed of changes to patients medication. Medicines use reviews (MURs) for such patients have been of great benefit to reinforce medication changes. Sustainability Following the initial evaluation, a business case was written for this service and presented to the PCT. The service was commissioned on the basis that it is cost effective, improves quality of life for epilepsy patients, provides specialist care closer to home, addresses the specific needs of learning disability patients, fits with the Quality, Innovation, Productivity and Prevention (QIPP) agenda, and reduces hospital admissions and neurology referrals. GPs were in favour of the service as it was shown to improve patient care and public health. As the project has been shown to be sustainable, funding has been allocated for a PwSI epilepsy post, to continue and develop the service. The PwSI epilepsy s base was transferred from the PCT to the Calderdale and Huddersfield Foundation Trust (CFHT) in April This has helped further integrate this primary care service with the neurology service in secondary care. A future development would be to use the predictive risk programme to target patients: presently seizure frequency is used to identify these patients. alcohol diet/smoking/exercise safety/first aid driving contraception Figure 3. Lifestyle advice given at patient review in Calderdale s epilepsy service (n=180) other hypertension smoking cessation GP assessment Figure 4. Proportion of patients referred to another healthcare professional and why in Calderdale s epilepsy service (n=180) Future of the PwSI epilepsy service The PwSI epilepsy review service has now been taken up by 20 GP practices in Calderdale PCT with 400 patients reviewed in the first year, saving a total of by prevention of emergency hospital admissions, follow-up neurology appointments and medication savings, for example through monitoring high-cost special formulations. As the project has developed, knowledge gained has been shared with other practitioners involved in epilepsy care. This has included meetings for non-medical prescribers, a multi disciplinary study day on epilepsy in the PCT, a Centre for Pharmacy Postgraduate Education (CPPE) epilepsy event for community pharmacists, a multi disciplinary study day on bone health and epilepsy, lectures at regional Epilepsy Action conferences, lectures at a postgraduate pharmacist course in medicines management at Leeds University and time-out sessions for GPs. Development of guidelines The consultant neurologists for CFHT have led the development of local epilepsy guidelines, 8 which specify the criteria for a structured management system in primary care. These were ratified in July They specify the areas that the shared care management system and annual review should seek to address. They incorporate a treatment algorithm and pointers for history taking, make recommendations relating to contra - Progress in Neurology and Psychiatry September/October

5 ception, pregnancy and the menopause, and provide guidance on the management of people with learning disability as well as information for patients and carers. Conclusion This article describes one of the first PwSI epilepsy review services in primary care in the UK. This innovative service has improved patient care over and above the primary care quality indicators for epilepsy. The service has been well received by epilepsy patients and carers. It has been shown to be sustainable and hence funding has been allocated for the PwSI epilepsy post in order to continue and develop the service. Acknowledgements Thanks to the head of Calderdale medicines management and her team, the neurologists, epilepsy nurses, epilepsy societies, all the GPs and practice staff in Calderdale involved in the service, and CRI pharmacy staff. Declaration of interests None declared. Carole Brown is a Pharmacist Practitioner in Epilepsy, Calderdale and Huddersfield Foundation Trust References 1. Wasted money, wasted Lives. Report by the All Parliamentary Group on Epilepsy, June Epilepsy: A Resource for Primary Care. Epilepsy Action. professionals/healthcare/primary-careresource-pack 3. National Institute for Health and Clinical Excellence. The epilepsies: the diagnosis and management of the epilepsies in adults and children in primary and secondary care. NICE Clinical Guideline CG137, January Scottish Intercollegiate Guidelines Network. Diagnosis and management of epilepsy in adults. SIGN Guidelines No. 70, updated Oct Shohet C, Yelloly J, Bingham P, et al. Association between quality of epilepsy management in primary care, general practice population deprivation status and epilepsy-related emergency hospitalisations. Seizure 2007;16: Jacoby A, Buck D, Baker G, et al. Uptake and costs for epilepsy: findings from a UK regional study. Epilepsia 1998;39: Rogers G, Thomas T. Cultivate an interest. Practitioner with special interest in epilepsy. Epilepsy Professional 2010;issue 16 March: Calderdale and Huddersfield NHS Foundation Trust Epilepsy Guidelines, Progress in Neurology and Psychiatry September/October