Medical Action Research Articles

Misdiagnosis in breast imaging: a statement paper from European Society Breast Imaging (EUSOBI)-Part 1: The role of common errors in radiology in missed breast cancer and implications of misdiagnosis.

Misdiagnosis in breast imaging can have significant implications for patients, healthcare providers, and the healthcare system as a whole. Some of the potential implications of misdiagnosis in breast imaging include delayed diagnosis or false reassurance, which can result in a delay in treatment and potentially a worse prognosis. Misdiagnosis can also lead to unnecessary procedures, which can cause physical discomfort, anxiety, and emotional distress for patients, as well as increased healthcare costs. All these events can erode patient trust in the healthcare system and in individual healthcare providers. This can have negative implications for patient compliance with screening and treatment recommendations, as well as overall health outcomes. Moreover, misdiagnosis can also result in legal consequences for healthcare providers, including medical malpractice lawsuits and disciplinary action by licensing boards. To minimize the risk of misdiagnosis in breast imaging, it is important for healthcare providers to use appropriate imaging techniques and interpret images accurately and consistently. This requires ongoing training and education for radiologists and other healthcare providers, as well as collaboration and communication among healthcare providers to ensure that patients receive appropriate and timely care. If a misdiagnosis does occur, it is important for healthcare providers to communicate with patients and provide appropriate follow-up care to minimize the potential implications of the misdiagnosis. This may include repeat imaging, additional biopsies or other procedures, and referral to specialists for further evaluation and management. Question What factors most contribute to and what implications stem from misdiagnosis in breast imaging? Findings Ongoing training and education for radiologists and other healthcare providers, as well as interdisciplinary collaboration and communication, is paramount. Clinical relevance Misdiagnosis in breast imaging can have significant implications for patients, healthcare providers, and the entire healthcare system.

Medical Board Discipline of Physicians for Spreading Medical Misinformation.

False medical information disseminated dangerously during the COVID-19 pandemic, with certain physicians playing a surprisingly prominent role. Medical boards engendered widespread criticism for not imposing forceful sanctions, but considerable uncertainty remains about how the professional licensure system regulates physician-spread misinformation. To compare the level of professional discipline of physicians for spreading medical misinformation relative to discipline for other offenses. This cross-sectional study analyzed and coded publicly reported medical board disciplinary actions in the 5 most populous US states. The analysis included data from January 1, 2020, through May 30, 2023, for California, Florida, New York, and Pennsylvania and from January 1, 2020, through March 30, 2022, for Texas. Medical board disciplinary proceedings that resulted in some form of sanction were analyzed. Codes were assigned for the different types of offenses relied on by medical boards for imposing physician discipline. Among 3128 medical board disciplinary proceedings in the 5 most populous states, spreading misinformation to the community was the least common reason for medical board discipline of physicians (6 [0.1%] of all identified offenses). Two reasons tied for third least common: patient-directed misinformation (21 [0.3%]) and inappropriate advertising or patient solicitation (21 [0.3%]). The frequency of misinformation conduct was exponentially lower than more common reasons for discipline, such as physician negligence (1911 [28.7%]), problematic record-keeping (990 [14.9%]), and inappropriate prescribing (901 [13.5%]). Patient-directed misinformation provided a basis for discipline 3 times as often as spreading misinformation to the community. The frequency of disciplinary actions for any reasons related to COVID-19 care, even if not about misinformation, was also quite low (10 [0.2%]). Sanctions in misinformation actions tended to be relatively light. The frequency of discipline for physician-spread misinformation observed in this cross-sectional study was quite low despite increased salience and medical board warnings since the start of the COVID-19 pandemic about the dangers of physicians spreading falsehoods. These findings suggest that there is a serious disconnect between regulatory guidance and enforcement and that medical boards relied on spreading misinformation to patients as a reason for discipline 3 times more frequently than disseminating falsehoods to the public. These results shed light on important policy concerns about professional licensure, including why, under current patient-centered frameworks, this form of regulation may be particularly ill-suited to address medical misinformation.

Multimedia-Based Education Led to Improvement in Disease Knowledge Among Patients with Cirrhosis.

Current evidence shows limited patient understanding of liver disease, coupled with no standard guidelines or methods to offer patient education in a busy clinical environment. We developed multimedia-based education (MBE) for those with cirrhosis & tested its effectiveness in improving patient knowledge from baseline to 1 month. This prospective study enrolled cirrhotic patients who had a scheduled visit with a hepatologist at an ambulatory academic practice or were admitted to the liver inpatient service. Once consented, patients completed a baseline knowledge questionnaire, and were given a link to watch the videos (text or email). Four videos were developed by the study team with input from clinicians and patients (liver function, symptoms and complications, medical management and preventive actions & nutrition). At month 1, the study coordinator confirmed with the patient that they had watched the videos at least once, and patients completed the same knowledge questionnaire. The scores between pre- and post-intervention were compared using the Wilcoxon signed rank test. Of the 120 enrolled, 113 completed baseline and 75 completed follow-up. 48% had alcohol-related liver disease as the underlying cause of cirrhosis. Mean MELD score at enrollment was 14.7 ± 8.14. There was a statistically significant improvement in knowledge scores across all domains from baseline to month 1 (p < 0.05). The overall knowledge score improved from 65 to 83% (p < 0.001), with highest improvement by 40% in the domain of liver function and causes of cirrhosis. MBE can help improve patients' knowledge about liver function, management, and prevention and can be used in both ambulatory and inpatient hepatology practice.

Effect Of Level 1 Progressive Mobilization On Oxygen Saturation In Patients With Decreased Consciousness

Background: Patients in the intensive care unit are individuals who are in critical condition due to failure of function of one or more organs, with hemodynamic instability. They require special care and intensive monitoring, in the hope that their condition can improve through appropriate medical action (Setiyawan, 2016). The incidence of stroke is increasing every year, there are 11 million stroke cases in the world, especially in low-income countries, especially in South Asian states and it causes 4 million deaths every year, around 30% of them in Southeastern countries. In addition, stroke is one of the leading causes of death and disability in adults in the United States. Every year, nearly 795,000 people in the country experience a stroke, either new or recurrent, and this causes approximately 130,000 deaths annually. (WHO, 2016). Research Objective: To understand the effect of level 1 progressive mobilization on changes in oxygen saturation in patients with decreased consciousness. Methodology: This research uses quantitative methods. The approach is quasi-experimental with a utilitarian design, where the intervention is applied to one group, then observations are made on the independent variables. Research Results and Discussion: Before progressive mobilization measures were carried out, the level 1 oxygen saturation value in patients with impaired consciousness at Grandmed Lubuk Pakam Hospital, of the 24 respondents, 2 respondents had oxygen saturation of 92% (8.3%), 4 respondents 93% (16, 7%), 7 respondents 94% (29.2%), 7 respondents 95% (29.2%), 3 respondents 96% (12.5%) and 7 respondents had oxygen saturation 98% (4.2%) . Conclusion: The average O2 saturation value in patients with decreased consciousness before doing level 1 progressive exercise was 93.33, whereas after it increased it was 95.67.

Poisoning with Local Anesthetics Following Circumcision : A Case Report

Introduction: Circumcision or posthectomy is the removal of the foreskin, this act seems commonplace practiced by paramedical personnel or unqualified traditional practitioners who may cause significant complications. Objective: Our work aimed to highlight one of the complications of this act which must remain a supervised medical act. Observation: We report the case of a 2-month-old infant who presented with complications related to anesthesia. the clinic was dominated by convulsions and alteration of the state of consciousness 15 minutes after circumcision in this well infant carrying without any particular history. The evolution was favorable thanks to support rapid and urgent about 20 minutes with the cessation of convulsions and a return to consciousness, the patient was monitored for 48 hours then return home was indicated due to the absence other complications. Conclusion: Circumcision is a widespread act throughout the world either by medical necessity or by religious tradition. its trivialization and its practice by non-experts, explains the multiple complications observed.

Legal Review of Legal Protection of People with Mental Disorders (ODGJ) Against Medical Actions based on Human Rights Principles

Every international human rights convention is based on the same principles that underlie health care. These principles include the following three fundamental ideas: equality, non-discrimination, and government obligations. Everyone has a fundamental right to mental health care, including those who are sick (ODGJ). Government funding is available for mental health institutions, mental health professionals, and mental health equipment so that ODGJ have equal access to treatment. This type of research is known as normative legal research, which analyzes and investigates the norms, doctrines, or principles of legal science by discussing legal issues and attempting to determine the basic concepts of certain legal events, relationships, rights, and legal entities in codified and structured law. A conceptual and legislative approach was taken in this study.

Évaluation de l’impact économique et du parcours patient lors du traitement de l’occlusion coronaire totale chronique

Chronic total occlusion (CTO) of coronary arteries is defined as complete absence of antegrade coronary flow without iodine passage, since more than 3 months. Coronary revascularization is a highly resource-intensive angioplasty procedure involving numerous medical devices (MDs). Its consumption and associated costs are not covered by either the medical act classification (CCAM) or the hospitalization fees and additional MD funding. The primary aim of this study is to analyze the financial sustainability of this activity for a public healthcare institution and to assess the budgetary impact of CTO treatment on the most expensive items of expenditure. The secondary aim is to describe the patient's intra-hospital pathway. CTO revascularization stays are categorized under the code 05K06 "Vascular Stents without Myocardial Infarction". Major cost items were identified using national coded expenditure data and compared with those from our cost study. Every CTO intervention from January to November 2021 were retrospectively retrieved. Establishment purchase prices in 2021 were used to determine MD costs. Clinical data were extracted from electronic patient records. Operative data (procedure duration, professionals involved, and MD used) were extracted. Human Resources (HR) costs were integrated into the calculations. A Sankey diagram was created. Data are expressed as mean ± standard deviation. In our study, 41 patients underwent 45 interventions. The median was 65 years. 78% of interventions were successful with a median duration of 113 minutes. 222 different MD references were used, with 27% reimbursed additionally and 73% funded within the homogeneous group of stays (HGS). The total cost of MD described in the coded expenditure data is 2142euro, of which 721euro is funded within the HGS. In our cohort, it represented averages of 2736euro ± 1393euro and 1710euro ± 926euro, respectively. Regarding HR, the total cost described in the coded expenditure data was 442euro compared to 410euro ± 169euro in our cohort. Finally, patient pathway analysis showed an average length of stay (LOS) of 1.8 days. Two pathways were identified depending on admission context: weekday hospitalization or cardiac intensive care. CTO revascularization is a planned intervention with a short LOS and a highly standardized patient pathway. Our study highlights a proliferation of MD references used during CTO revascularization due to innovative industrial developments. The cost differential with coded expenditure data confirms the need for a revision of the procedure and its categorization within an HGS, which is currently non-specific.

Under-Prescription of Drugs in the Elderly Population of Western Romania: An Analysis Based on STOPP/START Version 2 Criteria.

Background/Objectives: Numerous European countries, including Romania, are facing the concern of rapid ageing of their populations. Moreover, Romania's life expectancy ranks among the lowest in the European Union. In light of this, it is imperative that the assessment of medication-related harm be given national priority in order to secure and enhance pharmacotherapy and the medical act. In this study, we sought to describe and evaluate the under-prescribing practices among the Romanian elderly population. Methods: We conducted a cross-sectional study in urban areas of two counties in Western Romania (Timis and Arad) from November 2017 to February 2019. We collected chronic electronic prescriptions issued for elderly patients (>65 years old) with chronic conditions. The medication was prescribed by generalist or specialist physicians for periods ranging between 30 and 90 days. To assess inappropriate prescribing behaviours, a multidisciplinary team of specialists applied the Screening Tool of Older Persons' Prescriptions/Screening Tool to Alert to Right Treatment (STOPP/START) v.2 criteria to the collected prescriptions. Results: Within the 1498 prescriptions included in the study, 57% were issued to females, the mean age was 74.1 ± 6.95, and the average number of medicines per prescription was 4.7 ± 1.51. The STOPP criteria most commonly identified were the (1) long treatment duration (23.6%) and (2) prescription of neuroleptics (14.6%) or zopiclone (14.0%) as medications that increase the risk of falls. According to START criteria, the following medicines were under-prescribed: (1) statins (47.4%), (2) beta-blockers (24.5%), (3) antiresorptive therapy (10.0%), and (4) β2-agonists and muscarinic antagonists for chronic obstructive pulmonary disease (COPD) (4.5%). Within our study group, the prevalence of potentially inappropriate medications was 18.58%, whereas the prevalence of potential prescribing omissions was 49.2%. Conclusions: To decrease medication-related harm and morbid-mortality, and to increase the quality of life for elderly people in Romania, immediate actions are needed from national authorities. These actions include reinforcing primary care services, providing periodic training for physicians, implementing medication review services by pharmacists, and utilising electronic health records at their full capacity.

A-186 Patient Safety Rite in Diagnostic Services

Abstract Background Safety rites are well defined in hospitals, but still incipient in diagnostic services. They aim to identify near misses early, promote discussions and improvements with teams related to adverse incidents. This study presents the implementation of the Safety Rite in a large diagnostic service in Brazil, with its challenges and results. Methods Gemba Walk (GW), a practice of the Lean philosophy of checking operation processes, encouraging and collaborating between teams, in addition to identifying opportunities for improvement and enabling immediate decision-making. The laboratory created its own methodology called GW-MDU, which consists of a daily checklist of questions related to processes, efficiency and results. The GW begins with a visit by the leadership, or designated person, to all sectors, answering the checklist and evaluating the need for immediate actions and action plans, with registration in an application (APP). In January 2024, the Patient Quality and Safety System (SGQSP) included questions related to the WHO (World Health Organization) safety goals in the GW: 1. Did patient identification occur without complications/identification failures at all stages of the process? 2. Was there contrast extravasation? 3. Was there allergic reactions? 4. Was there an incorrect or change administration of medication or vaccine? 5. After the end of sedation(anestesia), was there a need to extend the recovery time? 6. Was there a patient fall? 7. Was there a puncture that resulted in a hematoma? 7. Was there an adverse event that required medical action? Every “No” answer to question 1 and “Yes” to questions 2 to 7, the leader must guarantee registration of the QMS, root cause analysis and action plan. After the GW, leadership conducts the Obeya Rite daily, including the Safety Rite, with analysis of the indicators and findings identified during the round.The Safety Rite methodology was tested in a Laboratory Unit where radiology and imaging diagnostic tests, hormonal tests and sample collection for clinical analysis are carried out. After the test, interviews were realized with the leaders to evaluate the application of the Rite. Improvements were implemented and later rolled out to the other Units. Results The Patient Safety Rite was implemented in 646 Laboratory Units, representing 35 brands of the laboratory group. From 12/20/23 to 02/15/24, 18,614 GW were carried out, of this total, for question 1, 82.7% answered “Yes”, 9% answered “No” and 8.3% answered No Applicable. For answers 2 to 7, 1.5% answered “Yes”, 48.2% answered “No” and 50.3% answered Not Applicable. A total of 40.264 incidents were opened in the QMS, 6.4% of which were related to Rite questions. Conclusions The rites consolidate indicators and information, allow the identification of risks and/or events proactively and help define and disseminate corrective actions and improvements in a timely manner to avoid recurrence. However, due to the high rate of “not applicable” responses, we still have challenges and opportunities in implementation, but the correctly used Safety Rite contributes to patient safety.

‘Downhill race for a rainbow jersey’: the epidemiology of injuries in downhill mountain biking at the 2023 UCI cycling world championships—a prospective cohort study of 230 elite cyclists

ObjectivesThis study aims to understand the prevalence, incidence rate, anatomical sites, injury severity and main medical actions carried out during official training and racing by elite downhill mountain biking (DHMTB)...

Ethical Decision Making in a Child with Brain Death

Diagnosing brain death in paediatrics is difficult due to emotional, ethical, and legal weightage. This can easily be resolved in a straightforward case following a series of examinations and investigations to confirm that the condition is irreversible. However, in some cases, consideration of religio-cultural, family preferences, and other contextual factors have to be carefully considered. This is due to challenges in ethical decision making whether to continue the treatment or to set for discontinuation of active management. There should be an emphasis on appropriate communication, resolution of conflicts and also a focus on supporting the family and healthcare providers involved in the care of the patient. This is to avoid misunderstanding of information and allowing continuous discussion on the right way forward. Decision making in a complex situation such as paediatric brain death would require ongoing negotiation based on the best interest and beneficence of the medical actions to avoid ongoing suffering for the patient and his/her family.

The meaning of life in medical action

The meaning of life in medical action

Women’s economic empowerment and intimate partner violence

This study explores the relationship between women’s economic empowerment and intimate partner violence (IPV), measured as women’s hospital visits for assault. Using longitudinal Swedish administrative data, I proxy women’s economic empowerment with a measure of potential relative earnings of married spouses caused by local changes in gender-specific labour demand. The findings reveal that an increase in potential relative earnings increases the probability of women’s hospital visits for injuries caused by assault, and the effect is particularly pronounced for women with low baseline bargaining power. Furthermore, exploiting detailed information on type of hospital visit, diagnosis and medical actions taken at the hospital, I show that the increase in hospital visits for assault is, at least in part, driven by an increase in care-seeking for IPV-related injuries rather than an increase in IPV itself.

Professional Learning in the Workplace: How and Why do Physicians Learn?

Learning in the workplace supports physicians in developing competences to ensure quality medical care. As such, learning in the workplace is essential for physicians’ life-long professional development. Notwithstanding its importance, research on physicians’ learning in the workplace and the corresponding motivational drivers is limited. In this study, 17 semi-structured interviews were conducted to explore experienced physicians’ learning activities and their motivation for learning in the workplace. In addition, it was examined whether differences could be noted in learning in the workplace depending on physicians’ experience, specialism, gender or the type of hospital they work in.Concepts from learning in the workplace and motivation theories, i.e. learning activities in the workplace, self-determination theory and achievement goal theory, guided the data analysis, and an inductive analysis was conducted as well. Results revealed various learning activities for instance but not limited to: learning by asking colleagues for feedback, asking for help while performing particular medical actions, helping students while conducting their assignments or observing colleagues. Besides, the participants indicated different motives for learning. Physicians reported that they are motivated to properly perform their job, they enjoy learning and/or like learning in relation to solving challenging cases. The study shows that participants’ differences in motivation can be related to seniority and the type of hospitals physicians are employed in.

Tinjauan Ketepatan Pengkodean Penyakit pada Rekam Medis Pasien di Rumah Sakit Tk. III Dr. R. Soeharsono Banjarmasin

Medical recorders in assigning disease codes appropriately according to the classification applied in Indonesia use the International Statistical Classification of Diseases and Related Health Problems 10 (ICD-10) guidelines on diseases and medical actions in health services and management so that there are no errors in determining disease diagnoses and actions to be taken to patients. Determination of the diagnosis of the disease and the actions that will be taken to the patient. Based on preliminary studies conducted at the Tk. III Dr. R. Soeharsono Banjarmasin Hospital in January 2023, it was found that there were still incompletely written disease diagnoses and incorrect disease diagnosis codes with ICD-10. The purpose of this study was to determine the completeness of the writing of disease diagnoses and the accuracy of disease coding in patient medical records. This type of research is descriptive quantitative. The research design used a cross sectional approach. Sampling was carried out using purposive sampling method based on the number of patient medical records on January 2 - January 28, 2023 and obtained 96 patient medical records. Data collection methods using observation and questionnaires. The conclusion is that in 96 patient medical record files at the Tk. III Dr. R. Soeharsono Banjarmasin Hospital there are 12 incomplete diagnoses filled in and there are 3 incorrect disease diagnosis codes, the cause is because the diagnosis coder has never attended training related to coding competence.

Ultrafast Metaphotonic PCR Chip with Near-Perfect Absorber.

Polymerase chain reaction (PCR) is the gold standard for nucleic acid amplification and quantification in diverse fields such as life sciences, global health, medicine, agricultural science, forensic science, and environmental science for global sustainability. However, implementing a cost-effective PCR remains challenging for rapid preventive medical action to the widespread pandemic diseases due to the absence of highly efficient and low-cost PCR chip-based POC molecular diagnostics. Here, this work reports an ultrafast metaphotonic PCR chip as a solution of a cost-effective and low-power-consumption POC device for the emerging global challenge of sustainable healthcare. This work designs a near-perfect photonic meta-absorber using ring-shaped titanium nitride to maximize the photothermal effect and realize rapid heating and cooling cycles during the PCR process. This work fabricates a large-area photonic meta-absorber on a 6-inch wafer cost-effectively using simple colloidal lithography. In addition, this work demonstrates 30 thermocycles from 65 (annealing temperature) to 95°C (denaturation temperature) within 3min 15s, achieving an average 16.66°Cs-1 heating rate and 7.77°Cs-1 cooling rate during thermocycling, succeeding rapid metaphotonic PCR. This work believes a metaphotonic PCR chip can be used to create a low-cost, ultrafast molecular diagnostic chip with a meta-absorber.

PERTANGGUNGJAWABAN RUMAH SAKIT TERHADAP MALPRAKTIK YANG DILAKUKAN TENAGA MEDIS DALAM PERSFEKTIF HUKUM PERDATA

Hospital liability due to negligence or carelessness or in the event of malpractice by medical personnel from a civil perspective really depends on the pattern of legal relations between medical personnel and the hospital, whether the pattern of legal relations is based on employment law relations or legal relations. This really determines the extent to which a hospital can offer medical personnel actions that result in harm to patients in carrying out health services as part of their professional duties. Based on this legal relationship pattern, the hospital's liability can be based on unlawful acts as regulated in Article 1367 at (3) of the Civil Code and/or will be free from liability if the hospital can prove that the relationship pattern of medical personnel with the hospital is based on a lease.

The Importance of Legislation in Emergency Department Care

It is well known that medical care in emergency services is preceded by a series of administrative and social checks in different health institutions; in such a way, that it is apparently designated by factors such as the right to an institution, belonging to a certain area, the hours in which patients come and, above all, the classification of the type of emergency that is attended. However, it is important to clarify and emphasize that above these edges are laws, regulations, procedures and decrees that we will address in this article with the sole purpose of establishing a current, updated and applicable regulatory framework for medical care in health services. emergencies in our country regardless of whether there is a right or designation of care areas, which we believe will help the health professional of this service to carry out his medical act safely and efficiently.

Legal liability of medical personnel and health workers who commit negligence during medical procedures (Normative Study After the Enactment of Law Number 17 of 2023 Concerning Health)

Medical personnel and health workers are part of health human resources who are basically tasked with providing health services to service recipients, in this case patients and/or providing the necessary medical measures. Medical personnel and health workers who commit negligence when carrying out their duties legally can be subject to legal liability. Since the enactment of Law Number 17 of 2023 concerning Health, there have been several important aspects of health law that have changed, one of which is related to legal liability. For this reason, it is necessary to conduct an assessment, especially about legal liability for medical personnel and health workers if they commit negligence when performing medical procedures. The type of research carried out is normative juridical research. The approach taken is a statutory approach and is descriptive analysis. The resources used for secondary data are by processing data from primary legal materials, secondary legal materials and tertiary legal materials. The data collection tool used is document study (library research) and analyzed by qualitative analysis. Based on the results of the study, it is known that the duties and functions of medical personnel and health workers in carrying out medical actions on patients are mainly to provide health services to patients in the form of promotive, preventive, curative, rehabilitative, and/or palliative. Then it is known that the legal responsibility of medical personnel and health workers when committing negligence after the enactment of Law Number 17 of 2023 concerning Health is divided into 3 (three) forms, namely administrative liability, namely the temporary deactivation of STR; and/or recommendations for revocation of SIP, civil liability in the form of compensation and criminal liability in the form of imprisonment and fines.

Two thirds of patients may not need routine 12-month specialist review in an epilepsy clinic: A cross-sectional study of clinic appointments

ObjectivesTimely access to specialist outpatient clinics can be difficult to achieve as outpatient services are often oversubscribed leading to unacceptable wait times. New patients, or those with emergent issues may wait for appointments whilst existing patients are booked in for routine reviews “just in case” there is a problem, using considerable clinic resources. We investigated routine 12-month review appointments to assess whether these appointments changed patient management. MethodsThe medical records of 100 randomly selected adult patients attending annual review appointments over 12 months at a publicly-funded specialist outpatient epilepsy clinic in Melbourne, Australia were audited. Demographic and clinical data as well as information about the content of each appointment were analysed to determine whether the appointment resulted in changes to epilepsy management (eg medication change), administrative actions (eg drivers license approval) or the provision of information or education. Logistic regression was performed to assess what clinical factors were associated with changes in patient care arising from the 12-month review appointment. ResultsAlmost half (47%) of appointments resulted in no change to patient care and 37% had only administrative outcomes, such as the completion of a regulatory driving report. Only 16% of appointments resulted in a change in medical management. The only factor that independently predicted a change in medical management was the occurrence of a seizure in the previous year. The only factor independently associated with not having any change in medical management or administrative action was having an unknown seizure type. Conclusions/ significanceOnly a small number of patients experience a change in medical management when attending a 12-month epilepsy clinic appointment, with a need for management change associated with the presence of ongoing seizure. Outpatient services should limit the use of routine annual follow up to those patients most likely to need intervention or support, creating “just in time” capacity for timely access to review as issues arise.