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

Abstract

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.

Predictors of referral for long‐term EEG monitoring for Medicare beneficiaries with drug‐resistant epilepsy

“…Additionally Medicare data was critical for including geographic implications and provider characteristics. It will be important to perform similar analyses on alternative datasets to better understand referral for patients with employer‐based insurance, as some prior studies have suggested Medicare beneficiaries may be less likely to undergo epilepsy surgery compared to those privately insured 9,14,41 …”

Delays in the diagnosis and surgical treatment of drug‐resistant epilepsy: A cohort study

“…Despite high‐level evidence supporting surgical intervention for DRE, 4–6 delays in referral to level 4 epilepsy centers for neurosurgical evaluation remain a significant problem 7,8 . Recent examinations of DRE referral patterns demonstrate that racial, socioeconomic status, and geographic disparities impact rates of surgical evaluation and intervention in the United States 9,10 …”

“…These delays have been associated with worsened quality of life, higher rates of psychological or mood disorders 5 and a further decline in socioeconomic status because of disability or unemployment. 9,11,12 Furthermore, a Canadian registry study by Burneo et al 13 examining patients with DRE from 2001 to 2010 reported that over 10% of patients died within 2 years of DRE diagnosis. Despite growing numbers of epilepsy centers and the continued innovation of surgical techniques and technologies, surgical intervention rates have seen only marginal increases over the past decade.…”

“…7,8 Recent examinations of DRE referral patterns demonstrate that racial, socioeconomic status, and geographic disparities impact rates of surgical evaluation and intervention in the United States. 9,10 Delays to surgical evaluation for DRE come with indelible risks. These delays have been associated with worsened quality of life, higher rates of psychological or mood disorders 5 and a further decline in socioeconomic status because of disability or unemployment.…”

“…[14][15][16] Systematic reviews of referral patterns specifically highlight the role geography plays in time to surgical evaluation for DRE. 9 Institutional evaluations of referral patterns in the United States primarily describe urban academic teaching centers, often located on the East Coast. However, there has been limited evaluation of DRE referral and surgical patterns in the Intermountain West (the geographic area in the United States generally comprising Colorado, Idaho, Montana, Nevada, New Mexico, Utah, and Wyoming).…”