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.
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.
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).
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.
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.
EngelJJrWiebeSFrenchJSperlingMWilliamsonPSpencerD: 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. Neurology60:538–5472003. (Erratum in Neurology 60:1396 2003)
EngelJJr, WiebeS, FrenchJ, SperlingM, WilliamsonP, SpencerD, : 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. 60:538–547, 2003. (Erratum in Neurology 60:1396, 2003))| false
ForrestCBNuttingPWernerJJStarfieldBvon SchraderSRohdeC: Managed health plan effects on the specialty referral process: results from the Ambulatory Sentinel Practice Network referral study. Med Care41:242–2532003
ForrestCB, NuttingP, WernerJJ, StarfieldB, von SchraderS, RohdeC: Managed health plan effects on the specialty referral process: results from the Ambulatory Sentinel Practice Network referral study. 41:242–253, 2003)| false
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]
National Association for Epilepsy Centers: (http://www.naec-epilepsy.org/spec_care/documents/NAEC-FinalGuidelineswithruralcenterrevision.pdf) [Accessed October 2, 2012])| false