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June 2008
Does our Practice Reflect the Evidence? A look at treatments for Epilepsy
The May issue of the Journal of Child Neurology has an article based on the research of one of our own MUSC medical students, Katherine S. Mastriani . With the help of Dr. Bernard L. Maria, Executive Director of the Darby Children's Research Institute, and her other co-authors, she first looked at the evidence for treatment options for epilepsy, and then asked a group of practicing child neurologists about their actual management of this condition. Her article is interesting not only for its comparison of recommendations to practice, but also for her attempt to thoroughly assess the level of available evidence.
There are different scales available to rate the strength of the evidence for a given study. Mastriani chose one of the most accepted scales, developed by the Centre for Evidence-Based Medicine in Oxford, England.
| In addition, she developed her own scale that assigned a range of values from positive to negative values. This scale was meant to represent the range of studies done, both good and bad, both supporting and disputing treatment recommendations. |
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Examining the evidence for when an antiepileptic drug should be administrated, she concluded that "primary research data most strongly support the practice of beginning an antiepileptic drug after a second unprovoked seizure." A strong 86 percent of the physicians in her survey reported following this recommendation.
She next examined the use of the ketogenic diet for treatment of epilepsy. Interestingly, this had been the topic of our latest EBM Noon Conference for residents, presented by Dr. Barbara Miller, PY1. Although there are nominally high levels of evidence for this therapy, such as the systematic review presented by Dr. Miller, the studies included in the review are not as strong as those for drug therapy. However, Mastriani concludes that the evidence shows that "over one-third of patients on the ketogenic diet can expect at least a 90 percent reduction in seizure activity" and that "more than 70 percent of patients can expect a 50 percent reduction in seizure activity."
The physicians she surveyed were less likely to follow the evidence on this therapy. In fact, 40% either did not ever prescribe this diet or rarely prescribed it, while 60 percent prescribed it as a last resort when other treatments have failed.
This study looked a how well the evidence was followed in practice. However, EBM practitioners know that while evidence can be used as guidelines for care, it cannot dictate care. In her discussion, Mastriani speculates on the reasons for the difference in following the recommendations for drug therapy vs. diet therapy. She mentions compliance and lack of dietician support; our residents talked about the severe restrictions of the diet itself. This discussion is immensely important, because its speaks to that final step of the EBM process - considering the evidence as it pertains to a particular patient, with that patient's values, preferences, economic and social situation, and co-morbidities. That discussion, which should be conducted with the patient whenever possible, is the bottom line in evidence-based practice.
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Laura Cousineau, MLS
MUSC Library
Dept. of Pediatrics EBM Faculty |
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