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The problem of evaluation of comprehensive care
From Prof. Dr. Ettore Beghi, Milan, Italy
Berlin (20. September 2008) – Comprehensive care in epilepsy, as with any chronic clinical condition, refers to the management of the disease and its complications and comorbidities aiming to obtain the maximal benefits in terms of satisfactory control of the symptoms in keeping with patients’ satisfaction and quality of life. Little is known about the impact of comprehensive care of epilepsy and this reflects into different patterns of care both at the primary level and in epilepsy clinics and other secondary and tertiary centres. There are several explanations for this: 1. The different characteristics and outcome of acute symptomatic seizures, isolated unprovoked seizures and epilepsy, which are frequently defined interchangeably; 2. The ill-defined association between epilepsy and several other clinical conditions, like depression (and other psychiatric disorders), headache and sleep disturbances; 3. The increasing number of drugs having different safety and tolerability profiles and effects on some comorbid conditions; 4. The differing perspectives of patients, caring physicians, and health care administrators regarding the cost-benefit ratio of the management of epilepsy; 5. An as yet lacking formal, evidence-based assessment of comprehensive care in epilepsy.
Acute symptomatic seizures (ie, seizures caused by immediate CNS insults), isolated unprovoked seizures and epilepsy (ie, repeated unprovoked seizures) represent clinical conditions having different severity and outcome and may require differing diagnostic and therapeutic management and a differing approach at the primary (ie, general practitioner), secondary (ie, neurologist), and tertiary (ie, epileptologist) level. As well, the medical interventions may differ at the time of occurrence of a seizure and in the follow-up, when a full diagnostic and therapeutic work-up is required. Comorbidities require proper attention because a bidirectional cause-effect relationship may be present (Slides 1 & 2) and because ad-hoc treatments may be indicated. Epilepsy complications may be identified and managed to the benefit of the patient, in terms of satisfaction and quality of life, and to reduce disease-related direct and indirect costs. Second-generation antiepileptic drugs (AEDs) are currently available in increasing numbers. Although these compounds do not compete with classic AEDs in terms of efficacy, their pharmacokinetic and tolerability profiles are different and, in some occasions, better than those of the competitors. In addition, some of them have been found effective against symptoms of other comorbid disorders, like depression, headache and pain (Slide 3). Doctors’ main objective in the overall management of epilepsy is seizure control. In contrast, for the patient the focus of the disease management would be the use of drugs with minimal or no impact on daily living activities and overall quality of life. In this regard, the tolerability of a treatment may be more important than its efficacy. The health-care administrator looks for a cost-effective management with scarce impact on the available resources, in terms of minimal access to health care facilities and low monetary costs.
Surprisingly, the poverty of good quality reports does not provide sufficient high-level evidence in support of evidence-based standards of care in patients with epilepsy in a number of differing contexts: 1. The role of primary care and its interface with secondary care; 2. The role of physicians involved in the acute management of the disease and those required to complete the diagnostic and therapeutic work-up; 3. The cost-benefit ratio of epilepsy clinics and other tertiary centres compared to the other facilities dedicated to the care of epilepsy; 4. The impact of educational tools on improving the care of epilepsy by the different actors; 5. The integration of the patients’ views into the decision process.
In the light of the available evidence on the effectiveness of epilepsy services, more studies with robust methodology are required to support the best evidence-based recommendations and identify the most effective models of service provision for patients with epilepsy.
Slide 1: Depression as a risk factor of epilepsy.
Slide 2: Comorbidity of migraine and epilepsy.
Slide 3: Effects of antiepileptic drugs on depression/mood, migraine and neuropathic pain.
Source: 8th European Congress on Epiteptology, Satellite Symposium: “Comprehensive Care of Epilepsy in Europe”, Berlin, 20. September 2008 (Medizin und PR Kommunikation).