ReviewUnderutilization of epilepsy surgery: Part II: Strategies to overcome barriers
Introduction
Despite high-quality evidence including randomized controlled trials (RCT), substantial supporting scientific literature, and well-established guidelines from professional societies, epilepsy surgery remains one of the most underutilized evidence-based treatments in modern medicine [1], [2], [3], [4], [5]. In part I of the series, we provided a comprehensive review of barriers to epilepsy surgery. Interventions to improve utilization of epilepsy surgery may address challenges that prevent access to surgical evaluation and prevent patients from completing necessary workup, ultimate completion of the surgery and post-surgical care. In this paper, we explore potential interventional strategies using education, technology, policy-change, and other approaches to empower patients and caregivers with adequate information. Further, we highlight interventions to address gaps in physician knowledge and practice, improve access to comprehensive epilepsy centers, streamline presurgical work-ups, mitigate systemic inequities, and increase research funding with the ultimate goal to reduce the treatment gap surrounding epilepsy surgery (Fig. 1).
Section snippets
Educational strategies
Patients’ fears and misperceptions regarding epilepsy surgery are one of the strongest barriers to pursuing epilepsy surgery (please review Part I: Table 1), and >75% of people with epilepsy (PWE) desire more information about epilepsy surgery [13], [6], [7], [8], [9], [10], [11], [12]. Patient-facing educational strategies (verbal teaching with traditional lectures, audio or videotapes, seminars, module-specific teaching, demonstrations, role playing, etc.) are systematically studied for many
Online tool for referral facilitation
One barrier to epilepsy surgery is recognition of ideal candidates, particularly in primary and secondary care centers. Online decision-support tools may help physicians without specialized epilepsy training to identify individual patients for referral to a comprehensive epilepsy center. Roberts et al. reported use of an online tool, Canadian Appropriateness of Epilepsy Surgery (CASES) tool, to facilitate appropriate referral for epilepsy surgery [45]. This evidence-based, clinical decision tool
Interventions for comprehensive epilepsy programs
After presurgical evaluation, strategies to prevent patient attrition prior to surgery are important. Use of an algorithmic and streamlined approach to preoperative workup and access to necessary diagnostic tools and expertise locally or within a network of other epilepsy centers may increase the likelihood of completed evaluations. For certain patient populations, the decision to offer epilepsy surgery may rely heavily on the experience of the referral center. Thus, recognizing neglected
Development of surgical epilepsy center
Access to epilepsy surgery is limited in resource poor settings where surgical options are available only in select government hospitals with long waiting periods or private corporate hospitals in large urban areas with exorbitant costs that most citizens cannot afford. Moreover, most centers in resource-limited settings lack adequate expertise and advanced diagnostic tools for the facility to perform intracranial monitoring. However, epilepsy surgery centers can be established even in
Policies and programs
Public policies can support epilepsy research, increase access to epilepsy surgery, and mitigate systemic inequities in the access of surgery. Community advocacy groups, lay patient and professional organizations can advocate and promote policies at the state and federal levels to facilitate epilepsy surgery evaluation [108].
Conclusion
In this review, we comprehensively discuss various interventional strategies that may help address challenges encountered during presurgical evaluation to the completion of epilepsy surgery. Solving the underutilization of epilepsy surgery involves educational interventions for patients/families, community, and referring providers, use of technological advancements, and creation of a standardized system in the comprehensive epilepsy center. Moreover, other potential solutions will involve
Declaration of Competing Interest
The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.
Acknowledgement
The authors wish to acknowledge the member institutions of the PERC Epilepsy Surgery group for their continued support to increase the utilization and understanding of pediatric epilepsy surgery.
Disclosures
DS receives research support from TRI, UAMS through the CTSA of the NIH (UL1 TR003107). RA receives research support from NIH NINDS R01 NS115929 and Procter Foundation (Procter Scholar Award 2018–2021).The other authors declare no potential conflicts of interest with respect to the research, authorship, and publication of this article.
Funding
Debopam Samanta is supported by the Translational Research Institute (TRI), grant UL1 TR003107 through the National Center for Advancing Translational Sciences of the National Institutes of Health (NIH). The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH.
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