Patterns of diagnosis and therapeutic care of epilepsy at a tertiary referral center in Nigeria

Abstract

Objective Epilepsy care in developing countries is challenged by the paucity of trained specialists, diagnostic tools, and antiepileptic drugs (AEDs). We retrospectively evaluated how epilepsy was managed in a Nigerian tertiary referral center, with the goals of determining diagnostic accuracy by comparing clinical and electroencephalography (EEG) diagnoses, the appropriateness of prescribed therapy by clinician specialization, and the association between therapy and patient outcomes. Methods We examined the medical records of 372 patients diagnosed with epilepsy in the center over a 6-month period from 2011 to 2012. Data were obtained on methods of diagnosis, clinician specialization, therapeutic care, and patient self- or caregiver-reported outcome on follow-up visits. Interrater agreement was assessed using Cohen's κ coefficient, and the diagnoses made by nonspecialist and specialist clinicians compared using the chi-square test. Results Of 372 patients diagnosed with epilepsy, only one had a brain computerized tomography (CT) scan. Seventy-six were differentially diagnosed for generalized or partial epilepsy by both clinical presentation and EEG. Low interrater agreement (κ = 0.05) was found between these methods of diagnosis. Of the 76 patients, 53 (69.7%) received therapies judged as appropriate, with no significant difference in prescription rates for appropriate therapy between nonspecialists and specialists (p = 0.536). Specific syndromic diagnoses were made only in 4% of patients, and only in patients who underwent EEG. Only three first-generation AEDs were prescribed, with 97.6% of patients receiving carbamazepine. Significance The discrepancy between diagnoses made on clinical features alone versus EEG diagnosis suggests that in many patients without concomitant EEG, the epileptic syndrome might have been erroneously classified, with increased risk of inappropriate treatment. Resources should be more properly directed toward increasing access to diagnostic facilities and newer generation AEDs. © Wiley Periodicals, Inc. © 2014 International League Against Epilepsy.