Abstracts

Rationale: Limited access to specialized epilepsy centers may lead to delays in referral for surgical workup for patients with intractable epilepsy. One potential method to address this disparity is formalized collaboration agreements between geographically connected epilepsy centers. This study aims to characterize the recently-initiated collaboration between the level III Mission Health Epilepsy Center (Mission) and the level IV Wake Forest Comprehensive Epilepsy Center (Wake) by assessing for changes in referral volume post-collaboration, and to explore patient-level factors associated with completion of surgical workup.  Methods: Epilepsy surgery referrals to Wake from all sources from 1/2012 - 5/2019 were retrospectively identified via EMR data extraction and intradepartmental records. The proportion of Mission to Wake referrals in the pre-collaboration period (1/2012 - 9/2015) was compared to the post collaboration period (10/2015 - 5/2019) using a two-proportion z test. Post-collaboration Mission-origin referrals were assessed for patient-level factors associated with completion of surgical conference presentation and completed epilepsy surgery. The variables studied were: Age, gender, insurance status, race, marital status, employment status, driving status, distance from Wake, income level, duration of epilepsy, seizure frequency, total AEDs, prior epilepsy surgery, psychiatric diagnoses, and presence of psychogenic/non-epileptic spells. The effects of these variables on referral process completion were analyzed using chi-square and two-sample t-tests.  Results: There was a significant increase in the proportion of Mission origin patients presented in surgical conference in the post-collaboration period (3.4% (3 of 88) versus 11.5% (13 of 113), p = .022). Of the 21 total post-collaboration Mission-origin referrals, 13 were presented in surgical conference, 4 have completed surgery, and 3 are in the process of active surgical workup. In our analysis of variables associated with referral completion, Mission-origin referrals with private insurance were more likely to be presented in surgical conference when compared to any other insurance status (88% versus 42%, χ2 = 4.20, p = .044), and patients who were employed or on temporary leave were more likely to be presented when compared to those unemployed or on permanent disability (90% versus 45%, χ2 = 4.68, p = .031). Successful completion of surgery was associated with positive driving status (67% versus 13%, χ2 = 4.11, p = .042) and shorter travel distance (mean distance 123.5 mi. versus 157.1 mi, p = .0028). Interestingly, none of the clinical epilepsy variables analyzed were significantly associated with completion of the referral process.  Conclusions: Completion of surgical workup remains a challenge for modern providers in caring for patients with intractable epilepsy. Formalized collaboration agreements may result in increased surgical referral volumes between geographically connected level III/IV epilepsy centers, and codify the importance of Level III epilepsy centers for initiating noninvasive workup and identifying surgical candidates. Our results demonstrate that access related and socioeconomoic factors such as insurance status and travel burden may be drivers of referral completion in this population, notwithstanding clinical factors. Providers at epilepsy centers should consider these findings when developing formal collaboration agreements to address epilepsy surgery gaps in their patient populations.  Funding: Funding source: NIH: NCATS UL1 TR001420