Reducing Emergency Visits and Admissions for Epilepsy Patients: Nationwide Children’s Dr. Anup Patel Answers Our Questions

By Clive Riddle, April 14, 2017 What can a single quality improvement project accomplish at a single hospital? Just ask Nationwide Children’s, who  performed a quality improvement project and found new, simple ways to significantly decrease the number of emergency department visits and hospitalizations in pediatric patients with epilepsy.” They achieved a 28% decline in emergency visits, a 43% decline in admissions and saved $2 million in costs for these patients. By sharing their research findings in the current issue of Pediatrics, and highlighted in Nationwide Children’s research publication Research Now, hospitals, physicians and purchasers performing care management can adopt Nationwide’s approach to their own settings. We are told that “Nationwide Children’s Hospital serves almost 3,500 children diagnosed with epilepsy. In 2012 and much of 2013, the Emergency Department was experiencing approximately 17 visits per 1,000 epilepsy patients per month. In the minds of both Emergency Medicine physicians and epilepsy subspecialists, that was too many.” The hospital shares that “the QI team identified ‘key drivers’ (or contributing factors) of ED visits, and found they centered on provider-to-provider communication issues and patient/family resources, education, beliefs and comorbidities. Then the team began interventions to target those key drivers. Most important was the establishment of an Urgent Epilepsy Clinic,” which they tell us involved family visits lasting 90 minutes or longer, with as little as three days’ notice. Nationwide Children’s also identified that “abortive seizure medication was under dosed (or not given at all). Nationwide Children’s built an alert system into its electronic health records – when a provider entered what appeared to be an incorrect dosage based on size and age, the provider would be notified of the proper dose.”  Their additional interventions developed from the project included a color-coded seizure action plan, which helped caregivers understand what a baseline seizure looks like and when to call Neurology; and a personalized magnet giving caregivers information about how to give abortive seizure medications.” The results? Emergency visits reduced from 17.0 to 12.2 per month per 1,000 children epilepsy patients during the past year. The average number of inpatient epilepsy children hospitalizations per month was reduced from 7 admissions per month per 1000 patients to 4 admissions per month per 1000 patients.  Anup Patel, MD, a pediatric epileptologist and member of the Division of Neurology at Nationwide Children’s, and leader of the QI project and resulting research paper was nice enough to respond to some follow-up questions I asked after reading about the project. First, I asked  him what is the approximate epilepsy incidence/1,000 population (pediatric preferably). He shared this information from Epilepsy.com which he recommends as a great source information on epilepsy: Epilepsy is the 4th most common neurological problem – only migraine, stroke, and Alzheimer’s disease occurs more frequently. There are many different ways to explain how often a disease occurs. Here’s a few points to consider. What is the incidence of epilepsy in the United States? ·         The average incidence of epilepsy each year in the U. S is estimated at 150,000 or 48 for every 100,000 people. ·         Another way of saying this- each year, 150,000 or 48 out of 100,000 people will develop epilepsy. ·         The incidence of epilepsy is higher in young children and older adults. This means that epilepsy starts more often in these age groups. ·         When the incidence of epilepsy is looked at over a lifetime, 1 in 26 people will develop epilepsy at sometime in their life. ·         Seizures are the number on most common Neurologic Emergency that we see in children. What is the prevalence of epilepsy in the United States? There are many different estimates of the prevalence of epilepsy. These numbers vary depending on when the studies were done, who was included, and a host of other factors. ·         The number of people with epilepsy, using prevalence numbers, ranges from 1.3 million to 2.8 million (or 5 to 8.4 for every 1,000 people). ·         The estimate currently thought to be most accurate is 2.2 million people or 7.1 for every 1,000 people. ·         However, higher numbers of people report that they have active epilepsy, 8.4 out of 1,000 people. These numbers are even higher when people are asked if they have ever had epilepsy (called lifetime prevalence). 16.5 per 1,000 people reported that they had epilepsy at some point in their life. Next I asked him about the second intervention in the project regarding abortive seizure medication under dosed or not given. How much is medication adherence/compliance an issue for this population?  Dr. Patel responds that “We know that medication adherence to daily seizure medications is a risk factor for ED visits in patients with epilepsy.  In regards to abortive seizure medication (medication given for long or repeat seizures), we found under dosing was an issue (previous literature – Patel in Epilepsy and Behavior 2014) and that parents were either anxious, did not remember, or did not get proper instruction on how to give medications.” Noting that the project identified comorbidities as a key driver, I asked him what are the typical comorbidities? He replied “Developmental delay, autism, cerebral palsy, depression, and anxiety.” I asked Dr, Patel to elaborate on the calculation that their interventions yielded $2 million in annual savings. He responded that “our average ED visit was $640 and a subsequent hospitalization averaged $14,500 in claims paid. When you look at the reduction of both ED visits and the hospitalizations associated with the ED visit, you get the $2 million savings per year”. Lastly, I asked if a similar approach work for an adult population as well. The short answer is yes.