Relationship between hospital surgical volume, lobectomy rates, and adverse perioperative events at US epilepsy centers

Clinical article

Restricted access

Object

Epilepsy surgery remains significantly underutilized. The authors recently reported that the number of lobectomies for localized intractable epilepsy in the US has not changed despite the implementation of clear evidence-based guidelines 10 years ago supporting early referral for surgery. To better understand why epilepsy surgery continues to be underused, the authors' objective was to carefully examine hospital-related factors related to the following: 1) where patients are being admitted for the evaluation of epilepsy, 2) rates of utilization for surgery across hospitals, and 3) perioperative morbidity between hospitals with low versus high volumes of epilepsy surgery.

Methods

The authors performed a population-based cohort study of US hospitals between 1990 and 2008 using the Nationwide Inpatient Sample (NIS), stratifying epilepsy surgery rates and trends as well as perioperative morbidity rates by hospital surgical volume.

Results

The number of lobectomies for epilepsy performed at high-volume centers (> 15 lobectomies/year) significantly decreased between 1990 and 2008 (F = 20.4, p < 0.001), while significantly more procedures were performed at middle-volume hospitals (5–15 lobectomies/year) over time (F = 16.1, p < 0.001). No time trend was observed for hospitals performing fewer than 5 procedures per year. However, patients admitted to high-volume centers were significantly more likely to receive lobectomy than those at low-volume hospitals (relative risk 1.05, 95% CI 1.03–1.08, p < 0.001). Also, the incidence of perioperative adverse events was significantly higher at low-volume hospitals (12.9%) than at high-volume centers (6.1%) (relative risk 1.08, 95% CI 1.03–1.07, p < 0.001).

Conclusions

Hospital volume is an important predictor of epilepsy surgery utilization and perioperative morbidity. Patients with medically refractory epilepsy should be referred to a comprehensive epilepsy treatment center for surgical evaluation by an experienced clinical team.

Abbreviations used in this paper:AED = antiepileptic drug; NIS = Nationwide Inpatient Sample; RR = relative risk; TLE = temporal lobe epilepsy; VNS = vagus nerve stimulation.

Article Information

Address correspondence to: Edward F. Chang, M.D., Department of Neurological Surgery, University of California, San Francisco, 505 Parnassus Avenue, Box 0112, San Francisco, California 94143-0112. email: ChangED@neurosurg.ucsf.edu.

Please include this information when citing this paper: published online October 26, 2012; DOI: 10.3171/2012.9.JNS12776.

© AANS, except where prohibited by US copyright law.

Headings

Figures

  • View in gallery

    Trends and rates of lobectomy for intractable focal epilepsy by hospital surgical volume, 1990–2008. Upper: Annual number of lobectomies for epilepsy were stratified by hospital caseload, examining high-volume (> 15 lobectomies/year), middle-volume (5–15 lobectomies/year), and low-volume (< 5 lobectomies/year) hospitals. Between 1990 and 2008, the number of lobectomies significantly decreased at high-volume hospitals (F = 20.4, p < 0.001), increased at middle-volume hospitals (F = 16.1, p < 0.001), and did not change at low-volume hospitals (F = 0.95, p = 0.34). Lower: Among all hospitalizations for intractable focal epilepsy (left, y axis), only 4.0% included lobectomy (right, y axis) at low-volume hospitals, while hospitalizations were significantly more likely to include lobectomy at both middle-volume hospitals (6.4%; RR 1.03, 95% CI 1.00–1.05) and at high-volume hospitals (8.9%; RR 1.05, 95% CI 1.03–1.08).

References

  • 1

    Arzimanoglou ABen-Menachem ECramer JGlauser TSeeruthun RHarrison M: The evolution of antiepileptic drug development and regulation. Epileptic Disord 12:3152010

    • Search Google Scholar
    • Export Citation
  • 2

    Choi HHeiman GAMunger Clary HEtienne MResor SRHauser WA: Seizure remission in adults with long-standing intractable epilepsy: an extended follow-up. Epilepsy Res 93:1151192011

    • Search Google Scholar
    • Export Citation
  • 3

    Choi HSell RLLenert LMuennig PGoodman RRGilliam FG: Epilepsy surgery for pharmacoresistant temporal lobe epilepsy: a decision analysis. JAMA 300:249725052008

    • Search Google Scholar
    • Export Citation
  • 4

    Clancy CMFranks P: Utilization of specialty and primary care: the impact of HMO insurance and patient-related factors. J Fam Pract 45:5005081997

    • Search Google Scholar
    • Export Citation
  • 5

    Committee of Quality of Health Care in America Institute of Medicine: Crossing the Quality Chasm: A New Health System for the 21st Century Washington, DCNational Academy Press2001

    • Search Google Scholar
    • Export Citation
  • 6

    Engel J Jr: Surgical treatment for epilepsy: too little, too late?. JAMA 300:254825502008

  • 7

    Engel J JrMcDermott MPWiebe SLangfitt JTStern JMDewar S: Early surgical therapy for drug-resistant temporal lobe epilepsy: a randomized trial. JAMA 307:9229302012

    • Search Google Scholar
    • Export Citation
  • 8

    Engel J JrWiebe SFrench JSperling MWilliamson PSpencer D: Practice parameter: temporal lobe and localized neocortical resections for epilepsy Report of the Quality Standards Subcommittee of the American Academy of Neurology, in association with the American Epilepsy Society and the American Association of Neurological Surgeons. Neurology 60:5385472003. (Erratum in Neurology 60:1396 2003)

    • Search Google Scholar
    • Export Citation
  • 9

    Englot DJBlumenfeld H: Consciousness and epilepsy: why are complex-partial seizures complex?. Prog Brain Res 177:1471702009

  • 10

    Englot DJChang EFAuguste KI: Efficacy of vagus nerve stimulation for epilepsy by patient age, epilepsy duration, and seizure type. Neurosurg Clin N Am 22:4434482011

    • Search Google Scholar
    • Export Citation
  • 11

    Englot DJChang EFAuguste KI: Vagus nerve stimulation for epilepsy: a meta-analysis of efficacy and predictors of response. A review. J Neurosurg 115:124812552011

    • Search Google Scholar
    • Export Citation
  • 12

    Englot DJOuyang DGarcia PABarbaro NMChang EF: Epilepsy surgery trends in the United States, 1990–2008. Neurology 78:120012062012

    • Search Google Scholar
    • Export Citation
  • 13

    Forrest CBNutting PWerner JJStarfield Bvon Schrader SRohde C: Managed health plan effects on the specialty referral process: results from the Ambulatory Sentinel Practice Network referral study. Med Care 41:2422532003

    • Search Google Scholar
    • Export Citation
  • 14

    Freeman WDVatz KA: The future of neurology. Neurol Clin 28:5375612010

  • 15

    Gazzola DMBalcer LJFrench JA: Seizure-free outcome in randomized add-on trials of the new antiepileptic drugs. Epilepsia 48:130313072007

    • Search Google Scholar
    • Export Citation
  • 16

    Gottfried ONRovit RLPopp AJKraus KLSimon ASCouldwell WT: Neurosurgical workforce trends in the United States. J Neurosurg 102:2022082005

    • Search Google Scholar
    • Export Citation
  • 17

    Haneef ZStern JDewar SEngel J Jr: Referral pattern for epilepsy surgery after evidence-based recommendations: a retrospective study. Neurology 75:6997042010

    • Search Google Scholar
    • Export Citation
  • 18

    Helmstaedter CKockelmann E: Cognitive outcomes in patients with chronic temporal lobe epilepsy. Epilepsia 47:Suppl 296982006

  • 19

    Jeha LENajm IBingaman WDinner DWiddess-Walsh PLüders H: Surgical outcome and prognostic factors of frontal lobe epilepsy surgery. Brain 130:5745842007

    • Search Google Scholar
    • Export Citation
  • 20

    Kwan PBrodie MJ: Early identification of refractory epilepsy. N Engl J Med 342:3143192000

  • 21

    Kwan PSperling MR: Refractory seizures: try additional antiepileptic drugs (after two have failed) or go directly to early surgery evaluation?. Epilepsia 50:Suppl 857622009

    • Search Google Scholar
    • Export Citation
  • 22

    Labiner DMBagic AIHerman STFountain NBWalczak TSGumnit RJ: Essential services, personnel, and facilities in specialized epilepsy centers—revised 2010 guidelines. Epilepsia 51:232223332010

    • Search Google Scholar
    • Export Citation
  • 23

    McClelland S IIIGuo HOkuyemi KS: Population-based analysis of morbidity and mortality following surgery for intractable temporal lobe epilepsy in the United States. Arch Neurol 68:7257292011

    • Search Google Scholar
    • Export Citation
  • 24

    McClelland S IIIGuo HOkuyemi KS: Racial disparities in the surgical management of intractable temporal lobe epilepsy in the United States: a population-based analysis. Arch Neurol 67:5775832010

    • Search Google Scholar
    • Export Citation
  • 25

    National Association for Epilepsy Centers: Guidelines for Essential Services Personnel and Facilities in Specialized Epilepsy Centers (http://www.naec-epilepsy.org/spec_care/documents/NAEC-FinalGuidelineswithruralcenterrevision.pdf) [Accessed October 2 2012]

    • Search Google Scholar
    • Export Citation
  • 26

    Prunetti PPerucca E: New and forthcoming anti-epileptic drugs. Curr Opin Neurol 24:1591642011

  • 27

    Skinner ACMayer ML: Effects of insurance status on children's access to specialty care: a systematic review of the literature. BMC Health Serv Res 7:1942007

    • Search Google Scholar
    • Export Citation
  • 28

    Spencer SHuh L: Outcomes of epilepsy surgery in adults and children. Lancet Neurol 7:5255372008

  • 29

    Steiner CElixhauser ASchnaier J: The healthcare cost and utilization project: an overview. Eff Clin Pract 5:1431512002

  • 30

    Thom MMathern GWCross JHBertram EH: Mesial temporal lobe epilepsy: How do we improve surgical outcome?. Ann Neurol 68:4244342010

    • Search Google Scholar
    • Export Citation
  • 31

    Wiebe S: Effectiveness and safety of epilepsy surgery: what is the evidence?. CNS Spectr 9:1201222004

  • 32

    Wiebe S: Still an elusive target: guiding practice for epilepsy surgery. Neurology 75:6786792010

  • 33

    Wiebe SBlume WTGirvin JPEliasziw M: A randomized, controlled trial of surgery for temporal-lobe epilepsy. N Engl J Med 345:3113182001

    • Search Google Scholar
    • Export Citation

Metrics

Metrics

All Time Past Year Past 30 Days
Abstract Views 141 141 10
Full Text Views 164 164 1
PDF Downloads 120 120 2
EPUB Downloads 0 0 0

PubMed

Google Scholar