While epilepsy is one of the most common neurological conditions in the United States, and the Veterans Health Administration (VA) anticipates an increase in its epilepsy population due to traumatic brain injury in veterans with combat service in Afghanistan and Iraq (hereafter OEF-OIF veterans),(cite) little is known about the quality of care provided to veterans with epilepsy. This lack of knowledge is due to the fact that, until recently, no validated measures of quality for the care of adults with epilepsy existed. The recent development of the QUality Indicators for Epilepsy Treatment (QUIET){Pugh, Berlowitz, et al. 2007 #4913} by this research team provide a foundation for examining the quality of epilepsy care with the VA. However, the CDC funding used to develop these indicators was restricted to examining quality for patients receiving care within the context of primary or general neurology care. Moreover, their limited scope may not address issues that may be relevant to the VA where significant numbers of epilepsy patients are elderly or have post- traumatic epilepsy as a result of OEF-OIF combat service. OBJECTIVES: The objective of the proposed study is to build upon our prior work by addressing the limitations of the existing quality measure. Specifically, we will: 1) Expand the scope of the QUIET indicators to individuals who also receive epilepsy specialty care. 2) Adapt the existing QUIET indicators to the VA population including issues that may be more relevant to veterans epilepsy (e.g., geriatric and post-traumatic epilepsy). METHODS: This project will build upon our previous work by engaging an expert panel of VA and DoD clinicians to examine the existing QUIET indicators. We will first conduct a focus group (N=8), at a professional society meeting, to identify important aspects of care quality within epilepsy specialty care (e.g. timely referral for surgery consultation) and aspects of epilepsy care that may be particularly relevant to the VA population. We will then conduct a systematic literature review to examine the evidence base for items identified by the expert panel. Our team will develop initial quality indicator (QI) statements that will be piloted to a group of epilepsy clinicians and health services researchers who will examine the QI statements for clarity, structure and ease of understanding what each indicator is trying to state. We will then use a modified Delphi Technique to identify statements that are valid and reliable measures of quality for epilepsy care. Quality Indicator statements will be rated by the 12-15 member expert panel for validity/ appropriateness as a quality measure, and feasibility (can be reliably measured) using a 9-point Likert scale. After the initial rating, the group will have a face-to-face meeting at a professional society meeting to discuss the initial ratings and concerns regarding each indicator. After the face-to-face meeting, panel members will re-rate each item. Items that reach consensus (defined by the RAND-UCLA Appropriateness Method) will be accepted as QUIET-VA indicators. A third round of ratings will be conducted for items which did not reach consensus as valid, reliable quality indicators. Items that reach consensus after the third round of ratings will be added to the QUIET-VA measure. Those that do not reach consensus on the third round of ratings will be dropped from consideration.
This project will build upon our prior work to expand the Quality Indicators in Epilepsy Treatment for use in the VA (QUIET-VA). Development of the QUIET-VA indicators will allow us to proceed with a body of research to assess and improve the quality of VA epilepsy care using the Quality Enhancement Research Initiative (QUERI) framework. Accordingly we will first identify gaps between best practices and clinical practice. Next we will identify variations in practice and identify barriers and facilitators related to high and lower quality VA epilepsy care and link variation in quality of care to patient outcomes. These studies will provide the foundation to develop and implement appropriate interventions to promote best practice in VA epilepsy care. In the long run, this program of research will improve the care of patients receiving VA epilepsy care and improve outcomes for the patient and the health care system
