Under its Evidence-based Practice Program, the Agency for Healthcare Research and Quality (AHRQ) is developing scientific information for other agencies and organizations on which to base clinical guidelines, performance measures, and other quality improvement tools. Contractor institutions review all relevant scientific literature on assigned clinical care topics and produce evidence reports and technology assessments, conduct research on methodologies and the effectiveness of their implementation, and participate in technical assistance activities.
Overview / Reporting the Evidence / Methodology / Findings / Future Research / Availability of Full Report
This project represents one phase of a multiphase task order nominated by the Centers for Disease Control and Prevention (CDC) to develop a framework for organizing the health care services necessary for providing optimal care to patients with low-prevalence, highly chronic conditions, in this case, epilepsy.
In this phase of the project, a clinical trial evidence base was developed through a systematic review of the literature pertinent to diagnostic, treatment, and monitoring interventions for patients with newly diagnosed epilepsy. Results have been qualitatively synthesized to provide an evidence-based evaluation of the health care services that contribute to optimal patient outcomes.
It is intended that this synthesis of the best available evidence will serve as an information resource for local decisionmakers and developers of practice guidelines and recommendations. It should also serve to highlight gaps in the literature and areas ripe for future research. Lastly, the approach to developing a matrix framework of patients and services, with a systematic review of the evidence addressing each patient-service intersect of the matrix, provides a useful model for assessing health care services for patients with other chronic conditions with relatively low prevalence.
The key questions that guided this review were the following:
This project was carried out in two phases. The first phase involved a stakeholder meeting at which a matrix framework of specific patient populations and health care interventions was developed. Literature citations were then broadly categorized according to the matrix of patients and interventions.
In the second phase, all interventions (diagnostic, monitoring, and treatment) for a single population of interest (patients with newly diagnosed epilepsy) were chosen as the subject of a full systematic review. In general, MetaWorks investigators used systematic review methods derived from the evolving science of review research.
The review followed a prospective protocol that was developed a priori and shared with the nominating partner on the project (CDC), a panel of technical experts (with representation from consumer groups and health care providers in neurology, epileptology, primary care, and nursing), and the Task Order Officer at the Agency for Healthcare Research and Quality (AHRQ). The protocol outlined the methods to be used for the literature search, study eligibility criteria, data elements for extraction, and methodologic strategies to minimize bias and maximize precision during the process of data collection, extraction, and synthesis.
The published literature was searched in two phases corresponding to the two distinct phases of this project, ultimately covering the period from 1980 through December 1, 1999. MEDLINE was first searched as follows:
In the second phase of the project, another search was run in MEDLINE using the following sequence:
Review articles for the manual search were also identified in MEDLINE by searching back to 1996 using the following sequence:
Bibliographies of these reviews were perused for other likely citations. In addition, the 1999 Current Contents' CD-ROM was searched for the following terms:
The Cochrane Library of Systematic Reviews was searched by:
Lastly, Internet searches were performed on December 2, 1999, by checking the following Web sites for studies, guidelines, authors, and special interest groups: Dr. Koop.com, WebMD.com, ReutersHealth.com, Intellihealth.com, Medscape.com, and NewsPage.com and the Epilepsy Foundation (efa.org).
All citations and abstracts were printed and screened at MetaWorks for any mention of patients with a first seizure, a first presentation, or a new diagnosis of epilepsy, for which full papers were obtained. The electronic searches noted above were supplemented by a search of the reference lists of all eligible studies and relevant review articles. To be included in the review, studies had to report results of any diagnostic, treatment, or monitoring intervention pertinent to newly diagnosed epilepsy in adults or children, with at least 10 patients as total sample size. Studies reported in English were accepted.
Each accepted study was extracted by one investigator and agreed to by a second. Key data elements sought for extraction from each study included study, patient, and intervention characteristics. In addition, for all diagnostic tests, sensitivity, specificity, and positive and negative predictive value, with its gold standard, were sought. All eligible papers were scored on features pertinent to study design, execution, and reporting, with a range of possible scores from 0.3 to 5.0.
No quantitative analyses were performed beyond descriptive statistics to summarize findings. Data were synthesized qualitatively. A group of 19 peer reviewers drawn from consumer groups and professional organizations, along with our technical experts and partners, was assembled to review and provide suggestions to the draft final report describing this project. Their comments were incorporated wherever possible within the original scope of the project.
Of 13,128 citations, 120 studies—mostly European and published in English since 1990—met all eligibility criteria. The study designs comprised 70 interventional and 50 observational studies. These studies covered 21,213 patients; all ages were represented, with balanced gender distribution and all major seizure types (generalized and partial).
No quantitative syntheses were possible because of insufficient and/or inconsistent reporting of results.
The evidence supports the following conclusions:
It is clear from this review of the literature addressing newly diagnosed patients that more research is needed to answer basic questions of diagnosis, monitoring, and treatment. This new research can be categorized as better studies and more studies.
In the better studies category, the following recommendations are made:
In the more studies category, the following recommendations are made:
The full evidence report from which this summary was derived was prepared for the Agency for Healthcare Research and Quality (AHRQ) and the Centers for Disease Control and Prevention (CDC) by MetaWorks, Inc. (an Evidence-based Practice Center) under contract No. 290-97-0016. Requestors should ask for Evidence Report/Technology Assessment No. 39, Management of Newly Diagnosed Patients with Epilepsy: A Systematic Review of the Literature (AHRQ Publication No. 01-E038). A booklet of appendixes is also available (order AHRQ Publication No. 01-R035).
This Evidence Report is also online at www.ncbi.nlm.nih.gov/books/bv.fcgi?rid=hstat1.chapter.55359. The appendixes for this report can be downloaded as a zipped file online at www.ahrq.gov/clinic/evrptfiles.htm#epilepsy.
AHRQ Publication Number 01-E037
Current as of February 2001
Internet Citation:
Management of Newly Diagnosed Patients with Epilepsy: A Systematic Review of the Literature. Summary, Evidence Report/Technology Assessment: Number 39. AHRQ Publication Number 01-E037, February 2001. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/clinic/epcsums/epilepsum.htm
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