Chipiliro

Report
Epilepsy Medication Audit at
QECH OPC
Dr Chipiliro kadzongwe
MMed Psych Trainee, CoM, UNIMA
Outline
• Introduction
• Methodology
–
–
–
–
Design
Sample size
Standards
Data collection
• Data analysis
– Results
• Conclusions
• Recommendations
Introduction
• Epilepsy is a chronic neurological disorder
characterized by recurrent unprovoked
seizures
• The majority of the seizures can be controlled
with appropriate medications with patients
able to return to function
Introduction
• Different causes
– Genetic
– past history of birth trauma
– brain infections
– head injury
– in some cases, no specific cause can be identified
Introduction
• Classification of epileptic seizures
– Clinical type
• Partial
• Generalized
– Epilepsy syndromes
Introduction
• Malawi epidemiology (Amos A & Wapling L,
2011)
– Prevalence 2.8%
– 55 % males
– 45 % females
Introduction
• Queen Elizabeth Central Hospital (QECH)
tertiary hospital in Blantyre
• Care for patients with epilepsy shared
between departments of internal medicine
and psychiatry
• Initial assessment and diagnosis conducted by
department of internal medicine
– Neurologist available occasionally
Introduction
• Follow up care is provided psychiatry nursing
staff
• In 2012 the clinic had
– an average of 51 patients per week
– 240 patients per month
– total of 2,875 visits
Introduction
• Main challenges
– Irregular availability of AEDs
– Staff availability
Introduction
• This was a baseline assessment for the
existing prescribing practices
Methods
• Prospective follow up audit on adult epilepsy
patients; at least 100 patients
• Assessment of health passport books
• Inclusion criteria
– Patients with an established diagnosis of epilepsy
Methods
• Exclusion criteria
– Patients attending clinic for the first time
– Children
• Data collected between March & April 2013
Methods
• Compared available standards
– Local
• Malawi standard treatment guidelines (MSGT) 2008
– International
• mhGAP Intervention Guide for mental, neurological and
substance use disorders in non-specialized health
settings: 2010
• Guidance on epilepsy in adults and children produced
by the National Institute for Health an Clinical
Excellence (NICE); 2004
Methods
• Standards
– Record show seizure type has been classified
– Records show that combination anti-epileptic drug
therapy, if prescribed , followed an adequate trial
of monotherapy
Methods
• Standards
– The prescribed AEDs are within the recommended
maintenance dose ranges
– Records show that all patients have had a review
in the previous 12 months
– Record shows that seizure frequency has been
documented in the past 12 months
Maintenance dose ranges for AEDs
Data collection
• The following documentation was sought
– a description of the seizures (ictal
phenomenology)
– seizure type
– reference to prescribed AEDs patient is taking,
where more than one drug was being taken,
documentation of at least two periods of
monotherapy that failed to gain adequate results
Data collection
– reference to the dosage of AED patient taking
– review of seizure frequency at least every 12
months
Results
• Baseline Characteristics
– 65 patient were included
– 65 % (42) of the patients were males
– 35 % (23) were females
Results
• Baseline characteristics
– Mean age of the patients is 30 years within the
range of 15 to 67 years
– The mean age of seizure onset was 18 years
within the range of 6 months to 65 years
Results
• Current Treatment
– AEDs currently being used in then clinic are
•
•
•
•
Sodium valproate (VPA)
Carbamazepine (CBZ)
Phenobarbital (PHB)
Phenytoin (PHY)
Results
• 69 % (45) of the clinic attendees were on
monotherapy while 31 % (20) were on
combination therapy
Results
• Seizure type
– 53 (82 %) did not have their seizure type
documented and classified
– 12 (18%) had seizures classified
Results
• Seizure frequency
– All patients had their seizure frequency recorded
in the last 12 month
– 65 % (42) of the patients had their seizures well
controlled
Results
• Seizure frequency
– 35% (23) had poor seizure control
– 48% (11) of the patients with poor seizure control
had no change in their medication
– With 2 (18%) patients only having a reason
indicated for not changing their medication
Results
• Commonly prescribed AEDs
AEDs
Number
Percentage (%)
PHB
33
51
PHY
8
12
VPA
3
5
CBZ
1
2
PHB & CBZ
12
19
PHB & PHY
3
5
PHB & VPA
2
3
PHY & CBZ
1
2
VPA & CBZ
1
2
PHB/PHY/CBZ
1
2
Results
• Starting therapy
Therapy
Percentage (n)
No documentation
49 % (32)
Single drug
49% (32)
Combined
2 % (1)
Results
• Minimum and maximum dose ranges for each
AEDs
AEDs
Minimum dose
Maximum dose
PHB
60mg
210mg (3)
PHY
100mg (7)
400mg
VPA
200mg (1)
1600mg
CBZ
200mg (7)
1400mg
Results
• In 28% (18) of the patients, the AEDs were not
in maintenance treatment range
Results
• Number of reviews in last 12 months
– No clear indication of review patients’ seizures
– 52% have 5 reviews in 12 months
Results
• HIV Status
Limitations
• Lack of documentation on when the patients
started treatment
• Medication collected by family member on
review
• Limited time for data collection
Conclusion
• Lack of documentation on seizure type
• Lack of justification for combination therapy
• 28 % of AEDs doses not within the
maintenance treatment ranges
• Lacks regular reviews
• Good documentation of seizure frequency
Recommendations
• Importance classification of epileptic seizures
• Recording the justification for combination
therapy
• Improved record keeping
• At least 2 reviews of seizures and medications
in 12 months
• Continue documentation on seizure frequency
Recommendations
• Training of nursing staff
• Institute standard prescribing guideline for the
epilepsy clinic
• Re-audit
Recommendations
• Other standards that could be audited
– Side-effects
– Drug interactions
• HAART
– Safety of daily activities
– Risks in pregnancy
– Prognosis
Acknowledgement
• Dr J. Ahrens, HoD, Department of Mental
Health, CoM
• Ms M. Kumwenda, psychiatric nurse, QECH
• Mr S. Maida
References
• 1. Stokes T, Shaw EJ, Juarez-Garcia A, CamossoStefinovic J, Baker R. Clinical Guidelines and
Evidence Review for the Epilepsies: diagnosis and
management of the epilepsies in adults and
children in primary and secondary care. London;
2004. Available at:
http://www.nice.org.uk/nicemedia/live/10954/2
9533/29533.pdf.
• 2. Oakley C, Coccia F, Masson N, McKinnon I,
Simmons M eds. 101 Receips for Audit in
Psychiatry. London: RCPsych; 2011:47–48.
References
• World Health Organisation Health. mhGAP
Intervention Guide. Geneva; 2010. Available
at:
http://www.who.int/mental_health/mhgap.
• MoH. Malawi Standard Treatment Guidelines.
Fourth. Lilongwe; 2008:25–27.
• Amos A, Wapling L. Epilepsy in Malawi. 2011.
Education
never
primary
seconda
ry
Total
10 15.38%
36 55.38%
19 29.23%
65 100.00%
Age of onset by age group
Age group
n
%
<15
28
43
15-24
19
29
25-34
9
14
35-44
6
9
45-54
1
1.5
55-64
1
1.5
>64
1
1.5

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