Rationale: The American Academy of Neurology recommends preconceptual folic acid (FA) supplementation be considered for all people with epilepsy of childbearing potential (PWECP). Perinatal FA supplementation is associated with reduced incidence of fetal neural tube defects (NTDs). Anti-seizure medications (ASMs) may increase risk of NTDs for offspring of PWECP. FA supplementation may provide additional benefit to offspring of PWECP in cognition,
1 verbal abilities,
2 and reduced risk of autistic traits.
3 This quality improvement (QI) project aims to 1) determine current rates of addressing FA supplementation and 2) increase rates using multi-modal interventions.
1 Meador KJ, Pennell PB, May RC, et al. Effects of periconceptional folic acid on cognition in children of women with epilepsy: NEAD study. Neurology. 2020;94(7):e729-e740.
2 Husebye ESN, Gilhus NE, Riedel B, Spigset O, Daltveit AK, Bjørk MH. Verbal abilities in children of mothers with epilepsy: Association to maternal folic acid status. Neurology. 2018;91(9):e811-e821.
3 Bjørk M, Riedel B, Spigset O, et al. Association of Folic Acid Supplementation During Pregnancy With the Risk of Autistic Traits in Children Exposed to Antiepileptic Drugs In Utero. JAMA Neurol. 2018;75(2):160-168.
Methods: All female patients with epilepsy age ≥ 12 years on daily ASM seen at Cincinnati Children’s Hospital Medical Center base campus neurology clinic for follow-up visits starting December 2022 were included. A baseline was established from a 12 week period prior to study initiation. For each visit, the following were documented by review of electronic medical records (EMR):
i. Whether FA was addressed
ii. Manner in which FA was addressed (counseling and/or prescription)
iii. Dose of FA recommended
iv. Concurrent ASMs prescribed
Adequately fulfilling the measure for having addressed FA supplementation required either counseling, prescription, or documentation of pre-menarchal status.
Results:
At baseline, providers addressed FA in 44% of 218 clinic visits. A provider survey identified key barriers to addressing FA including: 1) forgot, 2) insufficient time, 3) not part of routine, 4) patient unlikely to be sexually active, and 5) guideline uncertainty (Figure 1). Plan Do Study Act (PDSA) cycles have not yet accomplished a significant shift in rates of addressing FA in 373 clinic visits (Figure 2). There was a transient increase following release of a provider survey (PDSA #1), as well as SmartPhrase distribution (PDSA #2/3), though this did not reach significance. No improvement was seen following educational presentation (PDSA #4).
:
Findings are significant in that overall rates of addressing FA were poor, with substantial room for improvement. Using QI methodology, ongoing PDSA cycles will be targeted toward encouraging use of SmartPhrase by all providers, as well as implementation of other EMR-based interventions, as provider education was ineffective. Ultimately we hope to expand this project to include counseling on interactions between contraception and ASMs as well as ASM teratogenicity.
: None