Thomas Finnegan and Piyali Chatterjee Medscape, LLC, New York, NY, USA

ALIGNED PHYSICIAN-PATIENT EDUCATION INCREASES AWARENESS OF STRATEGIES TO IMPROVE TREATMENT OUTCOMES IN EPILEPSY

References

1. Epilepsy Foundation. An introduction to epilepsy. Updated 2014. http://www.epilepsy.com/start-here/introduction-epilepsy Accessed November 17, 2014.

2. Institute of Medicine (IOM). Epilepsy Across the Spectrum: Promoting Health and Understanding. Washington, DC: The National Academies Press; 2012.

3. Privitera M. Current challenges in the management of epilepsy. Am J Manag Care. 2011;17:S195-S203.

4. Witt JA, Elger CE, Helmstaedter C. Which drug-induced side effects would be tolerated in the prospect of seizure control? Epilepsy Behav. 2013 Oct;29(1):141-143.

5. Porter RJ, Burdette DE, Gil-Nagel A, et al. Retigabine as adjunctive therapy in adults with partial-onset seizures: integrated analysis of three pivotal controlled trials. Epilepsy Res. 2012;101:103-112.

6. Rheims S, Ryvlin P. Retigabine for partial onset seizures. Expert Rev Neurother. 2012;12:509-517.

7. American Epilepsy Society (AES). Epilepsy attitudes and understanding: survey report. 2010.

8. Chapman SC, Horne R, Chater A, Hukins D, Smithson WH. Patients’ perspectives on antiepileptic medication: relationships between beliefs about medicines and adherence among patients with epilepsy in UK primary care. Epilepsy Behav. 2014 Feb;31:312-320.

9. Paschal AM, Rush SE, Sadler T. Factors associated with medication adherence in patients with epilepsy and recommendations for improvement. Epilepsy Behav. 2014 Feb;31:346-350.

10. Kanner AM. Addressing cognitive and psychiatric effects of antiepileptic drugs. September 25, 2015. Medscape Education. http://www.medscape.org/viewarticle/849750. Accessed May 31, 2016.

11. Sirven JI, Krauss GL, Chung C. To titrate or not: optimizing treatment with antiepileptic drugs. August 31, 2015. Medscape Education. http://www.medscape.org/viewarticle/848142. Accessed May 31, 2016.

12. Shafer PO. Is your epilepsy treatment working? December 10, 2015. WebMD Education. http://education.webmd.com/viewarticle/855001 Accessed May 31, 2016.

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Acknowledgement

The educational intervention and outcomes measurement were funded through an independent educational grant from Sunovion Pharmaceuticals, Inc.

For more information, contact Thomas F. Finnegan, PhD, Associate Director, Educational Strategy, Medscape, LLC, tfinnegan@medscape.net.

INTRODUCTION

INSTRUCTIONAL METHOD

ASSESSMENT METHOD

RESULTS

Epilepsy is a spectrum of neurologic disorders characterized by seizures with unpredictable frequency that significantly impair patient quality of life (QoL). In the United States, about 150,000 new cases of epilepsy are diagnosed each year.1 Although highly prevalent, epilepsy remains a challenging disease to manage effectively, particularly because of comorbid psychiatric illness and adverse events related to AED therapy.2,3,4 Newer antiepileptic drugs (AEDs) may help to improve seizure control even in patients with suboptimal response to several previous treatments.5,6 However, according to the American Epilepsy Society,

only half of patients with the most frequent seizures were offered new treatment options.7 Along with the challenges encountered by physicians, patients with epilepsy are also challenged by their own disease. Patients often have limited understanding of the goals of therapy, potential adverse events, or when a discussion with their physician should occur regarding a potential change in therapy.8,9 A study was undertaken to determine if online parallel physician-patient education interventions could increase the awareness of strategies designed to improve treatment outcomes in epilepsy.

PHYSICIAN ACTIVITIES

Outcomes from 2 online 30-minute CME-certified activities were included in this analysis. Each activity was available on the Medscape Mobile application, ensuring real-time access by clinicians who rely on mobile devices for education. Both activities utilized synchronized slides and interactivity questions to encourage participant engagement and feedback. A transcript of the audio and slides for each of the activities was made available for downloading/printing for those wishing to view the activity offline. The specifics for each activity were as follows:

■ The video lecture, on the topic of adverse events associated with AEDs, was conducted by a single expert faculty psychiatrist and consisted of a series of synchronized slides.10 The educational intervention launched online on September 25, 2015, and data were collected through December 22, 2015

■ The video-based panel discussion involved 3 expert faculty and reviewed the effect of AED titration scheduling on the occurrence of adverse events.11 The educational intervention launched online on August 31, 2015, and data were collected through December 2, 2015

All activities compared participant’s responses to questions prior to exposure to the educational interventions with responses to those same questions after exposure to the educational interventions. Additional analysis was undertaken for the 2 physician-directed, CME-certified activities:

■ Linking pre-assessment and post-assessment responses from individual participants allowed each learner to serve as his/her own control (Figure 1)

■ A paired, 2-tailed t-test was used to assess whether the mean pre-assessment score was different from the mean post-assessment score. McNemar’s χ2 statistic was used to measure changes in responses to individual questions

■ P values were calculated for both t-test and χ2 statistics to determine significance level. P values less than .05 were considered statistically significant

PATIENT AND CAREGIVER-DIRECTED EDUCATION

An online text-based educational activity with graphics, approximately 7 minutes in length, was developed by a healthcare professional with experience counseling patients with epilepsy. The activity included interactivity questions to encourage patient engagement and participation.

■ The activity was designed to provide an overview to patients and caregivers regarding the goals of epilepsy treatment, breakthrough seizures, the importance of taking medication as indicated, and common adverse events12

■ The activity was hosted on the WebMD education website and data were collected from December 10, 2015 through June 1, 2016

This analysis is a subset of all clinician learners which includes 74 neurologists who completed the CME-certified panel discussion, 103 neurologists who completed the CME-certified video lecture, and 824 patients and caregivers who completed the text activity. Completion of both CME activities resulted in a 59% average increase in the number of neurologists making evidence-based decisions. As a result of participating in the educational intervention, specific areas of improvement included:

VIDEO LECTURE ■ Recognition that a history of postpartum depression

increases the risk of iatrogenic psychiatric symptoms in a patient receiving levetiracetam who is reporting symptoms of irritability and depression (relative pre-post percent improvement: 82%, P <.05; [Figure 2])

■ Knowledge that lamotrigine is a reasonable choice for AED in a patient with a history of previous and current depressive symptoms (relative pre-post percent improvement: 15%, P <.05; [Figure 3])

■ A non-statistical improvement in the identification of zonisamide as an inappropriate choice for an AED in a patient with cognitive symptoms while receiving topiramate (relative pre-post percent improvement: 21%, P =.068; [Figure 4])

PANEL DISCUSSION ■ Awareness that the addition of eslicarbazepine acetate to

valproic acid and lamotrigine is appropriate in a patient with 2 or 3 seizures per week, suicidal ideation, and cardiovascular comorbidities (relative pre-post percent improvement: 83%, P <.05 [Figure 5])

■ Knowledge that the rapid titration of a new AED increases the risk of intolerable adverse event (relative pre-post percent improvement: 15%, P <.05 [Figure 6])

■ Awareness that therapeutic window is an additional consideration for all patients >65 years of age when selecting and titrating AEDs (relative pre-post percent improvement: 42%, P <.05 [Figure 7])

PATIENT EDUCATION ACTIVITY ■ Importance of the patient informing their healthcare

provider that he or she had a seizure while taking an AED (relative pre-post percent improvement: 15% [Figure 8])

■ A larger proportion of women than men completed the educational activity (66% vs 33%) (Figure 9)

■ 42% of completers were >54 years of age (Figure 9)

■ 51% of completers were patients with epilepsy and 23% had family members with epilepsy (Figure 9)

■ 63% of completers were white and 11% were Asian (Figure 9)

FIGURE 1. Linked Learning Assessment

Pre-assessment Post-assessment

Wrong answer Right answer

Right answer Right answer

Right or wrong answer

Wrong answer

IMPROVED

REINFORCED

UNAFFECTED

12%

33% 55%

Linked LearnersComparing individual learner’s pre- and post-assessment answer choices; note that both the “Improved” and the “Reinforced” performers answered the post-assessment correctly.

VIDEO LECTURE

PANEL DISCUSSIONFollowing 2 generalized tonic-clonic seizures that occurred 48 hours apart, a 35-year-old woman was started on a regimen of levetiracetam at a dose of 500 mg twice daily and instructed by her neurologist to increase it to 1000 mg twice daily 1 week later; 3 weeks after reaching this dose, she started to exhibit increased irritability and poor frustration tolerance. At work, she was asked by her supervisor to go home after having been involved in a dispute with a coworker. One week later, she reported feeling depressed and guilty, crying constantly, having difficulty finding pleasure in any activity, and having thoughts of wanting to be dead. The patientʼs previous neurologic history was remarkable for migraines with auras occurring every 3 months since age 15. Her past medical history was remarkable for a post-partum depression at age 26, which persisted for 8 months.

Jim, a 50-year-old man, presents with a long history of partial-onset seizures. His current antiepileptic drugs (AEDs) include carbamazepine 800 mg/d, valproic acid 500 mg/d, and lamotrigine 600 mg/d. Despite AED therapy, he continues to have seizures 2- to 3-times per week. He also complains of dizziness, ataxia, and diplopia which he describes as being intolerable at times. His medical history is also significant for a history of suicidal ideation, hypertension, and hypercholesterolemia for which he is taking venlafaxine, atenolol, and atorvastatin, respectively.

FIGURE 2. If you were the treating neurologist, what conclusion would you reach regarding the patientʼs psychiatric complaints? FIGURE 5. If you decide to add another AED to Jimʼs regimen,

which of the following would be the most appropriate?

FIGURE 3. As the patientʼs past psychiatric history must be factored into the choice of antiepileptic drug (AED) to prescribe her, which of the following would you choose in this patient?

FIGURE 6. Jim reports that his seizures are disrupting his daily life and would like to have them controlled as quickly as possible. What would you tell him?

FIGURE 4. In considering the use of a different AED, which of the following would you avoid so as to prevent cognitive adverse events similar to those caused by topiramate from occurring in this patient?

FIGURE 7. If the patient were >65 years of age, what would be an additional consideration when titrating AEDs?

Neurologists (n=103)Pre-Assessment

%(n)Post-Assessment

%(n)

AThe patient’s psychiatric symptoms are a reaction to her new onset epilepsy

4% (4) 6% (6)

BThe patient’s depressive episode was caused by the high dose of levetiracetam

28% (29) 17% (17)

CThe patient’s history of postpartum depression placed her at an increased risk of iatrogenic psychiatric symptoms

33% (34) 60% (62)*

DThe irritability and poor frustration tolerance, but not the depressive episode, are symptoms that can be attributed to levetiracetam

35% (36) 17% (18)

*P <.05

Neurologists (n=74)Pre-Assessment

%(n)Post-Assessment

%(n)

A Eslicarbazepine acetate 16% (12) 30% (22)*

B Levetiracetam 53% (39) 50% (37)

C Zonisamide 15% (11) 15% (11)

D Perampanel 16% (12) 5% (4)

*P <.05

Neurologists (n=103)Pre-Assessment

%(n)Post-Assessment

%(n)

A Lacosamide 10% (10) 10% (10)

B Lamotrigine 65% (67) 75% (77)*

C Eslicarbazepine acetate 7% (7) 8% (8)

D Topiramate 17% (17) 7% (7)

E Pregabalin 2% (2) 1% (1)

*P <.05

Neurologists (n=74)Pre-Assessment

%(n)Post-Assessment

%(n)

AThat you would initiate the AED at the highest recommended dose to provide him with quick seizure relief

1% (1) 1% (1)

BThat you would uptitrate the AED rapidly to provide him with quick seizure relief

18% (13) 5% (4)

CThat rapid titration may lead to intolerable adverse effects

81% (60) 93% (69)*

*P <.05

Neurologists (n=103)Pre-Assessment

%(n)Post-Assessment

%(n)

A Lamotrigine 24% (25) 25% (26)

B Eslicarbazepine acetate 9% (9) 6% (6)

C Zonisamide 47% (48) 56% (58)*

D Perampanel 14% (14) 8% (8)

E Lacosamide 7% (7) 5% (5)

*P =.068

Neurologists (n=74)Pre-Assessment

%(n)Post-Assessment

%(n)

A Frailty scale 42% (31) 26% (19)

B Therapeutic window 32% (24) 46% (34)*

C CHADS2 score 4% (3) 4% (3)

DNeurological Disorders Depression Inventory for Epilepsy (NDDI-E)

22% (16) 24% (18)

*P <.05

40%

29%

31%

Reinforced Learners

ImprovedLearners

Una ectedLearners

14%

70%

16%

Una�ected Learners

ReinforcedLearners

ImprovedLearners

25%

59%

16%

Reinforced Learners

ImprovedLearners

Una ectedLearners

7%

81%

12%

Reinforced Learners

ImprovedLearners

Una ectedLearners

44%

37%

19%

Reinforced Learners

ImprovedLearners

Una ectedLearners

54%

27%

19%

Reinforced Learners

ImprovedLearners

Una ectedLearners

PATIENT EDUCATION ACTIVITY

FIGURE 8. What should you do if you have a seizure even while you are taking medicine?

FIGURE 9. Demographic data of patients who completed the entirety of the patient education activity

Choice Pre % Post %

Change your diet 15 1.1% 10 1.0%

Immediately tell your doctor so he/she can evaluate your medicine

1,002 74.4% 824 85.2%

Visit your doctor more often 116 8.6% 52 5.4%

Wait for your seizures to go away 214 15.9% 81 8.4%

CONCLUSIONS

The use of online video-based CME programming aligned with patient-directed education on the optimal management of epilepsy was effective at improving treatment decisions for patients with a history of depression, appropriate treatment selection for patients with poorly controlled seizures and multiple comorbidities, as well as an improvement for patients selecting the appropriate approach for reporting seizure activity while receiving an AED. Neurologists would benefit from additional education on treatment selection for patients with various medical and psychiatric conditions and on the impact of older age on treatment decisions. Patients should continue to receive education on symptom recognition and treatment-related issues, given the positive improvements seen in patient knowledge with the current patient-directed education.

% of Learners % of Completers

American Indian or Alaska Native 2.6% 2.8%

Asian 12.6% 11.0%

Black or African-American 7.3% 7.4%

Hispanic or Latino 4.5% 4.5%

I prefer not to answer 11.3% 10.7%

Native Hawaiian or other Pacific Islander 0.7% 0.9%

White, non-Hispanic 61.0% 62.6%

ETHNICITY

GENDER AGE

% of Learners % of Completers

I am a caregiver for someone with this condition

10.8% 11.0%

I am a family member of someone with this condition

22.8% 22.8%

I am simply interested in learning more about this condition

18.5% 15.2%

I have this condition 47.9% 51.1%

INTEREST

0.0

0.2

0.4

0.6

0.8

% of Learners

% of Completers

% of Learners

% of Completers

66.4% 66.9%

33.6%

FEMALE MALE

Valu

e

33.1%

Learners, %Completers, %

Learners, %Completers, %

Learners, %Completers, %

Learners, %Completers, %

Learners, %Completers, %

12.0%

10.3%

12.0%

11.4%

17.3%

16.1%

18.7%

20.3%

40.0%

41.8%

Under 25

25 to 34

35 to 44

45 to 54

Over 54