Abstracts

Rationale: Despite established safety and efficacy of epilepsy surgery, a significant proportion of eligible patients with drug-resistant epilepsy decline to proceed with surgery. Studies to evaluate barriers to epilepsy surgery have focused on patient’s reluctance to undergo pre-surgical evaluation. In a broader approach, this study aimed to evaluate the association of various demographic, disease specific and epilepsy evaluation variables; with patients’ decision to decline surgery after they are deemed eligible for surgery. Methods: This retrospective case-control study included patients discussed at the epilepsy surgery conference between January 1, 2009, and June 30, 2017, at a tertiary care hospital serving an urban Bronx community. We identified patients who were determined to be candidates for respective epilepsy surgery. Chi-square test for nominal variables and ANOVA for scale variables were utilized to evaluate their association with a patient’s decision to decline epilepsy surgery. Multivariate Binary Logistic Regression was used to identify variables that may predict a patient’s decision to decline surgery. Results: Among the 159 patients discussed over the 8.5 year study period, 87 patients were ultimately eligible for resective epilepsy surgery after a thorough evaluation. 34 (40%) of these patients declined to undergo surgery. Only 20% of eligible patients were employed while 70% of patients had a high-school diploma or higher education. Following the univariate analysis, variables independently associated with a patient’s decision to decline surgery were: employment [Odds Ratio (OR) 4.2 p 0.03], temporal lesion on MRI (OR 0.35 p 0.02), temporal EEG localization (OR 0.21, p 0.003) and temporal seizure onset zone (OR 0.19, p 0.001) (Figure 1). Following the multivariate Logistic Regression analysis, adjusting for other variables, factors associated with a patient’s decision to decline surgery were current employment (OR 7.5, p 0.04), the number of current anti-seizure drugs (AEDs) (OR 3.5, p 0.03) and concordance between seizure semiology, seizure onset on EEG and imaging.(OR 0.08, p 0.02) (Table 1).  Conclusions: The novel finding in this study is the association between employment status and the decision to decline epilepsy surgery: employed patients were 4.2 more likely to decline surgery than unemployed patients on univariate analysis and the association remained significant in the multivariate analysis. Future work should confirm this finding prospectively, determine if it holds in other patient populations and explore the decision to proceed with or decline epilepsy surgery from a patient-centered perspective. Identifying the role of factors such as the fear of losing employment due to complications from surgery and inability to take medical leave for an extended period of time play in the patient’s decision to proceed with epilepsy surgery may identify needs and suggest strategies to reduce barriers to this underutilized treatment. Funding: No funding