UCSF Epilepsy Center, University of California, San Francisco, CA, USA.
Neurology. 2012 Apr 17;78(16):1200-6. doi: 10.1212/WNL.0b013e318250d7ea. Epub 2012 Mar 21.
To examine national time trends of resective surgery for the treatment of medically refractory epilepsy before and after Class I evidence demonstrating its efficacy and subsequent practice guidelines recommending early surgical evaluation.
We performed a population-based cohort study with time trends of patients admitted to US hospitals for medically refractory focal epilepsy between 1990 and 2008 who did or did not undergo lobectomy, as reported in the Nationwide Inpatient Sample.
Weighted data revealed 112,026 hospitalizations for medically refractory focal epilepsy and 6,653 resective surgeries (lobectomies and partial lobectomies) from 1990 to 2008. A trend of increasing hospitalizations over time was not accompanied by an increase in surgeries, producing an overall trend of decreasing surgery rates (F = 13.6, p < 0.01). Factors associated with this trend included a decrease in epilepsy hospitalizations at the highest-volume epilepsy centers, and increased hospitalizations to lower-volume hospitals that were found to be less likely to perform surgery. White patients were more likely to have surgery than racial minorities (relative risk [RR], 1.13; 95% confidence interval [CI], 1.10-1.17), and privately insured individuals were more likely to receive lobectomy than those with Medicaid or Medicare (RR, 1.28; 95% CI, 1.25-1.30).
Despite Class I evidence and subsequent practice guidelines, the utilization of lobectomy has not increased from 1990 to 2008. Surgery continues to be heavily underutilized as a treatment for epilepsy, with significant disparities by race and insurance coverage. Patients who are medically refractory after failing 2 antiepileptic medications should be referred to a comprehensive epilepsy center for surgical evaluation.
在 I 级证据证明其疗效以及随后的实践指南推荐早期手术评估之后，研究治疗药物难治性癫痫的切除术在全国的时间趋势。
我们进行了一项基于人群的队列研究，时间趋势为 1990 年至 2008 年期间在美国医院因药物难治性局灶性癫痫住院的患者，根据全国住院患者样本报告，这些患者接受或未接受 lobectomy。
加权数据显示，1990 年至 2008 年，有 112026 例因药物难治性局灶性癫痫住院，6653 例接受了切除术（lobectomies 和部分 lobectomies）。随着时间的推移，住院人数呈上升趋势，但手术人数并未增加，导致手术率总体呈下降趋势（F = 13.6，p < 0.01）。与这一趋势相关的因素包括最高容量癫痫中心的癫痫住院人数减少，以及住院人数增加到手术可能性较低的低容量医院。白人患者比少数民族患者更有可能接受手术（相对风险 [RR]，1.13；95%置信区间 [CI]，1.10-1.17），私人保险患者比 Medicaid 或 Medicare 患者更有可能接受 lobectomy（RR，1.28；95% CI，1.25-1.30）。
尽管有 I 级证据和随后的实践指南，但从 1990 年到 2008 年，lobectomy 的利用率并没有增加。手术作为治疗癫痫的方法仍然严重未得到充分利用，存在显著的种族和保险覆盖差异。在服用 2 种抗癫痫药物后仍无效的患者应转诊至综合癫痫中心进行手术评估。
