Annals of African Medicine Vol. 14, No. 2; 2015
Original Article
Access this article online Quick Response Code:
Website: www.annalsafrmed.org DOI: 10.4103/1596-3519.149878 PMID: *****
A 3 year audit of adult epilepsy care in a Nigerian tertiary hospital (2011‑2013) Emmanuel Olatunde Sanya, Kolawole Wasiu Wahab, Olufemi Olumuyiwa Desalu, Hamsat Abiodun Bello, Babatunde Ayodeji Ademiluyi, Wemimo Adetunji Alaofin, Kudirat Busari Department of Medicine, University of Ilorin Teaching Hospital, Ilorin, Kwara, Nigeria
Correspondence to: Dr. Emmanuel O. Sanya, Department of Medicine, University of Ilorin, P. O. Box 5314, Ilorin, Kwara State, Nigeria. E‑mail: [email protected]
Abstract Background: Epilepsy audit provides positive feedback to physicians that could assist in improving the quality of health care services provided for patients. This study was carried out to evaluate care given to people with epilepsy with the aim of determining potentials for improvement. Materials and Methods: Medical records of patients with uncomplicated epilepsy who have attended the neurology clinic at the University of Ilorin Teaching Hospital for not less 12 months between years 2011and 2013 were reviewed. Results: A total of 125 patients were as evaluated; of which 64 (51%) were males and 61 (49%) were females. Their median age was 26 (21–40) years and median seizure duration of 9 (4–15) years. Close to 65% of the patients were below 30 years of age. Most patients (68%) were referred by general practitioners/family physicians. Generalized epilepsy was the predominant seizure type seen in 73 (58%) patients. Majority of patients (76%) were on antiepileptic drug (AED) monotherapy, and 28 (22%) were on two AEDs combination. Eighty-one patients (64%) used carbamazepine either singly (63%) or in combination (18%) at an average dose of 600 mg/day. The two other common AEDs used were: Sodium valproate (45%) and phenobarbitone (9%). Fifty-one patients (41%) had good seizure control (no seizure in preceding 1 year), 34 (27%) had partial control (1 attack/month). Overall, 66 patients (48%) had their medication changed between 2 and 3 times in the course of treatment, and the most common reason was poor seizure control. Twenty-one (21%) did not comply with the use of given AED. Conclusions: Less than half of our patients had good epilepsy control. To improve on drug compliance attending physicians need to prescribe more of the relatively cheaper AED like the phenobarbitone and to optimize drug dosage before switching to another. Keywords: Adult, audit, epilepsy care, seizure control
Résumé Contexte : Épilepsie vérification fournit une rétroaction positive aux médecins qui pourraient aider à améliorer la qualité des services de santé offerts aux patients. Cette étude a été réalisée afin d'évaluer les soins prodigués aux personnes atteintes d'épilepsie dans le but de déterminer les potentiels d'amélioration. Matériel et Méthodes : Des dossiers médicaux des patients atteints d'épilepsie non compliquée qui ont assisté à la clinique de neurologie à l'hôpital universitaire de l'Université d'Ilorin pour pas moins de 12 mois entre années 2011et 2013 ont été revus. Résultats : Un total de 125 patients ont été évalués ; dont 64 (51 %) étaient des hommes et 61 (49 %) étaient des femmes. Leur âge moyen était de 26 ans (21-40) et durée de saisie médiane de 9 ans (4 à 15 ans). Près de 65 % des patients étaient âgés de moins de 30 ans. La plupart des patients (68 %) ont été dirigés par le général praticiens/ médecins de famille. Épilepsie généralisée était le type de saisie prédominant dans 73 (58 %) des patients. Majorité des patients (76 %) sont des médicaments antiépileptiques (AED) en monothérapie, et 28 (22 %) étaient sur deux
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Sanya, et al.: Audit of epilepsy care combinaison de DEA. Quatre-vingt-un patients (64 %) vinifié carbamazépine non plus (63 %) ou en combinaison (18 %) à une dose moyenne de 600 mg/jour. Les deux autres communes DEA utilisés ont été: Sodium valproate (45 %) et phénobarbital (9 %). Cinquante et un patients (41 %) avaient saisie bon contrôle (aucune saisie en précédant d'un an), 34 (27 %) avait le contrôle partiel (< 12 attaques/an) et 41 (36 %) avaient de mauvais contrôle (> 1 attaque/ mois). Dans l'ensemble, 66 patients (48 %) ont eu leur médication changée entre 2 et 3 fois au cours du traitement, et la raison la plus courante était le contrôle de saisie mauvaise. Vingt et un (21 %) ne respectaient pas l'utilisation de donnée AED. Conclusions : Moins de la moitié de nos patients avaient épilepsie bon contrôle. Afin d'améliorer le respect de la drogue que les médecins ont besoin à prescrire plus de l'AED relativement moins cher comme le phénobarbital et d'optimiser la posologie du médicament avant de passer à un autre. Page | 98 Mots-clés: UNdult, audit, soins de l'épilepsie, contrôle de saisie
Introduction Epilepsy is a common neurological disorder that affects all age groups.[1] It is estimated that nearly 80% of the world’s 70 million people living with epilepsy reside in developing countries.[2,3] The economic, social and health care demands of epilepsy on the individual, family and the society are enormous. The disease is associated with considerable morbidity and has three‑fold mortality rates.[4,5] Body of evidences have shown that most epilepsies can be controlled using single antiepileptic drug (AED), while close to 25% of people with epilepsy will continue to need medication for life.[6] In Africa, the burden of epilepsy is enormous and the prevalence of epilepsy in sub‑Saharan Africa is 1–1.5%.[7] In the year 2012, the population of sub‑Saharan Africa was estimated to be 910.4 million,[7] which translate to 8.6 million people living with epilepsy in the sub‑region. There is presently a wide gap in epilepsy treatment in Africa with estimated magnitude of 49%.[8] Reasons that have been adduced for this include the high cost of treatment, limited availability of AEDs, superstitious and sociocultural beliefs.[2,3] Similarly, health care facilities in sub‑Saharan African are characterized by poor organization with lots of resource limitation and mismanagement.[2,8] In Nigeria for example financing epilepsy care remains poor and out‑of pocket expenses by patients and relatives are the major source of finance due to limited health insurance coverage.[9] Medical audit is one important way by which epilepsy care can be improved upon as it provides positive feedback for the medical practitioners.[10,11] Outcome measures that can be evaluated through audit include: Accurate diagnosis, seizure frequency and level of control, drug dosage, and number of clinic visitations and the level of documentations by physicians.[10] Seizure frequency is particularly an important index for assessing quality of epilepsy care similar to what obtains when blood pressure is used to determine level of control in hypertension.[12] Vol. 14, April-June, 2015
Evaluation of epilepsy care in developing countries is vital because the disease is common and vast health resources are consumed to care for epilepsy. The present level of epilepsy treatment in resource‑limited countries leaves much room for improvement. At present, only few studies have attempted to evaluate care given to patients with epilepsy in the sub‑Sahara Africa.[13,14] The aim of this study was to evaluate the level of care given to patients with epilepsy at the neurology clinic of the University of Ilorin Teaching Hospital (UITH) in Ilorin, middle belt Nigeria. The study also hopes to identify potentials for improvement.
Materials and Methods Medical records of patients (16 years and above) with epilepsy (≥2 unprovoked seizures >24 h apart) managed at the neurology out‑patient clinic of the UITH, Ilorin, were reviewed. The clinic has two trained neurologists and three neurology residents who assist in running the clinic once a week. The study period was from January 2011 to December 2013. To be included in the study, a patient must have had an uncomplicated epilepsy (no associated neurological impairment such as mental retardation or cerebral palsy), and be on prescription AEDs for not 1/month (c) poor control – more than one seizure/month. Ethical approval for the study was obtained from the Health Research in Ethics Committee of our institution. Annals of African Medicine
Sanya, et al.: Audit of epilepsy care
Statistical analysis Data were analyzed using Statistical Package for the Social Sciences (SPSS), version 18 (SPSS Inc., Chicago, IL, USA). Simple frequency tables were generated for the variables. Means and standard deviations were determined when the variables have normal distribution and median and interquartile range (IQR) if they were not normally distributed.
Results Demographic data A total of 125 patients with epilepsy were included in the study, and their ages ranged from 16 to 80 years with a median of 26 years and IQR of 21–40 years. The median seizure duration was 9 years and IQR of 9–15 years. There were 64 (51%) males and 61 (49%) females. Most of the patients (65%) were below the age of 30 years. Of the 125 patients, 85 (68%) were referred to the clinic by family physicians/general practitioners (GPs), 22 (17%) by none‑neurology physicians and surgeons referred 12 patients (10%). Eighty‑nine patients (71%) had 12 times/year. A total of 67 patients (54%) had electroencephalogram (EEG) recordings, of which 28 patients (42%) had abnormal findings. Sixteen patients (13%) had brain computed tomography (CT) scans and 2 (2%) had brain Annals of African Medicine
Table 1: Demographic and baseline character Clinical factors Sex Male Female Age group 16–20 21–30 31–40 41–50 51–60 ≥61 Marital status Single Married Divorced Source of referral Family physicians/GP Other physicians Surgeons Others Educational Illiterate ≤12 years schooling >12 years education Source of finance Patients Parents Spouse Others
Number (125)
Percentages
64 61
51 49
30 49 16 13 11 6
24 40 13 10 9 5
76 44 5
61 35 4
85 22 12 6
68 17 10 5
37 51 37
30 41 29
59 55 6 5
47 44 5 4
GP=General practitioner
magnetic resonance imaging (MRI) as part of their investigatory workup [Table 2]. Majority of patients (76%) were on traditional AED monotherapy and carbamazepine was the most prescribed drug. A total of 28 patients (22%) were on two AEDs combination, while two (2%) patients used three AEDs combination. Eighty‑one patients (65%) used carbamazepine monotherapy and 18 patients (14%) used it in combination with other AEDs. Sodium valproate was the second most prescribed AED and it was used by 44 patients (35%). A total of 11 (9%) and 9 patients (7%), were placed on phenobarbitone and phenytoin, respectively. The average daily dosages of the AEDs given to patients were: Carbamazepine and sodium valproate 600 mg/day each, phenobarbitone‑60 mg/day and phenytoin‑400 mg/day. Forty‑three patients (34%) were reported to have developed side effects to the prescribed AEDs. The three most frequently reported side effects were tiredness (12%), poor concentration (7%); and headaches (6%) [Table 3]. Eighteen patients (14%) had their medications stopped while 6 (5%) had newer AED added as an adjunct. Forty‑six patients (37%) had their medications changed during the course of treatment. The leading reasons that warranted change in medication were poor Vol. 14, April-June, 2015
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Sanya, et al.: Audit of epilepsy care
Table 2: Seizure characteristics Clinical factors
Page | 100
Seizure types Partial Complex Secondarily generalized Simple Generalized Unclassified Disease duration (years) 1-5 6-10 >10 Level of seizure control Good (0 attack/year) Moderate (≤11 attacks/year) ≥1 attack/month Clinic attendance/year 2–6 7–12 >12 EEG Yes No EEG finding Normal Epileptiform discharges Neuroimaging Brain CT Brain MRI
Number (n=125)
Percentages
10 32 9 72 2
8 25 7 58 2
42 28 55
34 22 44
51 34 40
41 27 32
78 36 11
62 29 9
77 48
62 38
36 41
47 53
16 3
84 16
EEG=Electroencephalogram, CT=Computed tomography, MRI=Magnetic resonance imaging
Table 3: Use of AEDs Clinical factors Number of AEDs 1 2 3 AEDs* Carbamazepine Sodium valproate Phenobarbitone Phenytoin Levetiracetam Topiramate Change in AEDs medication Yes No Reason for change in medication Poor seizure control Intolerable side effects Pregnancy Note documented Documented side effects of AEDs Tiredness Poor concentration Headaches Weight gain
Number Percentages (125) 95 28 2
76 22 2
80 44 11 9 4 2
64 35 9 7 3 2
60 65
48 52
30 19 2 9
50 32 3 15
15 7 5 3
12 5 4 3
*Multiple responses. AEDs=Antiepileptic drugs
seizure control (24%), intolerable side effects (10%) and pregnancy (2%). Twenty‑one patients (17%) did Vol. 14, April-June, 2015
not comply with prescribed medications. Reasons for these included financial constraints and a desire to try none‑orthodox therapy. There was poor documentation on one or more of drug side‑effects, dosages, complications, laboratory results and pharmacologic therapy given to patients in the majority of the reviewed case notes.
Discussion The significant findings of this study are that less than half of the patients with epilepsy (41%) had good epilepsy control, and 59% patients had persistent seizure despite being on AEDs. Among patients that achieved good seizure control, majority (86%) were treated with monotherapy using traditional AEDs, while none used the newer AEDs. In the group with poor control, 76% were on traditional AED polytherapy, and 8% had one of the newer AEDs added as an adjunct. The proportion of patients in this study that achieved good seizure control was higher than 30% reported by Ogunniyi et al. from South‑western Nigeria about two decades ago.[13] However, this value is lower than 50% reported by Gauffin et al. among young adults in Sweden and lower than 53% quoted by Feksi et al. from Kenya.[17] In this study, generalized epilepsy was the most predominant clinical type, a finding similar to what was reported three decades ago by Ogunniyi et al.[13] However, it contrasts what was recently reported by Owolabi et al.[18] Plausible reasons for the observed difference include patient’s selection in this study that excluded those with cerebral palsy and mental retardation which may be associated with difficult to treat epilepsies. Similarly, Owolabi et al. studied only symptomatic epilepsies resulting from brain tumors.[18] These could explain the observed difference in clinical presentation of epilepsy in both studies. Overall, more than half of the patients managed in our clinic continued to experience epileptic seizures despite being managed by the neurologists and placed on appropriate medication. Several reasons could be responsible for this observation. These included the use of fake and sub‑substandard medications, drug‑drug interaction and poor compliance with medication. In Nigeria, fake and substandard drugs are cheap and are readily available in several drug shops. These drugs have become a menace to health care system in the country and have negatively impacted treatment of several medical disorders.[19] Through the efforts of government regulatory agencies there have been a reduction in the prevalence of fake and substandard drug from 41% in 2002 to present estimate of 11%.[20] Poor compliance with medication Annals of African Medicine
Sanya, et al.: Audit of epilepsy care
was another factor that might have influenced care delivery in this study similar to findings in earlier publications.[2,3] The widespread poverty, illiteracy, sociocultural practices and belief, all have great impact on drug compliance by patients.[3,13,14] Although, 17% of patients were documented not to have complied with prescribed drug, this proportion was likely to be an understatement. As out‑of‑pocket expenditure was the major payment method for health care services in the country,[21] and 46% of patients were unemployed, and 53% depended on someone to pay their health bill. Other constraints that could have limited epilepsy care were the lack of necessary equipment to measure serum level of AEDs and video EEG. This has made it impossible to verify patient’s compliance and to assay serum drug level in cases with persistent seizures. Lack of facility for 24 h video EEG made it very difficult to exclude pseudo seizures from among those diagnosed to have poor drug response. In an earlier publication up to 30% of patients diagnosed to have poor response to AED were found to have psychogenic nonepileptic seizures or syncope using video EEG and other equipments.[22] Till date, traditional AEDs remain the first choice for most epilepsy except for certain epilepsy syndrome.[23] Majority of our patients were placed on carbamazepine and sodium valproate. Although, carbamazepine is a first line AED for focal epilepsy, it is very useful in primarily generalized epilepsy where valproate is not available. The caveat is that carbamazepine may worsen seizures in certain epilepsy such as myoclonic and absence seizures. Currently, phenobarbitone is the recommended AED of choice by the International League against epilepsy and the World Health Organization (WHO) for the developing countries being very cheap and a broad spectrum AED.[24,25] However, adult neurologists in Nigeria prefer carbamazepine to phenobarbitone due to feared neurocognitive side‑effects of the latter drug.[26,27] Results from earlier publications have shown that phenobarbitone has efficacy profile similar to newer AEDs,[28] and has retention rates of 84% and 76% after 1 and 2 years, respectively.[23,28] The frequency of feared behavioral and cognitive side effects of phenobarbitone is very low.[23] The probability of AED retention among patients in this study is low, as close to 48% of patients had their medication changed at least once in the course of treatment without attaining recommended maximum dosage. It is important therefore, that physicians optimize drug dosage before switching to another except there is serious side‑effect or clinical evidence of toxicity. Tiredness was the most reported side effects (16%) to AEDs and this is comparable to the finding by Goodwin et al.[29] Although, diagnostic Annals of African Medicine
neuroimaging (e.g. brain CT scan and MRI) is recommended after a first nonfebrile seizure to detect structural problems in and around the brain,[30] only few patients could afford such investigation in this environment due to limited finance. All our patients continued to visit the neurology clinic for follow‑up irrespective of their level of seizure control. This observation, contrast the finding from United Kingdom where patients follow‑up care was by the GPs.[29] An earlier result from our group has shown that GPs prefer neurologist to continue with epilepsy follow‑up care.[21] Reasons given were lack of confidence and interest in epilepsy and perhaps poor knowledge of the disease. Pitfall of such practice is that the patient will have to travel long distances, and wait for a long period to see a specialist. This trend will increase cost of care since indirect costs contribute substantially to cost of epilepsy care in developing countries.[21,30] For the GPs to readily accept and participate in epilepsy follow‑up care, there is a need to organize a regular update courses on epilepsy management as part of continuing medical education. This will encourage shared‑care at the primary and secondary health care levels, especially for patients with good control. It will no doubt reduce strain on the already stretched tertiary health care services.[30] Other benefits of shared epilepsy care include patient’s satisfaction and better compliance as well as reduction in cost of care.[31] The study noticed inadequate documentation regarding details of drug side effects, poor write‑ups regarding nontherapeutic measures given by doctors such as detailed counseling that are essential parts of epilepsy care. It can be argued that poor documentation constitute a drawback in this study. However, the observed insufficient documentation did not include disease signs and symptoms and the type and dosage of AEDs used in treating the disease. Part of our suggestion to improve epilepsy care in Nigeria is the development of epilepsy treatment guideline to ensure minimal care necessary in epilepsy treatment. This is because the standard of epilepsy, which is presently obtainable in most developed countries was possible through development of such national guidelines that were regularly updated.[32‑34] Therefore, neurologists in the country and possibly the sub‑region need to adapt for use the epilepsy guideline released by the WHO for resource limited tropical nations.[32,35]
Conclusion The leading factors found to militate against epilepsy care in this audit were: Poor finance, low compliance with medication, limited equipments and poor documentation by physicians. The proportion of Vol. 14, April-June, 2015
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patients with good seizure control in the present study was better than what was reported two decades ago, but there is much room for improvement. To further improve epilepsy care at the tertiary hospitals, more funds are needed to procure essential facilities. Patient’s compliance with medication can be encouraged upon through increase prescription and availability of phenobarbitone to the indigent patients instead of the relatively more expensive traditional AEDs. Newer AEDs may be used as adjunct in patients with poor seizure control to traditional AEDs and those that could afford the cost.
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Cite this article as: Sanya EO, Wahab KW, Desalu OO, Bello HA, Ademiluyi BA, Alaofin WA, et al. A 3 year audit of adult epilepsy care in a Nigerian tertiary hospital (2011-2013). Ann Afr Med 2015;14:97-102. Source of Support: Nil, Conflicts of interest: None
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Original Article
Access this article online Quick Response Code:
Website: www.annalsafrmed.org DOI: 10.4103/1596-3519.149878 PMID: *****
A 3 year audit of adult epilepsy care in a Nigerian tertiary hospital (2011‑2013) Emmanuel Olatunde Sanya, Kolawole Wasiu Wahab, Olufemi Olumuyiwa Desalu, Hamsat Abiodun Bello, Babatunde Ayodeji Ademiluyi, Wemimo Adetunji Alaofin, Kudirat Busari Department of Medicine, University of Ilorin Teaching Hospital, Ilorin, Kwara, Nigeria
Correspondence to: Dr. Emmanuel O. Sanya, Department of Medicine, University of Ilorin, P. O. Box 5314, Ilorin, Kwara State, Nigeria. E‑mail: [email protected]
Abstract Background: Epilepsy audit provides positive feedback to physicians that could assist in improving the quality of health care services provided for patients. This study was carried out to evaluate care given to people with epilepsy with the aim of determining potentials for improvement. Materials and Methods: Medical records of patients with uncomplicated epilepsy who have attended the neurology clinic at the University of Ilorin Teaching Hospital for not less 12 months between years 2011and 2013 were reviewed. Results: A total of 125 patients were as evaluated; of which 64 (51%) were males and 61 (49%) were females. Their median age was 26 (21–40) years and median seizure duration of 9 (4–15) years. Close to 65% of the patients were below 30 years of age. Most patients (68%) were referred by general practitioners/family physicians. Generalized epilepsy was the predominant seizure type seen in 73 (58%) patients. Majority of patients (76%) were on antiepileptic drug (AED) monotherapy, and 28 (22%) were on two AEDs combination. Eighty-one patients (64%) used carbamazepine either singly (63%) or in combination (18%) at an average dose of 600 mg/day. The two other common AEDs used were: Sodium valproate (45%) and phenobarbitone (9%). Fifty-one patients (41%) had good seizure control (no seizure in preceding 1 year), 34 (27%) had partial control (1 attack/month). Overall, 66 patients (48%) had their medication changed between 2 and 3 times in the course of treatment, and the most common reason was poor seizure control. Twenty-one (21%) did not comply with the use of given AED. Conclusions: Less than half of our patients had good epilepsy control. To improve on drug compliance attending physicians need to prescribe more of the relatively cheaper AED like the phenobarbitone and to optimize drug dosage before switching to another. Keywords: Adult, audit, epilepsy care, seizure control
Résumé Contexte : Épilepsie vérification fournit une rétroaction positive aux médecins qui pourraient aider à améliorer la qualité des services de santé offerts aux patients. Cette étude a été réalisée afin d'évaluer les soins prodigués aux personnes atteintes d'épilepsie dans le but de déterminer les potentiels d'amélioration. Matériel et Méthodes : Des dossiers médicaux des patients atteints d'épilepsie non compliquée qui ont assisté à la clinique de neurologie à l'hôpital universitaire de l'Université d'Ilorin pour pas moins de 12 mois entre années 2011et 2013 ont été revus. Résultats : Un total de 125 patients ont été évalués ; dont 64 (51 %) étaient des hommes et 61 (49 %) étaient des femmes. Leur âge moyen était de 26 ans (21-40) et durée de saisie médiane de 9 ans (4 à 15 ans). Près de 65 % des patients étaient âgés de moins de 30 ans. La plupart des patients (68 %) ont été dirigés par le général praticiens/ médecins de famille. Épilepsie généralisée était le type de saisie prédominant dans 73 (58 %) des patients. Majorité des patients (76 %) sont des médicaments antiépileptiques (AED) en monothérapie, et 28 (22 %) étaient sur deux
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Sanya, et al.: Audit of epilepsy care combinaison de DEA. Quatre-vingt-un patients (64 %) vinifié carbamazépine non plus (63 %) ou en combinaison (18 %) à une dose moyenne de 600 mg/jour. Les deux autres communes DEA utilisés ont été: Sodium valproate (45 %) et phénobarbital (9 %). Cinquante et un patients (41 %) avaient saisie bon contrôle (aucune saisie en précédant d'un an), 34 (27 %) avait le contrôle partiel (< 12 attaques/an) et 41 (36 %) avaient de mauvais contrôle (> 1 attaque/ mois). Dans l'ensemble, 66 patients (48 %) ont eu leur médication changée entre 2 et 3 fois au cours du traitement, et la raison la plus courante était le contrôle de saisie mauvaise. Vingt et un (21 %) ne respectaient pas l'utilisation de donnée AED. Conclusions : Moins de la moitié de nos patients avaient épilepsie bon contrôle. Afin d'améliorer le respect de la drogue que les médecins ont besoin à prescrire plus de l'AED relativement moins cher comme le phénobarbital et d'optimiser la posologie du médicament avant de passer à un autre. Page | 98 Mots-clés: UNdult, audit, soins de l'épilepsie, contrôle de saisie
Introduction Epilepsy is a common neurological disorder that affects all age groups.[1] It is estimated that nearly 80% of the world’s 70 million people living with epilepsy reside in developing countries.[2,3] The economic, social and health care demands of epilepsy on the individual, family and the society are enormous. The disease is associated with considerable morbidity and has three‑fold mortality rates.[4,5] Body of evidences have shown that most epilepsies can be controlled using single antiepileptic drug (AED), while close to 25% of people with epilepsy will continue to need medication for life.[6] In Africa, the burden of epilepsy is enormous and the prevalence of epilepsy in sub‑Saharan Africa is 1–1.5%.[7] In the year 2012, the population of sub‑Saharan Africa was estimated to be 910.4 million,[7] which translate to 8.6 million people living with epilepsy in the sub‑region. There is presently a wide gap in epilepsy treatment in Africa with estimated magnitude of 49%.[8] Reasons that have been adduced for this include the high cost of treatment, limited availability of AEDs, superstitious and sociocultural beliefs.[2,3] Similarly, health care facilities in sub‑Saharan African are characterized by poor organization with lots of resource limitation and mismanagement.[2,8] In Nigeria for example financing epilepsy care remains poor and out‑of pocket expenses by patients and relatives are the major source of finance due to limited health insurance coverage.[9] Medical audit is one important way by which epilepsy care can be improved upon as it provides positive feedback for the medical practitioners.[10,11] Outcome measures that can be evaluated through audit include: Accurate diagnosis, seizure frequency and level of control, drug dosage, and number of clinic visitations and the level of documentations by physicians.[10] Seizure frequency is particularly an important index for assessing quality of epilepsy care similar to what obtains when blood pressure is used to determine level of control in hypertension.[12] Vol. 14, April-June, 2015
Evaluation of epilepsy care in developing countries is vital because the disease is common and vast health resources are consumed to care for epilepsy. The present level of epilepsy treatment in resource‑limited countries leaves much room for improvement. At present, only few studies have attempted to evaluate care given to patients with epilepsy in the sub‑Sahara Africa.[13,14] The aim of this study was to evaluate the level of care given to patients with epilepsy at the neurology clinic of the University of Ilorin Teaching Hospital (UITH) in Ilorin, middle belt Nigeria. The study also hopes to identify potentials for improvement.
Materials and Methods Medical records of patients (16 years and above) with epilepsy (≥2 unprovoked seizures >24 h apart) managed at the neurology out‑patient clinic of the UITH, Ilorin, were reviewed. The clinic has two trained neurologists and three neurology residents who assist in running the clinic once a week. The study period was from January 2011 to December 2013. To be included in the study, a patient must have had an uncomplicated epilepsy (no associated neurological impairment such as mental retardation or cerebral palsy), and be on prescription AEDs for not 1/month (c) poor control – more than one seizure/month. Ethical approval for the study was obtained from the Health Research in Ethics Committee of our institution. Annals of African Medicine
Sanya, et al.: Audit of epilepsy care
Statistical analysis Data were analyzed using Statistical Package for the Social Sciences (SPSS), version 18 (SPSS Inc., Chicago, IL, USA). Simple frequency tables were generated for the variables. Means and standard deviations were determined when the variables have normal distribution and median and interquartile range (IQR) if they were not normally distributed.
Results Demographic data A total of 125 patients with epilepsy were included in the study, and their ages ranged from 16 to 80 years with a median of 26 years and IQR of 21–40 years. The median seizure duration was 9 years and IQR of 9–15 years. There were 64 (51%) males and 61 (49%) females. Most of the patients (65%) were below the age of 30 years. Of the 125 patients, 85 (68%) were referred to the clinic by family physicians/general practitioners (GPs), 22 (17%) by none‑neurology physicians and surgeons referred 12 patients (10%). Eighty‑nine patients (71%) had 12 times/year. A total of 67 patients (54%) had electroencephalogram (EEG) recordings, of which 28 patients (42%) had abnormal findings. Sixteen patients (13%) had brain computed tomography (CT) scans and 2 (2%) had brain Annals of African Medicine
Table 1: Demographic and baseline character Clinical factors Sex Male Female Age group 16–20 21–30 31–40 41–50 51–60 ≥61 Marital status Single Married Divorced Source of referral Family physicians/GP Other physicians Surgeons Others Educational Illiterate ≤12 years schooling >12 years education Source of finance Patients Parents Spouse Others
Number (125)
Percentages
64 61
51 49
30 49 16 13 11 6
24 40 13 10 9 5
76 44 5
61 35 4
85 22 12 6
68 17 10 5
37 51 37
30 41 29
59 55 6 5
47 44 5 4
GP=General practitioner
magnetic resonance imaging (MRI) as part of their investigatory workup [Table 2]. Majority of patients (76%) were on traditional AED monotherapy and carbamazepine was the most prescribed drug. A total of 28 patients (22%) were on two AEDs combination, while two (2%) patients used three AEDs combination. Eighty‑one patients (65%) used carbamazepine monotherapy and 18 patients (14%) used it in combination with other AEDs. Sodium valproate was the second most prescribed AED and it was used by 44 patients (35%). A total of 11 (9%) and 9 patients (7%), were placed on phenobarbitone and phenytoin, respectively. The average daily dosages of the AEDs given to patients were: Carbamazepine and sodium valproate 600 mg/day each, phenobarbitone‑60 mg/day and phenytoin‑400 mg/day. Forty‑three patients (34%) were reported to have developed side effects to the prescribed AEDs. The three most frequently reported side effects were tiredness (12%), poor concentration (7%); and headaches (6%) [Table 3]. Eighteen patients (14%) had their medications stopped while 6 (5%) had newer AED added as an adjunct. Forty‑six patients (37%) had their medications changed during the course of treatment. The leading reasons that warranted change in medication were poor Vol. 14, April-June, 2015
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Table 2: Seizure characteristics Clinical factors
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Seizure types Partial Complex Secondarily generalized Simple Generalized Unclassified Disease duration (years) 1-5 6-10 >10 Level of seizure control Good (0 attack/year) Moderate (≤11 attacks/year) ≥1 attack/month Clinic attendance/year 2–6 7–12 >12 EEG Yes No EEG finding Normal Epileptiform discharges Neuroimaging Brain CT Brain MRI
Number (n=125)
Percentages
10 32 9 72 2
8 25 7 58 2
42 28 55
34 22 44
51 34 40
41 27 32
78 36 11
62 29 9
77 48
62 38
36 41
47 53
16 3
84 16
EEG=Electroencephalogram, CT=Computed tomography, MRI=Magnetic resonance imaging
Table 3: Use of AEDs Clinical factors Number of AEDs 1 2 3 AEDs* Carbamazepine Sodium valproate Phenobarbitone Phenytoin Levetiracetam Topiramate Change in AEDs medication Yes No Reason for change in medication Poor seizure control Intolerable side effects Pregnancy Note documented Documented side effects of AEDs Tiredness Poor concentration Headaches Weight gain
Number Percentages (125) 95 28 2
76 22 2
80 44 11 9 4 2
64 35 9 7 3 2
60 65
48 52
30 19 2 9
50 32 3 15
15 7 5 3
12 5 4 3
*Multiple responses. AEDs=Antiepileptic drugs
seizure control (24%), intolerable side effects (10%) and pregnancy (2%). Twenty‑one patients (17%) did Vol. 14, April-June, 2015
not comply with prescribed medications. Reasons for these included financial constraints and a desire to try none‑orthodox therapy. There was poor documentation on one or more of drug side‑effects, dosages, complications, laboratory results and pharmacologic therapy given to patients in the majority of the reviewed case notes.
Discussion The significant findings of this study are that less than half of the patients with epilepsy (41%) had good epilepsy control, and 59% patients had persistent seizure despite being on AEDs. Among patients that achieved good seizure control, majority (86%) were treated with monotherapy using traditional AEDs, while none used the newer AEDs. In the group with poor control, 76% were on traditional AED polytherapy, and 8% had one of the newer AEDs added as an adjunct. The proportion of patients in this study that achieved good seizure control was higher than 30% reported by Ogunniyi et al. from South‑western Nigeria about two decades ago.[13] However, this value is lower than 50% reported by Gauffin et al. among young adults in Sweden and lower than 53% quoted by Feksi et al. from Kenya.[17] In this study, generalized epilepsy was the most predominant clinical type, a finding similar to what was reported three decades ago by Ogunniyi et al.[13] However, it contrasts what was recently reported by Owolabi et al.[18] Plausible reasons for the observed difference include patient’s selection in this study that excluded those with cerebral palsy and mental retardation which may be associated with difficult to treat epilepsies. Similarly, Owolabi et al. studied only symptomatic epilepsies resulting from brain tumors.[18] These could explain the observed difference in clinical presentation of epilepsy in both studies. Overall, more than half of the patients managed in our clinic continued to experience epileptic seizures despite being managed by the neurologists and placed on appropriate medication. Several reasons could be responsible for this observation. These included the use of fake and sub‑substandard medications, drug‑drug interaction and poor compliance with medication. In Nigeria, fake and substandard drugs are cheap and are readily available in several drug shops. These drugs have become a menace to health care system in the country and have negatively impacted treatment of several medical disorders.[19] Through the efforts of government regulatory agencies there have been a reduction in the prevalence of fake and substandard drug from 41% in 2002 to present estimate of 11%.[20] Poor compliance with medication Annals of African Medicine
Sanya, et al.: Audit of epilepsy care
was another factor that might have influenced care delivery in this study similar to findings in earlier publications.[2,3] The widespread poverty, illiteracy, sociocultural practices and belief, all have great impact on drug compliance by patients.[3,13,14] Although, 17% of patients were documented not to have complied with prescribed drug, this proportion was likely to be an understatement. As out‑of‑pocket expenditure was the major payment method for health care services in the country,[21] and 46% of patients were unemployed, and 53% depended on someone to pay their health bill. Other constraints that could have limited epilepsy care were the lack of necessary equipment to measure serum level of AEDs and video EEG. This has made it impossible to verify patient’s compliance and to assay serum drug level in cases with persistent seizures. Lack of facility for 24 h video EEG made it very difficult to exclude pseudo seizures from among those diagnosed to have poor drug response. In an earlier publication up to 30% of patients diagnosed to have poor response to AED were found to have psychogenic nonepileptic seizures or syncope using video EEG and other equipments.[22] Till date, traditional AEDs remain the first choice for most epilepsy except for certain epilepsy syndrome.[23] Majority of our patients were placed on carbamazepine and sodium valproate. Although, carbamazepine is a first line AED for focal epilepsy, it is very useful in primarily generalized epilepsy where valproate is not available. The caveat is that carbamazepine may worsen seizures in certain epilepsy such as myoclonic and absence seizures. Currently, phenobarbitone is the recommended AED of choice by the International League against epilepsy and the World Health Organization (WHO) for the developing countries being very cheap and a broad spectrum AED.[24,25] However, adult neurologists in Nigeria prefer carbamazepine to phenobarbitone due to feared neurocognitive side‑effects of the latter drug.[26,27] Results from earlier publications have shown that phenobarbitone has efficacy profile similar to newer AEDs,[28] and has retention rates of 84% and 76% after 1 and 2 years, respectively.[23,28] The frequency of feared behavioral and cognitive side effects of phenobarbitone is very low.[23] The probability of AED retention among patients in this study is low, as close to 48% of patients had their medication changed at least once in the course of treatment without attaining recommended maximum dosage. It is important therefore, that physicians optimize drug dosage before switching to another except there is serious side‑effect or clinical evidence of toxicity. Tiredness was the most reported side effects (16%) to AEDs and this is comparable to the finding by Goodwin et al.[29] Although, diagnostic Annals of African Medicine
neuroimaging (e.g. brain CT scan and MRI) is recommended after a first nonfebrile seizure to detect structural problems in and around the brain,[30] only few patients could afford such investigation in this environment due to limited finance. All our patients continued to visit the neurology clinic for follow‑up irrespective of their level of seizure control. This observation, contrast the finding from United Kingdom where patients follow‑up care was by the GPs.[29] An earlier result from our group has shown that GPs prefer neurologist to continue with epilepsy follow‑up care.[21] Reasons given were lack of confidence and interest in epilepsy and perhaps poor knowledge of the disease. Pitfall of such practice is that the patient will have to travel long distances, and wait for a long period to see a specialist. This trend will increase cost of care since indirect costs contribute substantially to cost of epilepsy care in developing countries.[21,30] For the GPs to readily accept and participate in epilepsy follow‑up care, there is a need to organize a regular update courses on epilepsy management as part of continuing medical education. This will encourage shared‑care at the primary and secondary health care levels, especially for patients with good control. It will no doubt reduce strain on the already stretched tertiary health care services.[30] Other benefits of shared epilepsy care include patient’s satisfaction and better compliance as well as reduction in cost of care.[31] The study noticed inadequate documentation regarding details of drug side effects, poor write‑ups regarding nontherapeutic measures given by doctors such as detailed counseling that are essential parts of epilepsy care. It can be argued that poor documentation constitute a drawback in this study. However, the observed insufficient documentation did not include disease signs and symptoms and the type and dosage of AEDs used in treating the disease. Part of our suggestion to improve epilepsy care in Nigeria is the development of epilepsy treatment guideline to ensure minimal care necessary in epilepsy treatment. This is because the standard of epilepsy, which is presently obtainable in most developed countries was possible through development of such national guidelines that were regularly updated.[32‑34] Therefore, neurologists in the country and possibly the sub‑region need to adapt for use the epilepsy guideline released by the WHO for resource limited tropical nations.[32,35]
Conclusion The leading factors found to militate against epilepsy care in this audit were: Poor finance, low compliance with medication, limited equipments and poor documentation by physicians. The proportion of Vol. 14, April-June, 2015
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patients with good seizure control in the present study was better than what was reported two decades ago, but there is much room for improvement. To further improve epilepsy care at the tertiary hospitals, more funds are needed to procure essential facilities. Patient’s compliance with medication can be encouraged upon through increase prescription and availability of phenobarbitone to the indigent patients instead of the relatively more expensive traditional AEDs. Newer AEDs may be used as adjunct in patients with poor seizure control to traditional AEDs and those that could afford the cost.
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Cite this article as: Sanya EO, Wahab KW, Desalu OO, Bello HA, Ademiluyi BA, Alaofin WA, et al. A 3 year audit of adult epilepsy care in a Nigerian tertiary hospital (2011-2013). Ann Afr Med 2015;14:97-102. Source of Support: Nil, Conflicts of interest: None
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