International Journal of Nutrition, Pharmacology, Neurological Diseases

ORIGINAL ARTICLE
Year
: 2020  |  Volume : 10  |  Issue : 4  |  Page : 188--193

Appropriateness of Electroencephalographic Referrals in a Tertiary Care Psychiatric Hospital: Retrospective Study from Oman


Said Al-Kaabi1, Salim Al-Huseini2, Bader AL-Habsi1, Naser Al Balushi3, Mohammed Al-Ruzaiqi1, Alia Al-Wahibi1, Shadha Al-Ghammari3, Nasser Al-Sibani3, Samir Al-Adawi3,  
1 Al Massarah Hospital, Ministry of Health, Muscat, Oman
2 Psychiatry Residency Program, Oman Medical Speciality Board, Muscat, Oman
3 Department of Behavioral Medicine, College of Medicine & Health Sciences, Sultan Qaboos University, Muscat, Oman

Correspondence Address:
Salim Al-Huseini
Psychiatry Residency Training Program, Oman Medical Specialty Board, Muscat, Oman, P.O. Box 35, P.C. 123, Al Khoudh, Muscat, Sultanate of Oman
Oman

Abstract

Objective: To investigate whether electroencephalogram (EEG) requests at a psychiatric tertiary care center in urban Oman are being made according to guidelines for best practice. Methods: This study was carried out at a psychiatry tertiary care hospital in Muscat providing the most comprehensive psychiatric service in the country. Cases were examined retrospectively for11months from January to December 2018. Relevant information was recorded on a proforma prepared for this study. The request was judged as being appropriate or otherwise according to international best practice. Results: During the study period, 421 patients were referred to the EEG laboratory. Approximately 71% of them were males and 29% were females. Approximately 94% of EEG results were deemed as being normal. In terms of appropriateness of requesting EEG, only 5% of the requests were considered “appropriate” according to the guidelines. The factors associated with the appropriateness of requests included age, abnormality in EEG, and the reason given for the request. Conclusions: The majority of EEG referrals were not being made per guidelines. More studies are needed to uncover and examine the factors contributing to the overprescription of EEG among physicians in Oman. Educating the physicians on the judicious use of EEG is therefore warranted.



How to cite this article:
Al-Kaabi S, Al-Huseini S, AL-Habsi B, Balushi NA, Al-Ruzaiqi M, Al-Wahibi A, Al-Ghammari S, Al-Sibani N, Al-Adawi S. Appropriateness of Electroencephalographic Referrals in a Tertiary Care Psychiatric Hospital: Retrospective Study from Oman.Int J Nutr Pharmacol Neurol Dis 2020;10:188-193


How to cite this URL:
Al-Kaabi S, Al-Huseini S, AL-Habsi B, Balushi NA, Al-Ruzaiqi M, Al-Wahibi A, Al-Ghammari S, Al-Sibani N, Al-Adawi S. Appropriateness of Electroencephalographic Referrals in a Tertiary Care Psychiatric Hospital: Retrospective Study from Oman. Int J Nutr Pharmacol Neurol Dis [serial online] 2020 [cited 2020 Nov 25 ];10:188-193
Available from: https://www.ijnpnd.com/text.asp?2020/10/4/188/299270


Full Text



 Introduction



Used by doctors in nearly every specialty, electroencephalography (EEG) has a wide variety of applications in the field of clinical medicine and research. It has been utilized extensively by psychiatrists, neurologists, pediatricians, and physicians to evaluate both normal and abnormal neural activities.[1] Though important for the evaluation of epilepsy, confessional states, cerebral tumors, prion diseases, and disordered metabolic states causing delirium, EEG comes with its own set of limitations, including lack of sensitivity and specificity to detect cerebral diseases (National Institute of Clinical Excellence.[2] With the introduction of magnetic resonance imaging and computed tomography, the importance of EEG was thought to be on the wane. However, the EEG laboratory persists as an indispensable tool for both research and diagnosis. It is costeffective and accessible in most corners of the world[3] More recently, miniaturized EEG technology has increasingly been made accessible to the general public and physicians alike.[4] But much like anything widespread and available, the question then arises about its judicious utilization. Studies abound on the overuseand misuse of EEG technology with issues, including inappropriate referrals.[5],[6] Common inappropriate referrals include requests to roll out epilepsy, monitor epilepsy therapeutically, or evaluate headache/giddiness/syncope. Studies have shown that as much as 40% of the requests for EEG were inappropriate and more than half of the referring doctors believed that EEG could diagnose or exclude epilepsy.[5],[7] In his work, Chadwick[8] regarded EEG as being one of the most “abused” kinds of medical technology. In this context, it is crucial to emphasize that the best practices for optimal use of EEG services are those adhering to the National Institute of Clinical Excellence.[2],[9] These guidelines have directed many studies across different regions in auditing the appropriateness of using EEG investigations.[10],[11],[12],[13] An extensive search of the literature from Arabian Gulf countries did not suggest the presence of a study on physician vigilance in utilizing such electrophysiological studies. To fill this gap in the existing literature, this study has embarked on auditing the utilization of EEG in Oman, a country lying in the south end of the Arabian Peninsula overlooking the Indian Ocean, with a population of approximately 4.5 million people. According to the Mental Health ATLAS 2017,[14] burden of mental disorders is currently at 3.9/100,000 people. The present study aims to audit the use of EEG in a psychiatrichospital. More specifically, the study focuses on the evaluation of the appropriateness of referrals using the established guidelines.[2],[9]

 Methods



Study design and setting

This is a retrospective study conducted at the EEG unit of Al Massara Hospital (AMH) in Muscat, Oman. Healthcare services in Oman are universally free for all citizens of the country and are classified into primary, secondary, and tertiary care. Offering comprehensive tertiary psychiatric care, AMH is the largest and only psychiatric hospital with EEG units, accepting referrals from medical and educational settings from all over the country. AMH is located in Muscat, the national capital.

Data collection and participants

All patients referred to the EEG unit between January 1, 2018, and December 31, 2018, were scrutinized for the present study. A proforma (data sheet) was prepared for this study by the principal investigatorand the following variables were obtained from medical records: age, sex, nationality (“Omani”, “Non-Omani”), the outcome of EEG request (“normal”, “abnormal”), visit type (“outpatient”, “inpatient”, “emergency”), the reason for referral, and requesting clinician (“medical officer”, “resident”, “specialist”, “consultant”). The appropriateness of the request was then deciphered (“appropriate” or “inappropriate”) based on national guidelines[2],[9] and published expert opinions.[15],[16] Referrals were considered inappropriate when EEG was requested to (i) exclude/rule out epilepsy, (ii) evaluate headache, (iii) diagnose or ruleout an organic basis for psychosis, and (iv) rule out behavioral abnormality.

Data analysis

Data analysis was done using the Statistical Package for Social Sciences (SPSS) software (IBM Corp. Released 2013. IBM SPSS Statistics for Windows, Version 22.0. Armonk, NY: IBM Corp.). Sociodemographic factors were described using descriptive analysis. We used the chi-square test to compare the statistical difference of the association between clinician-related factors and the appropriateness of EEG requests, and a P value <0.05 was deemed to be statistically significant.

Ethical approvalandconsent for publication

The study was granted ethical approval by the Ministry of Health Research and Ethics Committee, Governorate of Muscat, Director General Office, Ministry of Health Research. This study adhered to the World Medical Association’s Declaration of Helsinki (1964–2008) for Ethical Human Research, including confidentiality, privacy, and data management.[17]

Consent for publication

Consent for publication was obtained through ethics approval.

 Results



A total of 421 patients were eligible for inclusion in this study. The 421 patients were subcategorized into two age groups, ≤18 years and >18 years, and the vast majority of the sample constituted the latter category 91.7% (n = 386). Females represented 29.2% (n = 123) of the sample, while 70.8% (n = 298) were males. The majority of the requested EEG, 95.2% (n = 401), were for Omani patients. Most EEG requests were for patients presenting to outpatient services, 62.2% (n = 262), followed by inpatient service patients, 31.6% (n =133). Referrals from other hospitals formed the smallest proportion of the sample at 3.6% (n=15). Approximately 5% of the requests fulfilled the presently defined “appropriate” referral. A significant number of the requests deemed appropriate were for those suspected to have epilepsy.

From the total sample, it was found that the majority of requests, 94.1% (n =396), yielded normal results. Approximately 6% of all the patients undergoing EEG were reported as being abnormal, all of whom were already diagnosed with epilepsy. 27.8% of the EEG requests ([Table 1]) were made for the evaluation of organic causes. This was followed by requests to rule out epilepsy (14.5%). A significant proportion of referrals had no clear indication mentioned (28.0%). Other indications included behavioral abnormalities (12.1%), assessments for medico-legal reports (10.7%), and headache/miscellaneous symptoms (3.8%).{Table 1}

[Table 2] illustrates the analysis of various factors. The key finding was a significant association between the appropriateness of requests and being older than 18 years of age (P= 0.033). A significant association was also found between the EEG result and the appropriateness of EEG requests (P = 0.040). No significant gender differences were found between the two groups. Overall, there was a significant difference between “appropriate” and “inappropriate” EEG requests onsubgroup analysis for indications of EEG (P= 0.0001). Though consultants and specialists appeared better than nonspecialists in terms of appropriateness of requests ([Figure 1]),the association was not statistically significant (P= 0.953) ([Table 2]).{Table 2}{Figure 1}

 Discussion



Some previous reports have pointed out the injudicious use of EEG in medical settings.[18],[19],[20] As a result of such practices, guidelines have been forthcoming on its prudent utilization. To our knowledge, there is a dearth of studies of the patterns of referrals for EEG in Arabian Gulf countries. To fill the gap in the literature, this study has embarked on examining whether there is optimal appropriateness to utilizing EEGin psychiatric patient care in Oman.

With males over 18 years of age seeming to constitute the majority of referrals for EEG, the role of gender concerning referrals for EEG echoes similar studies from other parts of the world.[15],[16] As evidence of their predominance in the hospital populations, studies in Oman have shown that more males seek psychiatric consultation.[21] Moreover, this finding differs from that of Pearce and Cock[22] from the United Kingdom, which indicated a preponderance of females reported in referrals to EEG.

The majority (91.7%) of patients referred for EEG in this study were above the age of 18. This finding is similar to findings from other studies that suggest the majority of patients referred for EEG are those that fulfill a similar age criterion.[23] But some studies employ younger populations.[24] The variation in age probably stems from the fact that some studies focused predominantly on the pediatric population and others focused on adults.[2] The present tertiary care center has the bulk of its services utilized by adults.In Oman, child psychiatry services are still in their rudimentary phase and often seek consultation from pediatric clinics, specifically developmental pediatrics.[25]

The crux of the present study was to examine whether the referrals for EEG are appropriate or otherwise. The present study suggests that approximately 94% of EEG requests are incongruent with existing guidelines. We found that the majority of requests for EEG fall short of international best practices.[2],[9] The currently reported magnitude of inappropriate referrals ostensibly exceeded numbers reported in the existing literature, which have been found to range from 26%[10] to 55%.[26],[27],[28],[29] It might be worthwhile to speculate the reason behind such a trend. In the existing literature, high referral rates have been suggested to stem from the misconceptions of the clinical utility of EEG along with widely held and incorrect assumptions among physicians that EEG can easily diagnose seizures or organic psychiatric disorders.[7],[30] Relevant to this, the present study revealed that almost 94.1% of the EEGs performed were normal. This figure is more than many other studies done in this respect, including a study in Zimbabwe,[31] where around 47% of the EEGs were normal. A similar trend has been reported in Nepal revealing around 56% as normal EEGs.[32] In Oman, some preliminary studies have suggested that there is a preponderance of a culture-specific idiom of distressamong patients referred to psychiatric services.[33] The most common presentations among those accessing psychiatric service are erratic behavior with a strong inclination towards dissociative symptoms.[34] Dissociative symptoms tend to overlap with symptoms of neuropsychiatric disorders and epilepsy. In a society where psychiatric symptoms being regarding as “supernatural forces” is a commonality,[34] such “fanfare” around seeking interventions such as EEG on the part of physicians might constitute an implicit process to “medicalize” presenting complaints. Studies exploring specific sociocultural factors influencing the patient and the physician, which lead to overutilization of EEG, are therefore needed.

This study found that the most common reason for EEG referral was a history of paroxysmal events. This is in keeping with studies showing that the most frequent reasons for EEG referrals are to help diagnose/classify epilepsy. It has also been done, though less frequently, to exclude a general medical condition such as delirium as a cause of or contributing factor to the presenting symptoms.[35],[36] Moreover, a good portion of referrals were those with no clear indication mentioned on the referral (28%). However, the proportion was better than those reported in many other studies, including those from Nepal[32] and the UK.[7]

Much like any other research, the presentstudy presents its own set of limitations. Firstly, the retrospective study design followed in this study is often undercut by the robustness of a prospective study. Related to this, retrospective studies are often limited to the astuteness of the clinician writing out comprehensive and protracted information. This further fuels the need for the utilization of a prospective study. A major assumption this makes is that it is the physicians who make the decision of whether or not to refer a patient to the EEG unit. However, it might as well be possible that the patient might coerce the physicians, albeit indirectly, to provide them with a referral to the EEG unit.

 Conclusion



Despite the aforementioned lack of a robust methodology, this study did indicate a significantly high tendency of physicians working in Oman to request EEG. The observed rate appears to outshine previous reports from other countries. There exists a need for multicenterstudies to assess the extent of this problem in clinical settings in Oman and to arrange for educational programs for physicians to rectify this issue. We recommend that specific educational interventions be put in place among the referring physicians and other related staff, training them to develop a proper understanding of EEG referrals and guideline implementation.

Availability of Data and Materials: This is a research article and all data generated or analyzed during this study are included in this published article.

Acknowledgment

The authors wish to thank psychiatric nurses/technicians at the EEG unit for their support in carrying out this study.

Financial support or sponsorship

Nil.

Conflict of Interest

There are no conflicts of interest.

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