Abstract
Background: Epilepsy is a chronic neurologic condition that requires specialist follow-up and frequent medication adjustments. A multidisciplinary Veterans Affairs (VA) clinic model was implemented in which clinical pharmacist practitioners (CPPs) provide follow-up care under epileptologist oversight. This quality improvement study evaluated the economic and clinical impact of CPP-led follow-up visits in a VA epilepsy clinic, focusing on visit-level cost avoidance compared with neurologist-provided care. Methods: This single-center, retrospective quality improvement project at a VA epilepsy clinic evaluated pharmacist-led follow-up epilepsy care between October 2021 and April 2025. The primary outcome was visit-level cost avoidance associated with CPP-led follow-up visits compared with physician provided follow-up. Cost avoidance was estimated using VA salary data, with each follow-up visit requiring approximately 1.5 h of work (30 min preparation, 30 min appointment, 30 min documentation), totaling 264 annual hours (12.7% full-time equivalent) at an annualized volume of 176 CPP visits. Secondary outcomes included reimbursement-equivalent value estimated through intervention-based assignment of evaluation and management (E/M) codes (99212–99,215) and 2025 Medicare Physician Fee Schedule rates, with a commercial payer scenario using a 1.3 multiplier, as well as clinical intervention patterns including the proportion of follow-up visits managed by CPPs versus physicians, frequencies of antiseizure medication (ASM) changes, nonpharmacologic interventions, mental health screenings, referrals, laboratory orders, and mean wait time for follow-up appointment. New patient visits, nurse practitioner visits, and non-epilepsy neurology encounters were excluded from the cost analysis. Results: Over 3.5 years, 1596 total encounters were completed, including 1214 followup visits analyzed for cost and clinical outcomes. Of these follow-up visits, CPPs managed 617 (51%) and neurologists 597 (49%). Intervention-based EM classification yielded a base-case distribution of 10% 99,212, 55% 99,213, 30% 99,214, and 5% 99,215, corresponding to an annualized Medicare-equivalent value of 17,478 USD (United States Dollar), increasing to 22,722 USD with the commercial multiplier. VA salary modeling estimated to be 114.80 USD per CPP follow-up visit versus 216.50 USD per neurologist visit, corresponding to 101 USD cost avoidance per CPP encounter and approximately 17,888 USD annual cost avoidance at an annualized volume of 176 CPP follow-up visits. Mean follow-up wait time decreased from 29 to 8 days after CPP integration. Among CPP encounters, ASM changes occurred in 236 of 617 visits (38%), nonpharmacologic interventions in 89 visits (14%), and mental health screenings in 325 visits (53%), with CPPs also placing 44 specialty consultations (7%) and ordering 146 laboratory tests (24%). Peer review of 70 CPP progress notes in epilepsy clinic between 2022 and 2025 found all met predefined criteria for accuracy and clinical appropriateness. Conclusion: CPP integration into a VA epilepsy clinic enabled pharmacists to absorb over half of follow-up volume while shortening wait times and delivering clinically meaningful care. Pharmacist-led encounters were characterized by frequent ASM adjustments, mental health screening, and safety and adherence counseling and produced substantial visit-level cost avoidance and demonstrable reimbursement equivalent value compared with neurologist staffing. These findings support CPP-led follow-up as a strategy to expand access, preserve epileptologist capacity, and reduce per-visit costs.