Download Quality Measures Redux

Measure Revisited
The epilepsy quality measures, previously mentioned in the “Measure for Measure” blog of 9/10 are
being published in the January 4 edition of the Neurology Journal. 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 which 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 objections:
The make-up of the committee to determine these standards is overly weighted by “Epilepsy Specialists”
(fourteen of these). I think the views of general, practicing neurologists should have been taken into
account when a document of this nature is 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 the 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.
Next, I will discuss my reactions to the eight specific measures. In particular I will comment on the
practicality of the 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 measurecertainly 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 each visit. 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 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 between the ages of 12 and 44 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 noncompliant 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.”