Hill Chloé E, Hochster Daniel, Baker Jessica E, Herman Alison L, Shaheid Nishad, O'Kula Susanna S, Parent Jack M, Zahuranec Darin B, Skolarus Lesli E
Department of Neurology, University of Michigan, Ann Arbor, Michigan, USA.
University of Michigan Medical School, Ann Arbor, Michigan, USA.
Epilepsia Open. 2025 Jun;10(3):855-865. doi: 10.1002/epi4.70045. Epub 2025 Apr 19.
Epilepsy surgery offers a potential cure for drug-resistant epilepsy (DRE), yet surgery is underutilized. An estimated 5% of patients with DRE undergo long-term EEG monitoring (LTM) annually, the requisite first step of evaluation for surgical candidacy. Much of the variation in LTM referral may be attributable to individual neurologist practice rather than patient characteristics. We explored neurologist behaviors and practices in epilepsy surgery referral to guide future interventions to expand patient access to surgery.
This qualitative interview study recruited neurologists who treated adults with epilepsy. Interviews were grounded in the Theoretical Domains Framework (TDF) of behavior change to identify facilitators and barriers to neurologist referral for epilepsy surgery evaluation. Transcripts of semi-structured interviews were analyzed with deductive coding guided by the TDF domains as well as emergent coding of subcodes/themes.
Of 40 invited neurologists, 13 (33%) participated. Median time since medical school graduation was 14 years (range 5-45); four had no subspecialty training, and nine completed epilepsy/neurophysiology fellowships; nine practiced in community settings. Referral rates for presurgical evaluation ranged from less than 1 annually to 1 monthly. The most important TDF domains identified as facilitators of neurologist referral were knowledge, skills, optimism, and beliefs about capabilities. Domains identified as barriers of neurologist referral included reinforcement and environmental context and resources, both at the intersection of referring provider and epilepsy center and with regard to perceived patient burden. Social influences and social/professional role and identity operated as facilitators or barriers.
Looking toward future interventions to improve rates of presurgical evaluation, attention should be focused on the most pertinent and most modifiable domains. Neurologists' skills and their perception of their capabilities operate as facilitators; thus, disseminating effective communication approaches to patient discussions may support increased neurologist referral. To address environmental context & resource barriers specifically, inter-institutional communication, presurgical evaluation pathway coordination, and resources/support for patients could be targeted to improve neurologist referral.
Epilepsy surgery, while effective, is underutilized. There is variability in how individual neurologists refer patients with drug-resistant epilepsy for epilepsy surgery. This interview study identified methods to facilitate referral for epilepsy surgery evaluation, such as improving patient/provider discussions about surgery. Several approaches could also alleviate barriers to presurgical evaluation, such as better inter-institutional communication, expanded care coordination, and greater resources for patients.
癫痫手术为耐药性癫痫（DRE）提供了潜在的治愈方法，但手术的利用率较低。据估计，每年有5%的DRE患者接受长期脑电图监测（LTM），这是评估手术候选资格的必要第一步。LTM转诊的很大一部分差异可能归因于个体神经科医生的做法，而非患者特征。我们探讨了神经科医生在癫痫手术转诊方面的行为和做法，以指导未来扩大患者手术机会的干预措施。
这项定性访谈研究招募了治疗成人癫痫患者的神经科医生。访谈基于行为改变的理论领域框架（TDF），以确定神经科医生转诊进行癫痫手术评估的促进因素和障碍。对半结构化访谈的记录进行分析，采用由TDF领域指导的演绎编码以及子代码/主题的新出现编码。
在40名受邀的神经科医生中，13名（33%）参与了研究。自医学院毕业以来的中位时间为14年（范围5 - 45年）；4名没有亚专业培训，9名完成了癫痫/神经生理学 fellowship；9名在社区环境中执业。术前评估的转诊率从每年不到1例到每月1例不等。被确定为神经科医生转诊促进因素的最重要TDF领域包括知识、技能、乐观态度以及对自身能力的信念。被确定为神经科医生转诊障碍的领域包括强化因素以及环境背景和资源，这在转诊医生与癫痫中心的交叉点以及对患者负担的感知方面均有体现。社会影响以及社会/职业角色和身份既起到促进作用，也构成障碍。
展望未来提高术前评估率的干预措施，应将注意力集中在最相关且最可改变的领域。神经科医生的技能及其对自身能力的认知起到促进作用；因此，传播有效的患者讨论沟通方法可能有助于增加神经科医生的转诊。为了具体解决环境背景和资源障碍，可以针对机构间沟通、术前评估途径协调以及为患者提供资源/支持，以改善神经科医生的转诊情况。
癫痫手术虽然有效，但利用率较低。个体神经科医生在将耐药性癫痫患者转诊进行癫痫手术方面存在差异。这项访谈研究确定了促进癫痫手术评估转诊的方法，例如改善患者/医生关于手术的讨论。几种方法还可以减轻术前评估的障碍，例如更好的机构间沟通、扩大护理协调以及为患者提供更多资源。
