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Epilepsy Medication A udit at QECH OPC

Epilepsy Medication A udit 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 .

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Epilepsy Medication A udit at QECH OPC

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  1. Epilepsy Medication Audit at QECH OPC Dr Chipiliro kadzongwe MMed Psych Trainee, CoM, UNIMA

  2. Outline • Introduction • Methodology • Design • Sample size • Standards • Data collection • Data analysis • Results • Conclusions • Recommendations

  3. 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

  4. Introduction • Different causes • Genetic • past history of birth trauma • brain infections • head injury • in some cases, no specific cause can be identified

  5. Introduction • Classification of epileptic seizures • Clinical type • Partial • Generalized • Epilepsy syndromes

  6. Introduction • Malawi epidemiology (Amos A & Wapling L, 2011) • Prevalence 2.8% • 55 % males • 45 % females

  7. 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

  8. 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

  9. Introduction • Main challenges • Irregular availability of AEDs • Staff availability

  10. Introduction • This was a baseline assessment for the existing prescribing practices

  11. 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

  12. Methods • Exclusion criteria • Patients attending clinic for the first time • Children • Data collected between March & April 2013

  13. 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

  14. 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

  15. 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

  16. Maintenance dose ranges for AEDs

  17. 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

  18. Data collection • reference to the dosage of AED patient taking • review of seizure frequency at least every 12 months

  19. Results • Baseline Characteristics • 65 patient were included • 65 % (42) of the patients were males • 35 % (23) were females

  20. 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

  21. Results • Current Treatment • AEDs currently being used in then clinic are • Sodium valproate (VPA) • Carbamazepine (CBZ) • Phenobarbital (PHB) • Phenytoin (PHY)

  22. Results • 69 % (45) of the clinic attendees were on monotherapy while 31 % (20) were on combination therapy

  23. Results • Seizure type • 53 (82 %) did not have their seizure type documented and classified • 12 (18%) had seizures classified

  24. 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

  25. 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

  26. Results • Commonly prescribed AEDs

  27. Results • Starting therapy

  28. Results • Minimum and maximum dose ranges for each AEDs

  29. Results • In 28% (18) of the patients, the AEDs were not in maintenance treatment range

  30. Results • Number of reviews in last 12 months • No clear indication of review patients’ seizures • 52% have 5 reviews in 12 months

  31. Results • HIV Status

  32. Limitations • Lack of documentation on when the patients started treatment • Medication collected by family member on review • Limited time for data collection

  33. 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

  34. 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

  35. Recommendations • Training of nursing staff • Institute standard prescribing guideline for the epilepsy clinic • Re-audit

  36. Recommendations • Other standards that could be audited • Side-effects • Drug interactions • HAART • Safety of daily activities • Risks in pregnancy • Prognosis

  37. Acknowledgement • Dr J. Ahrens, HoD, Department of Mental Health, CoM • Ms M. Kumwenda, psychiatric nurse, QECH • Mr S. Maida

  38. References • 1. Stokes T, Shaw EJ, Juarez-Garcia A, Camosso-Stefinovic 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/10954/29533/29533.pdf. • 2. Oakley C, Coccia F, Masson N, McKinnon I, Simmons M eds. 101 Receips for Audit in Psychiatry. London: RCPsych; 2011:47–48.

  39. 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.

  40. Education

  41. Age of onset by age group

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