Disparities in time to surgery and use of surgery for temporal lobe epilepsy

INTRODUCTION: This study aimed to determine whether patients who self-identify as Asian/Pacific Islander, Hispanic or African American race or who do not speak English experience longer delays in time to surgery and whether they are at risk of underutilizing recommended surgical treatment for intractable mesial temporal lobe epilepsy (MTLE). METHODS: We conducted a retrospective cohort study of 213 patients with health insurance diagnosed with intractable MTLE and recommended for surgery during admission to the Epilepsy Monitoring Unit of a tertiary referral center between January 1, 1993, and December 31, 2010. Follow-up was completed through December 31, 2012. A multivariate Generalized Linear Model (GLM) for risk of not having surgery, Kaplan-Meier survival curves graphing time from diagnosis to surgery, and log rank tests were completed using STATA 12.1. RESULTS: A total of 156 patients (73.2%) underwent surgical treatment of MTLE. After diagnosis, patients who did not speak English experienced significantly longer delays in time to surgery, with the longest delays experienced by those who spoke an Asian dialect (P-value 0.0085). Patients of African American followed by Asian/PI race experienced longer delays in time to surgery than Hispanics or Non-Hispanic whites (P-value 0.0045). After controlling for covariates including language in a GLM, Asian/PI and African Americans were likewise at greater risk of not obtaining epilepsy surgery compared to non-Hispanic whites (RR 2.77, P-value 0.002; RR 3.11, P-value <0.0005 respectively). Speaking a non-English language was also uniquely associated with a greater likelihood of not having surgery (RR 1.77, P-value 0.042), as was presence of non-concordant seizures on electroencephalogram (OR 1.912, P-value 0.002). Hispanic patients were as likely to pursue surgery as non-Hispanic whites (RR 0.934, P-value 0.835). Other demographic and clinical factors, such as median household income, sex, laterality of Mesial Temporal Sclerosis, and year of admission did not contribute significantly to the GLM model (P-value >0.20). DISCUSSION & CONCLUSIONS: Both race and language uniquely contribute to disparities in the surgical management of intractable TLE. Asian/PI and African American patients as well as those who do not speak English experience longer delays in time to surgery and are at greater risk of not obtaining surgical treatment. Culturally sensitive patient-physician communication and patient education materials might increase use of evidence-based surgery among minority groups. Next steps include statistical analysis using a Cox proportional hazards model, and incorporation of qualitative focus group data to better elucidate the reasons such disparities exist.