Abstracts

Rationale: Anti-seizure medications can lower levels of folic acid, a B vitamin critical for neural tube formation. As the neural tube forms early in pregnancy, often before a woman knows she is pregnant, folate supplementation is important even prior to pregnancy. Pregnancy is unplanned in more than half of women with epilepsy. Accordingly, the Epilepsy Quality Measure from the American Academy of Neurology recommends counseling about folate supplementation for all women with epilepsy of childbearing potential >12 years of age. A review of Children’s Hospital of Philadelphia epilepsy providers (n=9) showed that folate supplementation was addressed at only 16% of appropriate visits, indicating a substantial practice gap.

Methods: This was a quality improvement project, using the A3 framework. Our SMART aim was to increase the percentage of office visits for females with epilepsy >12 years of age in which folate supplementation counseling was addressed from 16% to 50% by July 2020. We performed biweekly chart review of office visits for applicable patients seen by providers in the CHOP Epilepsy QI Workgroup to establish baseline performance rate, and we continued to track progress over time. Root cause analysis was conducted via Go-and-See methods via interview of providers immediately following applicable visits (Figure 1) and Fishbone diagram creation. Countermeasures were designed to address the main root causes identified, and they were implemented through iterative plan-do-study-act (PDSA) cycles.

Results: The top root causes identified were limited time, lack of provider knowledge about guidelines, and forgetting to counsel. PDSA cycles were as follows: (1) Inclusion of a field to indicate whether folate counseling was done in an epilepsy office visit Epic SmartForm, (2) Provider education, (3) Creation of an electronic medical record (EMR) dotphrase containing patient education material on the topic, (4) Introduction of an EMR speed button to more easily add the dotphrase information and serve as a visual reminder to counsel, (5) Introduction of a best practice advisory (BPA) alert for applicable patients, and (6) BPA made mandatory to close chart. With these efforts, we surpassed our initial goal and achieved a counseling rate of 74% (Figure 2).

Conclusions: This quality improvement project successfully improved our pilot group’s rate of folate counseling for adolescent females with epilepsy through a combination of education and electronic health record-based interventions. The next step will be to sustain the improvement achieved within our pilot group while spreading the improvement efforts to the rest of the Division of Neurology. Additionally, we plan to use this project model to improve patient counseling for other topics, particularly those rooted in national quality metrics.

Funding: Please list any funding that was received in support of this abstract.: n/a.