Primary care doctors’ management behavior with respect to epilepsy in Kerala, southern India
Research highlights
► A questionnaire survey about primary care doctors’ epilepsy management behavior in a developing country. ► Very few of them had ever diagnosed focal seizures. ► Majority of them would overutilize expensive antiepileptic drugs (AED) in combination and in suboptimal doses. ► Majority of them would prescribe continuous AED prophylaxis for febrile convulsions. ► Very few of them knew about alternate management options for AED-resistant seizures.
Introduction
Epilepsy is a major public health problem as it affects an estimated 50 million people worldwide [1]. Nearly 80% of the burden of epilepsy worldwide is borne by developing countries [2], that is, low-income and middle-income countries according to the World Bank listing [3]. A recent survey conducted jointly by the World Health Organization (WHO), the International League Against Epilepsy (ILAE), and the International Bureau for Epilepsy (IBE) revealed that specialists provide care for people with epilepsy in only 56% of low-income countries, compared with 89% of high-income countries [4]. In India, which has more than 1 billion people and at least 5 million persons with active epilepsy, there are about 1000 neurologists, that is, one neurologist for every 5000 persons with epilepsy [2]. Furthermore, whereas nearly two-thirds of the Indian population resides in rural areas, nearly all the neurologists practice in or close to big cities and towns [2]. As a majority of persons with epilepsy in India and in other developing countries are diagnosed, treated, and followed up by primary and secondary care doctors, it is important to study their management behavior.
The diagnosis of epilepsy is fundamentally a clinical judgment, and the accuracy of the diagnosis depends on the skill of the physician in obtaining a reliable history of the seizures from a witness and the patient. The electroencephalogram (EEG) is obtained to gather information to support the clinical diagnosis of epilepsy and to aid in the syndromic classification of epilepsy. Imaging is performed to identify any structural abnormalities in the brain responsible for the epileptic seizures. The approach to pharmacological treatment of epileptic disorders has changed substantially during the past two decades because of improved knowledge of the efficacy and tolerability of the standard (old) antiepileptic drugs (AEDs), the introduction of several new AEDs, and the availability of alternate treatment options for AED-resistant epilepsies. The management of a person with epilepsy at the community level has become far more complex now than in years past, and therefore primary and secondary care doctors may lack the knowledge to make a judicious choice from the bewildering array of investigative and therapeutic options available today.
Despite the aforementioned problems and their specific relevance to developing countries, there have been few attempts, all from developed countries [5], [6], [7], [8], [9], [10], to study the behavior with respect to epilepsy management of primary care doctors from developing countries, including India. Against this background, we gathered information about the epilepsy management behavior of primary care doctors of the south Indian state of Kerala.
Section snippets
Study site and subjects
This study was conducted under the supervision of the Madhavan Nayar Center for Comprehensive Epilepsy Care, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, Kerala (Fig. 1). We studied 500 doctors, who were randomly selected during a community-level medical practitioners’ annual state-level 1-day conference held in November 2009 at Kozhikode, Central Kerala (Fig. 1) using a questionnaire. None of the selected practitioners declined to participate. We categorized
Demographic characteristics
The 500 medical practitioners comprised 292 (58.4%) general practitioners, 93 (18.6%) internists, 89 (17.8%) pediatricians, and 26 (5.2%) psychiatrists (Table 1). None practiced neurology. More than three-fourths of them had more than 10 years of experience; only 10% had less than 5 years of experience. Although 80% had solo practices at their residences or at a private clinic nearby, the remaining 20% worked in state government-run primary heath centers.
Knowledge of epileptic seizures
Febrile seizures were the commonest
Discussion
We report our findings from a questionnaire-based study conducted to understand the management behavior of 500 community-level medical practitioners with respect to epilepsy in Kerala. This sample comprised at least a few representatives from each of the 14 districts of Kerala, and had a reasonable representation with respect to qualifications (with general practitioners the largest group and psychiatrists the smallest) and type of practice (within governmental and nongovernmental practices).
Conclusions
Our study revealed several deficiencies in the management behavior of primary care doctors with respect to epilepsy in a developing region. Very few of them had ever diagnosed focal seizures, and the majority of them overutilize EEGs, would prescribe continuous AED prophylaxis for febrile convulsions, would use relatively expensive AEDs often in combination and in suboptimal doses, and did not know about alternate management options for AED-resistant epilepsies. We hypothesize that a
Acknowledgments
We thank all the primary care doctors who took time to complete the questionnaire. This study was funded by Piramal Health Care Limited, India.
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