Payer type and prediction of the time from epilepsy onset to neurosurgical intervention and from first diagnostic MRI to neurosurgical consultation in lesional drug-resistant epilepsy at a California level IV epilepsy center.

Abstract

Objective: The aim of this study was to identify socioeconomic factors that underlie disparity by insurance type on time to surgery from epilepsy onset and from first diagnostic imaging identifying a structural lesion in children with drug-resistant epilepsy (DRE).

Methods: Retrospective data were abstracted from children (< 18 years) who underwent epilepsy surgery at the University of California, San Francisco (UCSF), between 2012 and 2022 with a diagnosis of DRE and structural abnormality on MRI. Univariable and multivariable Cox proportional hazard regression were used to assess associations between socioeconomic barriers (English-language speaking, ethnicity, race, single-parent household, number of parents working, number of siblings, receipt of Supplemental Security Income [SSI], distance from hospital, and practice setting of referral center) and time from epilepsy onset to surgery. Secondary outcomes included durations during the surgical workup: timing to first diagnostic MRI, neurosurgery clinic visit, and surgery.

Results: Fifty-two patients with public insurance and 48 patients with private insurance underwent resective surgery for DRE. Preoperative clinical variables and Engel class outcome did not differ between groups. The majority of socioeconomic variables differed between the groups. Time to surgery from epilepsy onset was longer in the public insurance group (mean 62.4 [SE 7.0] vs 44.3 [SE 6.0] months, HR 0.65, 95% CI 0.43-0.97) as was time from first diagnostic MRI to first neurosurgery clinic visit (21.7 [SE 3.9] vs 11.5 [SE 3.5] months, HR 0.60, 95% CI 0.40-0.90). Time from epilepsy onset to first diagnostic MRI and neurosurgery clinic visit to surgery did not differ across groups. On multivariable analysis, a greater number of antiseizure medications (ASMs) trialed was an independent predictor of longer time to surgery (HR 0.84, 95% CI 0.77-0.92) and first diagnostic MRI (HR 0.90, 95% CI 0.83-0.99) from epilepsy onset. A single-parent household (HR 0.60, 95% CI 0.38-0.95) and receiving SSI (HR 0.57, 95% CI 0.33-0.97) were associated with longer time to surgery from MRI diagnosis. A single-parent household was associated with a longer time to the neurosurgery visit from the first diagnostic MRI study (HR 0.52, 95% CI 0.33-0.83).

Conclusions: Children with DRE and MRI findings of a structural abnormality with public insurance received surgery later from the time of epilepsy onset compared with those with private insurance at UCSF. During the course between epilepsy onset and surgery, the time from first diagnostic MRI to the first neurosurgery visit accounted for delay between groups. While socioeconomic variables differed between patients with private and public insurance, insurance type was the most consistent variable associated with disparity in the time interval to surgery.