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of everyone affected by epilepsy

3.6.2 Achieving seizure control

Relevant Tools: A.16
With effective management, up to 70% of people with active epilepsy could become seizure-free.1

Using this website can help you and your practice to work towards that goal. However, the GMS contract recognises that seizure control is often under the influence of factors outside the GP's control, and therefore also recognises that many patients will be exception reported for this indicator. Some patients prefer not to take AEDs at all, or prefer to take a reduced, less effective dose that gives them fewer side-effects. Some patients are unable to take their medication consistently enough to control their seizures, while others develop sensitivities to AEDs. Some patients have seizures that cannot be controlled despite maximal input from epilepsy specialists. Others do not wish to take part in an epilepsy review. A very small number will have a serious competing pathology, such as a terminal illness, which makes carrying out an epilepsy review irrelevant.

Some reasons for making an exception report for this indicator are listed in A.16 along with the relevant Read codes.

Exception reporting

To ensure that practices do not lose out on quality payments through factors beyond their control, despite providing a quality service, an annual system of exception reporting is being put in place. Under the GMS contract it is noted that exception reporting is expected to be more common in epilepsy than in other chronic conditions (eg for brain-damaged patients whose seizures are difficult to control, patients who find the side-effects of medication intolerable, etc).2

Clinicians should record justification for all exceptions in the patient's notes (see Table 6). However, it should be remembered that just because a patient with epilepsy is excepted it does not mean that they will not benefit from an annual review.

Criteria for exception reportingApplication to epilepsy
Patients who have been recorded as refusing to attend review who have been invited on at least three occasions during the preceding 12 monthsMay be common because of perceived stigma, or they may be seizure-free with no problems
Patients for whom it is not appropriate to review the chronic disease parameters due to particular circumstances eg terminal illness, extreme frailtyMay apply to some residential care patients and extreme co-morbidity eg brain tumours
Patients newly diagnosed within the practice or who have recently registered with the practice, who should have measurements made within three months and delivery of clinical standards within nine months eg blood pressure or cholesterol measurements within target levelsNot feasible for a standard of seizure-free in last 12 months – so new diagnoses and registrations should probably be exception reported
Patients who are on maximum tolerated doses of medcation whose management reamins suboptimalImportant as this excludes 'chronic epilepsy' patients whose seizures cannot be stopped despite comprehensive specialist attention Note: it is recommended that all maximum tolerated dose Read codes entered on a patient's notes should also have 'medication review' recorded as well
Patients for whom prescribing a medication is not clinically appropriate eg those who have an allergy, another contraindication, or have experienced an adverse reaction 
Where a patient has not tolerated medicationMay apply to many patients with epilepsy who cannot tolerate high enough doses of AEDs to control their seizures
Where a patient does not agree to investigation or treatment (informed dissent), and this has been recorded in their medical recordsMay well apply to those patients who do not accept the diagnosis, refuse to attend for special assessment, or decline to attend annual review
Where the patient has a supervening condition that makes treatment of their condition inappropriate eg cholesterol reduction where the patient has liver diseaseMay reduce the range of AEDs suitable eg with liver failure
Where an investigative service or secondary care service is unavailableMay be some problems here; greater primary care surveillance will increase referral to secondary care, who may not be able to cope

Advice for women of childbearing age

Using this website should help you locate women of childbearing age and deliver the appropriate information and advice regarding contraception, conception and pregnancy (see Guidelines for women).

Practices are required to deliver all three pieces of advice in order for the patient to be included in the target. Three separate Read codes must be recorded, one for each piece of advice offered. Only coding one or two out of three will mean that the practice will NOT receive the QOF points. This applies even if all three pieces of advice are provided in one booklet/leaflet. When one or more of these elements are not clinically relevant, for example the patient is already pregnant, has had a hysterectomy, or is post-menopausal, then normal exception reporting rules apply, as described above.

References

1 Frost S et al. 2002. National Statement of Good Practice for the Treatment and Care of People Who Have Epilepsy. Liverpool: Joint Epilepsy Council.

2 British Medical Association, 2013. QOF guidance, 2013-2014. [online] (Accessed 01/05/2013).

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