Variability in recommending epilepsy surgery across Level IV epilepsy centers in the United States
Year: 2026
Type: article
Study design: Observational Study
Abstract: OBJECTIVE: Surgery is an effective, yet underutilized treatment for children with drug-resistant epilepsy. Although predictors of surgical outcomes are well described, the decision to recommend surgery varies by institution. We aim to evaluate the rates of not recommending surgery, identify associated patient characteristics, and quantify variability across centers. METHODS: We queried the Pediatric Epilepsy Research Consortium Surgery database, a prospective multicenter cohort of children (0-18 years) undergoing initial evaluation for epilepsy surgery. Patients with documented surgical decisions were included. Demographic, clinical, and presurgical evaluation variables were compared by surgical recommendation status. Logistic regression identified factors associated with not recommending surgery. Mixed-effects models quantified between-center variability. RESULTS: Among 2480 patients across 29 centers, 532 (21%) were not recommended epilepsy surgery (median center rate 17%, interquartile range [IQR] 10%-28%). After accounting for patient characteristics associated with surgical candidacy, substantial variation in decision-making remained across centers, with a median twofold difference in the odds of not recommending surgery between otherwise similar patients evaluated at different institutions (Median Odds Ratio = 2.25; Intraclass Correlation Coefficient = .18). The clinical characteristics most strongly associated with not recommending surgery included monthly or less frequent seizures (odds ratio [OR] 2.17, 95% confidence interval [CI] 1.75-2.69), non-structural etiology (OR 2.02, 95% CI 1.56-2.61), and taking ≤2 anti-seizure medications (ASMs) (OR 1.67, 95% CI 1.34-2.08, all p's < .01). These characteristics showed minimal clustering across centers (ICCs < .05). SIGNIFICANCE: One in five children evaluated for epilepsy surgery are not recommended to pursue surgical treatment. Although clinical factors influence decision-making, they do not explain the substantial variation in recommendations across pediatric epilepsy centers. Similar children evaluated at different institutions had significant differences in the odds of not being recommended surgery, suggesting that institutional decision-making contributes importantly to surgical candidacy.
Source: Epilepsia
DOI: 10.1002/epi.70440
Authors: Avery R. Caraway, Nancy A. McNamara, Andrew T. Knox, Debopam Samanta, Steven M. Wolf, Edward J. Novotny, Adam P. Ostendorf, Krista L. Eschbach, Dewi F. Depositario‐Cabacar, Cemal Karakas, Pilar D. Pichon, Kurtis I. Auguste, Danilo R. Bernardo, Pradeep K. Javarayee, Rani K. Singh, Michael A. Ciliberto, Shilpa B. Reddy, Kristen H. Arredondo, Ahmad Marashly, Fernando N. Galan, Dallas M. Armstrong, Janelle L. Wagner, Lily C. Wong‐Kisiel, Jeffrey B. Bolton, Jenny J. Lin, Zachary M. Grinspan, Taylor J. Abel, Jason Coryell, M. Scott Perry, the rest of the PERC Surgery Special Interest Group
Institutions: Cook Children's Medical Center, Beaumont Hospital, Royal Oak, Corewell Health William Beaumont University Hospital, University of Wisconsin–Madison, University of Wisconsin Health, University of Arkansas for Medical Sciences, New York Medical College, Seattle Children's Hospital, Norcliffe Foundation, Nationwide Children's Hospital, Children's Hospital Colorado, Children's National, George Washington University, Children's Hospital of Orange County, University of California, San Francisco, Medical College of Wisconsin, Levine Children's Hospital, University of Iowa, Monroe Carell Jr. Children's Hospital, Dell Children's Medical Center of Central Texas, UT Health Austin, Johns Hopkins University, Nemours Children's Health System, The University of Texas Southwestern Medical Center, Medical University of South Carolina, Mayo Clinic, Boston Children's Hospital, Children's Healthcare of Atlanta, Weill Cornell Medicine, University of Pittsburgh Medical Center, Intermountain Healthcare, Primary Children's Hospital
Language: English
Subfield: Psychiatry and Mental health
Field: Medicine
Domain: Health Sciences
Open Access status: bronze
OpenAlex ID: W7203833855