Journal article
Variability in recommending epilepsy surgery across Level IV epilepsy centers in the United States
Epilepsia (Copenhagen)
08/20/2026
DOI: 10.1002/epi.70440
PMID: 42621761
Abstract
Surgery is an effective, yet underutilized treatment for children with drug-resistant epilepsy. Although predictors of surgical outcomes are well described, the decision to recommend surgery varies by institution. We aim to evaluate the rates of not recommending surgery, identify associated patient characteristics, and quantify variability across centers.
We queried the Pediatric Epilepsy Research Consortium Surgery database, a prospective multicenter cohort of children (0-18 years) undergoing initial evaluation for epilepsy surgery. Patients with documented surgical decisions were included. Demographic, clinical, and presurgical evaluation variables were compared by surgical recommendation status. Logistic regression identified factors associated with not recommending surgery. Mixed-effects models quantified between-center variability.
Among 2480 patients across 29 centers, 532 (21%) were not recommended epilepsy surgery (median center rate 17%, interquartile range [IQR] 10%-28%). After accounting for patient characteristics associated with surgical candidacy, substantial variation in decision-making remained across centers, with a median twofold difference in the odds of not recommending surgery between otherwise similar patients evaluated at different institutions (Median Odds Ratio = 2.25; Intraclass Correlation Coefficient = .18). The clinical characteristics most strongly associated with not recommending surgery included monthly or less frequent seizures (odds ratio [OR] 2.17, 95% confidence interval [CI] 1.75-2.69), non-structural etiology (OR 2.02, 95% CI 1.56-2.61), and taking ≤2 anti-seizure medications (ASMs) (OR 1.67, 95% CI 1.34-2.08, all p's < .01). These characteristics showed minimal clustering across centers (ICCs < .05).
One in five children evaluated for epilepsy surgery are not recommended to pursue surgical treatment. Although clinical factors influence decision-making, they do not explain the substantial variation in recommendations across pediatric epilepsy centers. Similar children evaluated at different institutions had significant differences in the odds of not being recommended surgery, suggesting that institutional decision-making contributes importantly to surgical candidacy.
Details
- Title: Subtitle
- Variability in recommending epilepsy surgery across Level IV epilepsy centers in the United States
- Creators
- Avery R Caraway - Cook Children's Medical CenterNancy A McNamara - Beaumont Hospital, Royal OakAndrew T Knox - University of Wisconsin–MadisonDebopam Samanta - University of Arkansas for Medical SciencesSteven M Wolf - New York Medical CollegeEdward J Novotny - Norcliffe FoundationAdam P Ostendorf - Nationwide Children's HospitalKrista L Eschbach - Children's Hospital ColoradoDewi F Depositario-Cabacar - George Washington University HospitalCemal Karakas - George Washington University HospitalPilar D Pichon - Children's Hospital of Orange CountyKurtis I Auguste - University of California, San FranciscoDanilo R Bernardo - University of California, San FranciscoPradeep K Javarayee - Medical College of WisconsinRani K Singh - Levine Children's HospitalMichael A Ciliberto - University of IowaShilpa B Reddy - Monroe Carell Jr. Children's HospitalKristen H Arredondo - Dell Children's Medical Center of Central TexasAhmad Marashly - Johns Hopkins UniversityFernando N Galan - Nemours Children's Health SystemDallas M Armstrong - The University of Texas Southwestern Medical CenterJanelle L Wagner - Medical University of South CarolinaLily C Wong-Kisiel - Mayo ClinicJeffrey B Bolton - Boston Children's HospitalJenny J Lin - Children's Healthcare of AtlantaZachary M Grinspan - Cornell UniversityTaylor J Abel - University of Pittsburgh Medical CenterJason Coryell - Primary Children's HospitalM Scott Perry - Cook Children's Medical Centerrest of the PERC Surgery Special Interest Group
- Resource Type
- Journal article
- Publication Details
- Epilepsia (Copenhagen)
- DOI
- 10.1002/epi.70440
- PMID
- 42621761
- NLM abbreviation
- Epilepsia
- ISSN
- 1528-1167
- eISSN
- 1528-1167
- Publisher
- Wiley; HOBOKEN
- Grant note
- Cook Children's Medical Center
The authors acknowledge the Pediatric Epilepsy Research Consortium (PERC) members who provided patient information to the database and helped contribute to this paper. The authors also acknowledge the Cook Children's Medical Center for funding and housing the PERC Surgery Database.
- Language
- English
- Electronic publication date
- 08/20/2026
- Academic Unit
- Neurology; Stead Family Department of Pediatrics; Neurology (Pediatrics)
- Record Identifier
- 9985219318302771
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