Underutilization of epilepsy surgery: Part I: A scoping review of barriers

Samanta, Debopam; Ostendorf, Adam P.; Willis, Erin; Singh, Rani K.; Gedela, Satyanarayana; Arya, Ravindra; Perry, Μ. Scott

doi:10.1016/j.yebeh.2021.107837

Cited by 61 publications

(51 citation statements)

References 99 publications

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“…[4] Despite the accumulation of solid evidence of the use of epilepsy surgery and other nonmedical treatment approaches for DRE, these are underutilized due to the need for an expert interdisciplinary team dedicating to conduct all necessary evaluations [detailed history, physical examination, recording of ictal events with simultaneous electroencephalography( EEG) and video monitoring, neuropsychological evaluation, advanced anatomic and functional neuroimaging]. [5,6] This complex workup usually requires multiple outpatient and inpatient visits, all of which became significantly restricted during the novel coronavirus disease 2019 (COVID-19) pandemic. A global survey reported that >90% of pediatric neurology services had been affected by restricted outpatient care, decreased access to EEG, limited use of dietary therapy, restricted admission in epilepsy monitoring units, and canceled or limited epilepsy surgery.…”

Section: Introductionmentioning

confidence: 99%

Conceptualization and implementation of an interdisciplinary clinic for children with drug-resistant epilepsy during the COVID-19 pandemic

Samanta

Elumalai

Desai

et al. 2021

Epilepsy & Behavior

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Section: Introductionmentioning

confidence: 99%

Conceptualization and implementation of an interdisciplinary clinic for children with drug-resistant epilepsy during the COVID-19 pandemic

Samanta

Elumalai

Desai

et al. 2021

Epilepsy & Behavior

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“…Despite the evidence and new clinical practice guidelines recommending earlier referrals for epilepsy surgery, significant barriers remain resulting in delayed referral patterns and increased hospitalizations for epilepsy without a similar trend in the number of epilepsy surgeries performed. [ 8 , 17 , 21 ] In our study of the NIS from 2012 to 2014, we found many statistically significant barriers that limit access to epilepsy surgery. The three most significant barriers were race (Black), income (<$40,000), and location (rural).…”

Section: Discussionmentioning

confidence: 90%

“…[ 18 ] It can be inferred from our data as well as the literature that there is a significant socioeconomic bias in patient selection for epilepsy surgery. [ 21 ]…”

Section: Discussionmentioning

confidence: 99%

“…This is likely because epilepsy providers are primarily located in urban centers and visiting these centers are not feasible for many patients. [ 21 ] Lack of proximity to specialists may also affect referral patterns or knowledge of specialists on the part of primary care providers. [ 31 ] Forming collaborative relationships between community and tertiary centers are a proven method to increase the number of referrals for epilepsy surgery and patients whose cases are discussed in a multidisciplinary epilepsy conference.…”

Section: Discussionmentioning

confidence: 99%

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Utilization of epilepsy surgery in the United States: A study of the National Inpatient Sample investigating the roles of race, socioeconomic status, and insurance

Bernstein

Kashyap

Kortz

et al. 2021

Surgical Neurology International

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Background: Epilepsy is estimated to affect 70 million people worldwide and is medically refractory in 30% of cases. Methods: This is a retrospective cross-sectional study using a US database from 2012 to 2014 to identify patients aged ≥18 years admitted to the hospital with epilepsy as the primary diagnosis. The sampled population was weighted using Healthcare Cost and Utilization Project guidelines. Procedural ICD-9 codes were utilized to stratify the sampled population into two cohorts: resective surgery and implantation or stimulation procedure. Results: Query of the database yielded 152,925 inpatients, of which 8535 patients underwent surgical intervention. The nonprocedural group consisted of 76,000 White patients (52.6%) and 28,390 Black patients (19.7%) while the procedural group comprised 5550 White patients (64%) and 730 Black patients (8.6%) (P < 0.001). Patients with Medicare were half as likely to receive a surgical procedure (14.8% vs. 28.4%) while patients with private insurance were twice as likely to receive a procedure (53.4% vs. 29.3%), both were statistically significant (P < 0.01). Those in the lowest median household income quartile by zip code (<$40,000) were 68% less likely to receive a procedure (21.5% vs. 31.4%) while the highest income quartile was 133% more likely to receive a procedure (26.1% vs. 19.5%). Patients from rural and urban nonteaching hospitals were, by a wide margin, less likely to receive a surgical procedure. Conclusion: We demonstrate an area of need and significant improvement at institutions that have the resources and capability to perform epilepsy surgery. The data show that institutions may not be performing enough epilepsy surgery as a result of racial and socioeconomic bias. Admissions for epilepsy continue to increase without a similar trend for epilepsy surgery despite its documented effectiveness. Race, socioeconomic status, and insurance all represent significant barriers in access to epilepsy surgery. The barriers can be remedied by improving referral patterns and implementing cost-effective measures to improve inpatient epilepsy services in rural and nonteaching hospitals.

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“…Anterior temporal lobectomy and related procedures are the most common type of resection performed for drug-resistant epilepsy, with good evidence for improved outcomes compared to medical management [2,3]. Nevertheless, epilepsy surgery is underutilized [4,5].…”

Section: Introductionmentioning

confidence: 99%

Patient preferences pertaining to treatment options for drug-resistant focal epilepsy

Sinha¹,

Yang²,

Wallace³

et al. 2022

Epilepsy & Behavior

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Objective: To determine patient acceptability of benefit-risk trade-offs in selecting treatment options for drug-resistant mesial temporal lobe epilepsy, including open brain surgery, laser ablation (laser interstitial thermal therapy [LITT]), and continued medications. Methods: A discrete-choice experiment survey was developed, consisting of 20 versions that were randomly assigned to respondents. Each version had 8 sets of constructed treatment alternatives, representing open brain surgery, LITT, or continued medical management. For each set, respondents indicated the treatment alternative they would choose first. Treatment alternatives were characterized by varying levels of chance of seizure freedom for at least 2 years (20-70%), risk of 30-day mortality (0-10%), and risk of neurological deficits (0-40%). Respondents' choices were analyzed using random-parameters logit models to quantify acceptable benefit-risk trade-offs. Preference heterogeneity was evaluated using latent-class analysis. Results: The survey was administered to 2 cohorts of adult patients with drug-resistant epilepsy: a Duke cohort identified using diagnostic codes (n = 106) and a web-recruited panel with a self-reported physician diagnosis of drug-resistant epilepsy (n = 300). Based on mean preference weights, respondents who indicated a willingness to consider surgical intervention would accept a reduction in chance of seizure freedom from 70% to a minimum-acceptable benefit (MAB) of 23% if they could undergo LITT rather than open brain surgery. For a reduction in 30-day mortality from 1% to 0%, MAB was 52%. For a reduction in risk of long-term deficits from 10% to 0%, MAB was 39%. Latent-class analysis revealed additional choice patterns identifying respondent groups that more strongly favored continuing medications or undergoing surgery. Conclusion: Patients who are receptive to surgery would accept significantly lower treatment effectiveness to undergo a minimally invasive procedure relative to open brain surgery. They also were willing to accept lower treatment benefit to reduce risks of mortality or neurological deficits.

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Underutilization of epilepsy surgery: Part I: A scoping review of barriers

Cited by 61 publications

References 99 publications

Conceptualization and implementation of an interdisciplinary clinic for children with drug-resistant epilepsy during the COVID-19 pandemic

Conceptualization and implementation of an interdisciplinary clinic for children with drug-resistant epilepsy during the COVID-19 pandemic

Utilization of epilepsy surgery in the United States: A study of the National Inpatient Sample investigating the roles of race, socioeconomic status, and insurance

Patient preferences pertaining to treatment options for drug-resistant focal epilepsy

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