Inequities in access to pediatric epilepsy surgery: a bioethical framework

Ibrahim, George M.; Barry, B; Fallah, Aria; Snead, O. Carter; Drake, James M.; Rutka, James T.; Bernstein, Mark

doi:10.3171/2011.12.focus11315

Cited by 22 publications

(9 citation statements)

References 28 publications

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“…Access to epilepsy surgery remains a considerable challenge in contemporary healthcare systems 5 . The average delay between a diagnosis of medically intractable epilepsy and referral for surgical consideration and surgery can be as long as 15-22 years 6,7 .…”

Section: Original Articlementioning

confidence: 99%

Predictors of Surgical Candidacy in 414 Epilepsy Patients Admitted to the EMU

Mansouri

Fallah

Ibrahim

et al. 2013

Can. J. Neurol. Sci.

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Objectives:Admission to an Epilepsy Monitoring Unit (EMU) is essential for pre-surgical evaluation of patients with medically-refractory epilepsy; however, prolonged referral times and resource limitations are significant access barriers. Therefore, identification of pre-EMU variables that predict potential surgical candidates can assist in the triage of patient admissions to the EMU.Methods:In this hypothesis-generating study, a retrospective analysis of patients admitted for pre-surgical evaluation to the Toronto Western Hospital EMU (2004-2011) was performed. Univariate and multivariate logistic regression was used to identify variables that could independently predict subsequent surgical candidacy following EMU evaluation.Results:Four hundred and fourteen patients were admitted to the EMU. Overall, 259 patients (62.5%) were identified as potential surgical candidates. One hundred and seven patients (25.8%) required invasive electroencephalogram (iEEG) implantations; of 75 patients consenting to iEEG analysis 39 underwent a subsequent resective procedure. Male patients and those with a lesion on MRI were 1.9 times more likely to be surgical candidates (95% CI 1.18-2.98 and 0.94-3.80, respectively), while patients with non-localizable seizures were seven times less likely (95% CI 0.02-1.25).Conclusion:In this retrospective, hypothesis-generating study male gender, presence of a lesion on MRI and localizable seizures on routine outpatient EEG analysis independently predicted subsequent resective epilepsy surgical candidacy in EMU patients. Upon validation by other studies, these variables may be considered by clinicians referring patients to the EMU in order to improve wait times and optimize patient care.

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Section: Original Articlementioning

confidence: 99%

Predictors of Surgical Candidacy in 414 Epilepsy Patients Admitted to the EMU

Mansouri

Fallah

Ibrahim

et al. 2013

Can. J. Neurol. Sci.

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“…This could make a case that epilepsy surgery may have been unfairly neglected compared to surgical treatment of other public health conditions [197]. Health care providers also have an ethical obligation to identify and facilitate access to epilepsy surgery for these vulnerable subgroups [198]. Whether minimally invasive surgeries may be a cost effective or efficacious option is an ongoing discussion, as subjects may be more willing to undergo minimally-invasive procedures due to lower perceived risks [199].…”

Section: Discussionmentioning

confidence: 99%

Epilepsy surgery in low- and middle-income countries: A scoping review

Watila

Xiao

Keezer

et al. 2019

Epilepsy & Behavior

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Background: Epilepsy surgery is an important treatment option for people with drug resistant epilepsy. Although surgical procedures are under-utilized worldwide, it is far worse in Low-and Middle-Income Countries (LMIC) and it is less clear to what extent people with drug resistant epilepsy receive such treatment at all. Here we review the existing evidence for the availability and outcome of epilepsy surgery in LMIC, and discuss some challenges and priority. Methods: We used the six stage methodological framework developed by Arskey and O'Malley as a guide. We searched PubMed, Embase, Global Health Archives, Index Medicus for South East Asia Region (IMSEAR), Index Medicus for Eastern Mediterranean Region (IMEMR), Latin American & Caribbean Health Sciences Literature (LILACS), African Journal Online (AJOL), and African Index Medicus (AIM) to identify the relevant literature. Results: We retrieved 148 articles on epilepsy surgery from 31 countries representing 22% of the 143 LMIC. Epilepsy surgery appears established in some of these centers in Asia and Latin America, while some are in their embryonic stage reporting procedures in a small cohort performed mostly by motivated neurosurgeons. The commonest surgical procedure reported was temporal lobectomies. The post-operative seizure-free rates and quality of life are comparable to those in the high-income countries (HIC). Some models have shown that epilepsy surgery can be performed within a resourcelimited setting through collaboration with international partners and through the use of information and communication technology. The cost of surgery is a fraction of what is available in HIC. Conclusion: This review has demonstrated the availability of epilepsy surgery in few LMIC. The information available is inadequate to make any reasonable conclusion of its existence as routine practice. Collaborations with international partners can provide an opportunity to bring high-quality academic training and technological transfer directly to surgeons working in these regions and should be encouraged.

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“…We have previously explored this topic as it relates to the use of palliative surgical procedures to achieve a reduction in seizure frequency in children with medically intractable epilepsy 37 . As such children have a lower margins of improvements in their quality of life, they risk having a lower priority placed on treatments that can improve their lives, the socalled "double jeopardy" [38][39][40] . It has been suggested that implementation of A4R applies a human rights approach to health 41 , which would take into consideration the respective benefit to marginalized or vulnerable patient groups.…”

Section: Discussionmentioning

confidence: 99%

Priority Setting in Neurosurgery as Exemplified by an Everyday Challenge

Ibrahim

Tymianski²,

Bernstein³

2013

Can. J. Neurol. Sci.

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Background:The allocation of limited healthcare resources poses a constant challenge for clinicians. One everyday example is the prioritization of elective neurosurgical operating room (OR) time in circumstances where cancellations may be encountered. The bioethical framework, Accountability for Reasonableness (A4R) may inform such decisions by establishing conditions that should be met for ethically-justifiable priority setting.Objective:Here, we describe our experience in implementing A4R to guide decisions regarding elective OR prioritization.Methods:The four primary expectations of the A4R process are: (1) relevance, namely achieved by support for the process and criteria for decisions amongst all stakeholders; (2) publicity, satisfied by the effective communication of the results of the deliberation; (3) challengeability through a fair appeals process; and (4) Oversight of the process to ensure that opportunities for its improvement are available.Results:A4R may be applied to inform OR time prioritization, with benefits to patients, surgeons and the institution itself. We discuss various case-, patient-, and surgeon-related factors that may be incorporated into the decision-making process. Furthermore, we explore challenges encountered in the implementation of this process, including the need for timely neurosurgical decision-making and the presence of hospital-based power imbalances.Conclusion:The authors recommend the implementation of a fair, deliberative process to inform priority setting in neurosurgery, as demonstrated by the application of the A4R framework to allocate limited OR time.

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Inequities in access to pediatric epilepsy surgery: a bioethical framework

Cited by 22 publications

References 28 publications

Predictors of Surgical Candidacy in 414 Epilepsy Patients Admitted to the EMU

Predictors of Surgical Candidacy in 414 Epilepsy Patients Admitted to the EMU

Epilepsy surgery in low- and middle-income countries: A scoping review

Priority Setting in Neurosurgery as Exemplified by an Everyday Challenge

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