Patient and Pre-Surgical Testing Characteristics Contributing to Duration of Evaluation: Identifying Best Practices and Opportunities to Streamline Pediatric Epilepsy Surgery Evaluation

Document Type

Conference Proceeding

Publication Date

12-7-2024

Abstract

Rationale: Longer duration of epilepsy prior to surgery is a predictor of poor outcome. While referral delays of surgical candidates are well documented, factors causing delay during the pre-surgical evaluation are unclear and may vary depending on institutional characteristics. By benchmarking duration of pre-surgical workup at multiple centers and identifying patient and evaluation characteristics contributing to duration, we can ascertain best practices and address modifiable contributors to reduce delays.

Methods: We queried the Pediatric Epilepsy Research Consortium Surgery Database, a prospective, observational multicenter study enrolling children 0-18 years at 27 US pediatric epilepsy centers, for all patients undergoing initial pre-surgical evaluation for drug resistant epilepsy (DRE). We included patients with completed evaluations and data on duration from initiation of pre-surgical evaluation to final surgical decision. We compared patient characteristics and evaluation components between those with long duration evaluations ( >75% quartile) and those with short (< 25% quartile). Akaike Information Criteria (AIC) selection identified variables associated with longer duration. From these, we developed a logistic prediction model for evaluation duration, using a random 80/20 training/testing split of the entire cohort. The model was tested among institutions with ≥10 patients in the cohort to assess accuracy predicting long durations. Linear models for each site assessed each variable’s impact on duration. Variables with < 10% of the patient population at each site were excluded. Beta values were compared to identify intra- and inter-institution variability and to delineate institutions with shortest added duration for each variable.

Results: Of 2318 patients undergoing surgical evaluation, 1682 (73%) from 23 sites had complete data. Median evaluation duration was 8 weeks (IQR 3-22), 458 (27%) with short duration evaluations and 425 (25%) long duration. Multiple patient and evaluation characteristics were associated with duration (Table 1). 9/13 variables associated with duration met inclusion criteria using AIC methods across all sites when contributing all variables to the logistic model. Three sites with < 10 patients were excluded from the model. For 15 sites (75%), the model predicted long durations with >75% accuracy. Table 2 provides average duration each variable contributes to evaluation by site. Those highlighted in green indicate shortest durations compared to other groups.

Conclusions: Duration of pre-surgical evaluation for DRE can be accurately modeled using multiple patient characteristics and testing strategies commonly employed in epilepsy surgery evaluations. This predictive model can not only estimate evaluation duration, but also identify opportunities to improve systemic efficiency. Institution level modeling identifies specific program strengths providing opportunity to learn from successful processes. Subsequent research will focus on institutional process mapping to better understand systemic practices leading to improved efficiencies, then sharing these processes across the consortium to shorten evaluation durations.

Comments

American Epilepsy Society Annual Meeting, December 6-10, 2024, Los Angeles, CA

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