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Role of ECoE
- Categorized in: 2013 Compendium of Federal Medicine
When a patient is referred to an epilepsy center for seizure characterization, a complete history of seizures is obtained. Particular attention is given to whether the spells are stereotypic. Stereotypic seizures, however bizarre, are more likely to be epileptic seizures than non-stereotypic seizures. Patients undergo continuous video EEG monitoring in the epilepsy monitoring unit (EMU). Patients are observed continuously, often discontinuing AED medications. Typical seizures are video-recorded and EEG data is analyzed to determine if the seizure is epileptic. This type of expertise and EMUs generally are available only in only a few locations in the VA system, most representing the ECoE network.
If a patient undergoing a seizure characterization evaluation is found to have epileptic seizures, his or her medications are changed and optimized. When no reasonable medication alternatives exist, surgical treatment is considered. If the seizures are thought to be nonepileptic, the epileptologist determines whether the episodes are physiologic or psychogenic. PNES is diagnosed in the vast majority of these cases.
In the VA population, PNES commonly is seen as a comorbid condition with other prevalent disorders such PTSD and/or TBI. As noted previously, many of these patients have been treated for months to years with AEDs because of an erroneous epilepsy diagnosis. These AEDs have many potential adverse effects that may make management of the underlying disorder more difficult. When epileptologists discontinue these unnecessary and potentially harmful medications, they facilitate optimal treatment of the underlying condition. Though these patients are not diagnosed with having epilepsy, they clearly need specialty care by an ECoE to help clarify their diagnosis and guide treatment. Many ECoE sites find that approximately one-fourth of patients undergoing video-EEG monitoring end up being diagnosed with PNES. 9
Establishing the VA ECoE
Establishing the VA ECoE The Veterans Mental Health and Other Care Improvements Act of 2008 (PL 110-387/s.2162)10 orders the Secretary of Veterans Affairs and the VHA on specific provisions of healthcare to maximize and centralize resources for veterans diagnosed with spells, specifically epilepsy, through establishment of ECoEs. The ECoE program is expected to leverage technology, enhance affiliation, expand research opportunities and improve access for specialized quality care. Efforts to utilize lean processes encompassing good financial stewardship maximizing efficiency are essential for veteran-centric care. A successful program hinges on the collaborations of multiple stakeholder partnerships which include the DOD, epilepsy organizations and Congress.
As shown in the ECoE regional map (Figure 1a), 16 ECoE sites nationally divided into four regions are in operation and managed by a national clinical director and four regional directors. The fenced congressional funding is distributed among the established sites. To meet specifications outlined in the law and to ensure similar representational strength across the nation, the regional boundary lines are state driven and not aligned with Veterans Integrated Service Network (VISN) (Figure 1b), as the case may be for many other VA programs.
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