Received: 28 April 2020 
|
  Revised: 3 August 2020 
DOI: 10.1111/epi.16664
FULL LENGTH ORIGINAL RESEARCH
Trends in lobectomy/amygdalohippocampectomy over time
and the impact of hospital surgical volume on hospitalization
outcomes: A population-based study
Churl-Su Kwon1,2,3   | Leah Blank2,3
1
Department of Neurosurgery, Icahn School
of Medicine at Mount Sinai, New York,
NY, USA
2
Department of Neurology, Icahn School of
Medicine at Mount Sinai, New York, NY,
USA
3 differences in outcomes between (1) high-volume (HV), middle-volume (MV), and
Division of Health Outcomes &
Knowledge Translation Research, Icahn
School of Medicine at Mount Sinai, New
York, NY, USA
Correspondence
Churl-Su Kwon, Icahn School of Medicine
at Mount Sinai, One Gustave L. Levy Place,
New York, NY 10029.
Email: churlsu.kwon@mssm.edu
© 2020 International League Against Epilepsy
Epilepsia. 2020;00:1–10.  |
|
  Accepted: 3 August 2020
  | Lan Mu2,3  | Nathalie Jetté2,3
Abstract
Objective: Despite national guidelines supporting surgical referral in drug-resistant
epilepsy, it is hypothesized that surgery is underutilized. We investigated the vol-
umes of lobectomy/amygdalohippocampectomy surgeries over time and examined
low-volume (LV) hospitals and (2) Level 4 Centers versus non–Level 4 Centers.
Methods: The 2003-2014 National Inpatient Sample (the largest all-payer hospi-
talization database, representative of the US population) was utilized. Epilepsy was
identified using a previously validated International Classification of Diseases,
Ninth Revision, Clinical Modification (ICD-9-CM) case definition and surgeries
using ICD-9-CM procedure codes. A hospital was considered a Level 4 Center if
it performed intracranial electroencephalographic (EEG) monitoring. Tumor sur-
geries were excluded. Linear regression was used to perform trend tests. Weighted
multivariate logistic regression was used to summarize association of surgery with
outcomes.
Results: A total of 4,487 lobectomy/amygdalohippocampectomy surgeries were per-
formed in children and adults with epilepsy. Lobectomy/amygdalohippocampectomy
surgeries significantly decreased over time (slope: −0.24, P  <  .001). This declin-
ing surgical trend was greater for all resective/disconnective surgery (slope: −0.45,
P < .001), and greatest when compared to all types of epilepsy surgery, for example,
resection/disconnection/radiosurgery/laser interstitial thermal therapy/vagus nerve
stimulation/deep brain stimulation/responsive neurostimulation/intracranial EEG
(slope: −0.95, P < .001). LV compared to HV hospitals had higher odds of transfer
to other facilities (13.60% vs 4.24%, odds ratio [OR] = 2.76, 95% confidence interval
[CI] = 1.11-6.82). LV hospitals had higher odds of surgical complications versus
MV (12.69% vs 6.80%, OR = 2.20, 95% CI = 1.01-5.09). HV hospitals incurred the
least total charges. There were no differences in discharge status, adverse events,
length of stay, or cost between Level 4 Centers versus non–Level 4 Centers.
Significance: Lobectomies/amygdalohippocampectomies are decreasing over
time, suggesting ongoing underutilization. LV centers are associated with greater
wileyonlinelibrary.com/journal/epi     1
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2      KWON et al.

complication and transfer rates. Future studies are required to understand the reason
for worse outcomes in LV centers and to determine whether a minimum number of
surgeries must be performed to meet necessary standards.

KEYWORDS
epilepsy surgery, hospital volume, Level 4 Center, lobectomy trends

1  |   IN TRO D U C T ION
Drug-resistant epilepsy patients often fail to receive a pre-
surgical evaluation, although level 1 evidence suggests that
individuals who fail two antiseizure medications are not
likely to respond to further medication trials.1,2 Since the piv-
otal randomized-controlled trial (RCT) for epilepsy surgery
showing its effectiveness in appropriately selected candidates
with drug-resistant epilepsy, temporal lobectomy has been a
well-established, safe, and effective mode of treatment.3,4
Seizure freedom can be achieved for a significant proportion
of these patients, with the number needed to treat with sur-
gery for an additional patient to become seizure-free being
two. This RCT showed seizure freedom in 73% of those who
underwent surgery at 2 years of follow-up versus 0% in those
treated with medicine alone.3 Ten-year follow-up studies also
report good results, with seizure freedom in 50%-60% of pa-
tients undergoing temporal lobectomy and 30%-40% of those
undergoing frontal lobe resections.5–7 Despite national guide-
lines supporting surgical referral in drug-resistant epilepsy, it
is thought that surgery is underutilized.8
In this study, we sought to examine the trends of epilepsy
surgery utilization since the publication of national guide-
lines and investigate whether there were any differences in
outcomes between high, middle, and low surgical volume
hospitals as well as Level 4 Centers versus non–Level 4
Centers. We hypothesize that epilepsy surgery remains un-
derutilized, with the proportion of those drug-resistant not
changing and with increasing numbers of active epilepsy pa-
tients over time.
2  | METHODS
2.1  |  Study design and data source
The National Inpatient Sample (NIS) database for the years
2003-2014 was used to perform a retrospective population-
based observational study. The NIS is a component of the
Healthcare Cost and Utilization Project (HCUP), supported
by the Agency for Healthcare Research and Quality. Sampled
from the State Inpatient Database (SID), the NIS comprises
patient- and hospital-level factors from ~8 million yearly hos-
pital admissions. The NIS includes around a 20% stratified
Key Points
• Lobectomies/amygdalohippocampectomies
are decreasing over time, suggesting ongoing
underutilization
• Low-volume centers are associated with greater
complication and transfer rates
• No differences are seen in outcomes between
Level 4 Centers and non–Level 4 Centers for
lobectomies/amygdalohippocampectomies
• A minimum number of surgeries performed to
meet necessary standards may be considered
sample of discharges from community hospitals (all nonfed-
eral, short-term general and special hospitals, special chil-
dren's hospitals), whose facilities and services are available
to the public. Discharges from rehabilitation and long-term
acute care hospitals are not included in this sample. From
1988 to 2011, the NIS database was created by including
100% of all discharges from 20% of US hospitals every year
and was restructured in 2012 as a 20% national patient-level
sample; thus, for our hospital volume comparison analysis,
we used only up to 2011 data.9
To create the NIS database, samples of discharges are ex-
tracted from the SID hospitals that are stratified based on the
following hospital characteristics: census division, hospital
teaching status, bed size, location, and ownership. The NIS
covers >95% of the US population, and its weighted design
enables calculation of precise national level estimates. The
NIS includes data on patient demographics, hospital charac-
teristics, admission/discharge dispositions, location, primary
payer status, diagnoses, procedures, patient diagnosis–related
group, charges, length of stay, and comorbidities.
2.2  |  Cohort identification
Patients of any age were included if they had a primary or
secondary diagnosis of epilepsy identified in the NIS data-
base (2003-2014) using a previously validated case defini-
tion of the International Classification of Diseases, Ninth
KWON et al.
Revision, Clinical Modification (ICD-9-CM) diagnosis
codes and had an epilepsy-related neurosurgical interven-
tion based on ICD-9-CM procedure codes (Supplementary
Table  S1).10,11 Hospitalizations with a diagnosis of status
epilepticus (ICD-9-CM: 345.2 and 345.3) without a con-
current epilepsy diagnosis code were excluded from the
study cohort. Tumor surgeries were also excluded. To look
at trends of elective admissions for epilepsy surgery, the
following cohorts were identified and compared: lobec-
tomy/amygdalohippocampectomy versus all resective/
disconnective surgeries versus all epilepsy surgery types
(resection/disconnection/radiosurgery/laser interstitial
thermal therapy [LITT]/vagus nerve stimulation/deep brain
stimulation/responsive neurostimulation/intracranial elec-
troencephalogram; Supplementary Table  S1). Thereafter
only lobectomy/amygdalohippocampectomies were inves-
tigated over time, and the impact was assessed of hospital
surgical volume between high surgical volume (HV; high-
est quartile) versus mid-volume (MV; middle two quar-
tiles) versus low-volume (LV; lowest quartile) hospitals on
outcomes. A breakdown of each epilepsy surgery type over
time was investigated (Supplementary Table S2). We also
examined to see whether there were any differences in out-
comes in Level 4 Centers versus non–Level 4 Centers for
lobectomy/amygdalohippocampectomy surgeries. Because
this study was performed across hospitals in the USA, we
used the National Association of Epilepsy Centers defini-
tion of a Comprehensive Epilepsy Program, and as such,
Level 4 Centers were defined as those where intracranial
electroencephalographic monitoring was performed at the
hospital.
2.3  |  Outcome measures
Primary outcomes measured included (1) discharge dispo-
sition (discharge home/routine/home, transfer to short-term
hospital/skilled nursing facility/intermediate care facility/
another type of facility, discharge against medical advice, in-
hospital mortality, destination unknown), (2) length of stay
(LOS), (3) total hospital charges, and (4) complications (sur-
gical, medical).
Surgical complications were defined using ICD-9-CM
codes including stroke/hematoma, intracranial infections
postoperatively, hydrocephalus, insertion of ventriculoperi-
toneal shunt, and meningitis (Supplementary Table S3).12 In-
hospital medical complications included cardiac, respiratory,
renal/urinary, and thromboembolic causes (Supplementary
Table S3).13
Secondary outcomes of interest were (1) trends of elec-
tive epilepsy surgeries comparing lobectomies/amyg-
dalohippocampectomies versus resective/disconnective
surgeries versus all epilepsy surgery types (resection/
|
     3
disconnection/radiosurgery/LITT/vagus nerve stimulation/
deep brain stimulation/responsive neurostimulation/intra-
cranial electroencephalogram) and (2) percentage of lobec-
tomies/amygdalohippocampectomies by hospital volume in
persons with epilepsy.
2.4  |  Key covariate
The key independent variable of interest was an elective ad-
mission for epilepsy surgery.
2.5  |  Other covariates
Covariates included age at admission, sex, race, median
household income for patient's ZIP code, expected primary
payer, bed size of hospital, location/teaching status of hos-
pital, region of hospital, and Elixhauser Comorbidity Index.
Using the ICD-9-CM codes and Elixhauser comorbidity soft-
ware, 29 Elixhauser comorbidities (Supplementary Table S4)
were identified.14 These comorbidities were transformed into
a comorbidity index for each discharge record.
2.6  |  Statistical analysis
Categorical variables are expressed as frequencies and per-
centages, and continuous variables with mean, range, and
standard error. Categorical variables were compared by Rao-
Scott chi-squared tests and continuous variables by weighted
linear regression for hospital volume analyses. Regression
analysis was conducted to examine the associations between
(1) discharge disposition, (2) surgical complications, and (3)
medical complications and hospital volume. Length of stay
and total charges were log-transformed due to skewness.
Ordinary least square regression analyses were performed on
log-transformed data to test the association between (1) LOS
and (2) total mean charge and hospital volume having con-
trolled for the same set of covariates as in the logistic regres-
sion model. Subgroup differences between Level 4 Centers
and non–Level 4 Centers were estimated using standardized
mean difference (SMD) scores, calculated with mean and
variances of covariates. SMD scores are applied because they
are not biased by sample size and permit relative balance of
covariates. Only covariates with SMD > 10% were entered in
the multivariate analysis.15
Trends in epilepsy surgeries (lobectomy/amygdalohip-
pocampectomy surgeries vs all resective/disconnective
surgeries vs all epilepsy surgery types) over time were per-
formed using linear regression models for time series data
with maximum likelihood estimation from 2003 to 2014.
Frequencies and percentages by hospital volume were
 |
4      KWON et al.
calculated for lobectomy/amygdalohippocampectomy for
each year from 2003 to 2011. Total annual primary epilepsy
discharges were used as the denominator for total epilepsy
surgical volumes.
In all analyses, national level estimates were calculated
after accounting for survey (stratum and cluster) weights.
Statistical Analysis Software (SAS) version 9.4 was used to
conduct all analyses (SAS Institute).
3  |   R ES U LTS
A total of 4487 elective lobectomy/amygdalohippocampec-
tomy surgeries were performed in children and adults with
epilepsy from 2003 to 2011. HV and MV hospitals performed
more elective lobectomy/amygdalohippocampectomy sur-
geries in younger people (HV: 29.80 years, MV: 30.84 years,
LV: 37.79 years; P < .01). Hospitalizations in HV and MV
hospitals were primarily in those who had private insurance
(HV: 58.20%, MV: 58.08%, LV: 50.62%; P < .01), whereas
LV hospitals had greater admissions in those who were on
Medicare (HV: 11.30%, MV: 14.19%, LV: 28.99%; P < .01).
About half the population were female (54.72%). The majority
of surgeries were performed in urban teaching hospitals (HV:
96.55%, MV: 88.17%, LV: 86.03%; P < .01). No significant
differences in race, median household income, or Elixhauser
Comorbidity Index were noted across hospital volumes.
Lobectomy/amygdalohippocampectomy surgeries signifi-
cantly decreased over time (slope: −0.24, P < .001; Figure 1).
To determine whether this trend was due to other types of
surgery being performed more frequently, all resective/dis-
connective surgeries as well as all epilepsy surgery types
(resection/disconnection/radiosurgery/LITT/vagus nerve
stimulation/deep brain stimulation/responsive neurostimu-
lation/intracranial electroencephalogram) were investigated.
However, a declining surgical trend was even greater for all
resective/disconnective surgery (slope: −0.45, P  <  .001),
and greatest when comparing to all types of epilepsy sur-
gery (slope: −0.95, P < .001). There was no significant trend
over time when comparing across hospital volumes for per-
centages of lobectomies/amygdalohippocampectomies per-
formed (Figure 2).
As compared to HV hospitals, LV hospitals had signifi-
cantly higher odds of transfer to other facilities (13.60% vs
4.24%, odds ratio [OR] = 2.76, 95% confidence interval
[CI] = 1.11-6.82). No discharges against medical advice
were noted in this cohort. There were no inpatient mortal-
ities across hospitals. The mean LOS was not significantly
different across different hospital volumes (HV: 7.35  days,
MV: 7.46 days, LV: 7.59 days); however, one would expect
significantly higher LOS in LV hospitals if patients were not
transferred to other types of facilities. HV hospitals incurred
the lowest total charge (HV: $89,914, MV: $103,244, LV:
$96,623). As compared to MV hospitals, LV hospitals had
higher odds of surgical complications (12.69% vs 6.80%, OR
= 2.20, 95% CI = 1.01-5.09) (Tables 1-6). A significantly
greater proportion of stroke, hematoma formation, and hy-
drocephalus occurred in LV hospitals as compared to MV
and HV hospitals (Supplementary Table S3). There were no
differences in medical complications across different hospital
volumes.
There were no differences in discharge status, adverse
events, LOS, or cost between Level 4 Centers versus non–
Level 4 Centers (Supplementary Tables S5-S12).
4  |  DISCUSSION
In this study, we show that rates of surgical lobectomies/
amygdalohippocampectomies decreased over the 2003-2014
F I G U R E 1   Trends of surgery
in elective admissions for epilepsy as
a percentage of all primary epilepsy
discharges comparing lobectomies/
amygdalohippocampectomies versus
resective/disconnective surgeries versus
all epilepsy surgery types (resection/
disconnection/radiosurgery/laser
interstitial thermal therapy/vagal nerve
stimulation/deep brain stimulation/
responsive neurostimulation/intracranial
electroencephalogram)
KWON et al.
F I G U R E 2   Percentage of lobectomies/
amygdalohippocampectomies performed by
hospital volume from 2003 to 2011
period. This decrease in trend was also seen when looking
at all epilepsy surgery types, that is, not just resective sur-
geries (Figure 1). This decrease is of concern, because it oc-
curred in a period of increasingly publicized evidence of the
efficacy of temporal lobectomy including RCTs and society
guidelines recommending early referral for surgery in the
treatment of drug-resistant epilepsy.3,4,8 The declining surgi-
cal rate is concerning and adds to prior studies showing that
epilepsy surgery is underused.16–18
Regarding the overall number of surgeries, there is no
change (nonsignificant decreasing trends) between 2003 and
2009 and again between 2010 and 2014. However, there ap-
pears to be an increase in overall numbers from 2009 to 2010.
The number of LITT surgeries has been gradually increas-
ing, but numbers do not compensate for the decrease in the
number of resective surgeries, let alone other surgeries. Other
than very small increases seen for LITT, intracranial elec-
troencephalography, and responsive neurostimulation since
2010, most other surgical modalities have been generally de-
creasing from 2010. The 2008 economic recession would not
be expected to affect the true number of candidates for epi-
lepsy surgery, but across every surgical type there is a drop
in frequencies from 2008 to 2009, with a subsequent rise in
numbers in 2010. This may be because during the recession
fewer people had insurance and sought elective medical care
in addition to the adoption of Obamacare in 2010. It is likely
that these two factors combine to explain the sudden rise in
surgeries performed between 2009 and 2010. Moreover, the
overall number of potential candidates for surgery has been
increasing over time (Supplementary Table S2). This reflects
what the Centers for Disease Control and Prevention has
shown, with the number of active epilepsy cases increasing
over time in US adults and children.19 In the USA, 40% of per-
sons with epilepsy are drug-resistant.20 Despite the introduc-
tion of 20+ new antiseizure medication over several decades,
|
     5
the proportion of drug-resistant epilepsy patients has not
changed.21 Thus, with the significantly increasing numbers
eligible for surgery and decreasing (nonsignificant) trends of
actual surgery performed, we are seeing persistent underuti-
lization of epilepsy surgery in the USA. A nationwide study
using the American College of Surgeons National Surgical
Quality Improvement Program database looked at trends of
spinal and cranial surgeries from 2006 to 2013.22 The total
number of spinal and cranial cases increased throughout the
study period.
It is also notable that the number of Level 4 Centers in-
creased during this time period, which suggests that the un-
derutilization is less likely to be a capacity problem. It is
likely that the observed underutilization is multifactorial,
with a combination of inappropriate or delayed referrals for
surgical evaluation in persons with drug-resistant epilepsy,
and the associated patient/caregiver and provider-reported
barriers to epilepsy surgery, for example, minority race/
ethnicity, lower income and Medicaid insurance status, age
(>60 years old), misconceptions about epilepsy surgery risks,
and psychiatric comorbidities. That we are seeing decreasing
trends of epilepsy surgery over this same period may point to
a lack of referral and underutilization problem.
Importantly, our study differs in several key ways from
the previous examination of national rates of epilepsy sur-
gery through 2008.16 Ideally, the denominator for surgical
rates would be patients with drug-resistant epilepsy, who
are potential candidates for resective surgery. Prior stud-
ies have attempted to use “intractable localization related
epilepsy codes” (ICD-9-CM 345.41 or 345.51)16; however,
these are known to be generally unreliable.23 Our study
uses total epilepsy discharges as the denominator for sur-
gical volume. Epilepsy, unlike epilepsy syndrome, is gen-
erally accurately coded in administrative data, and despite
multiple new medications introduced in the past 20 years,
 |
6      KWON et al.

T A B L E 1   Baseline characteristics stratified by hospital volume for 2003-2011

Mid-volume hospital,
Low-volume hospital, number of 1st quartile < number of High-volume hospital, number of
surgeries ≤ 1st quartile surgeries ≤ 4th quartile surgeries > 4th quartile

Weighted Weighted Weighted

n n % n n % n n % P
Total 94 445 9.92 396 1891 42.14 454 2151 47.93
Age, y
Mean (range), 37.79 (2-79), 30.84 29.80 <.01
standard error 1.47 (0-67), 1.19 (0-69), 1.48
Gender
Male 39 182 40.91 183 876 46.30 220 1046 48.62 .35
Female 55 263 59.09 213 1016 53.70 234 1105 51.38
Race
White 59 277 62.28 296 1418 74.97 327 1550 72.05 .50
Black 9 43 9.58 22 103 5.46 39 184 8.57
Hispanic 18 86 19.33 52 248 13.11 60 283 13.18
Other 8 39 8.81 26 122 6.46 28 133 6.20
Median household income for patient's ZIP code
$1-$39,999 21 101 22.57 90 418 22.12 104 490 22.78 .95
$40,000-$50,999 25 117 26.36 96 457 24.19 124 582 27.03
$51,000-$65,999 25 120 26.86 111 536 28.37 128 614 28.56
$66,000+ 23 108 24.21 99 479 25.33 98 465 21.63
Expected primary payer
Medicare 27 129 28.99 57 268 14.19 51 243 11.30 <.01
Medicaid 12 59 13.18 89 422 22.34 113 529 24.61
Private 48 225 50.62 229 1098 58.08 263 1252 58.20
insurance
Other 7 32 7.21 21 102 5.39 27 127 5.89
Elixhauser Comorbidity Index
Mean (range), 1.60 0.89 (−18 to 0.77 (−15 to .42
standard error (−13 to 22), 22), 0.32 27), 0.20
0.50
Bed size of hospital
Small 5 21 4.81 43 190 10.06 16 74 3.43 .54
Medium 22 103 23.20 42 208 11.01 51 236 10.98
Large 67 321 71.99 311 1493 78.92 387 1841 85.59
Location/teaching status of hospital
Rural/urban 13 62 13.97 48 224 11.83 15 74 3.45 <.01
nonteaching
Urban teaching 81 383 86.03 348 1668 88.17 439 2077 96.55
Region of hospital
Northeast 26 123 27.60 116 573 30.28 88 420 19.53 .17
Midwest 16 78 17.43 49 238 12.61 91 447 20.78
South 25 115 25.90 119 523 27.65 213 992 46.12
West 27 129 29.07 112 557 29.46 62 292 13.57
KWON et al.
|
     7

the proportion of drug-resistant epilepsy is thought to be

Ref
stable.24

.90
.04

—
—
Note: Unadjusted model tests association between discharge disposition and hospital volume without controlling for any other factors. Adjusted model adjusts for the following factors: age, expected primary payer, location,
P
In addition, when looking at health care outcomes as-
sociated with epilepsy surgery, we found that LV centers
are associated with higher complication and transfer rates.

M:L: 1.73 (0.70-4.28)

H:L: 2.76 (1.11-6.82)
Although the severity of complications unfortunately cannot
Adjusted model

be further investigated within this dataset, we found signifi-

OR (95% CI)

cantly higher odds of transfer occurring in LV hospitals. This

potentially implies that had these patients not been trans-
ferred to another facility, they would more likely have had
Ref
—

—
—
greater length of inpatient stay. This is consistent with prior
data from a nonrepresentative subset of the adult population
including Centers for Medicare and Medicaid Services and
Ref
.68
.02

the American College of Surgeons National Surgical Quality

—

—
—
P

Improvement Program,17 as well as earlier data in the NIS.16

We took this a step further, and showed that HV centers not
only have better immediate outcomes, but they are able to
M:L: 2.15 (0.96-4.83)
H:L: 3.55 (1.37-9.20)
Unadjusted model

do this with total lower costs than MV and LV centers. This

reaffirms the need to consider the use of specialized teams
OR (95% CI)

with more experience when treating potential epilepsy surgi-

cal candidates and suggests that national accreditation soci-
eties may want to consider a minimum number of surgeries
Ref
—

—
—

performed annually.
A recent study demonstrated the benefits of specialist
High-volume hospital

neurology and comprehensive epilepsy care on mortality in

patients with epilepsy, demonstrating that referral to a com-
prehensive epilepsy program is associated with reduced pre-
mature mortality.25 Interestingly, there did not appear to be
95.76%

a difference in outcome between Level 4 Centers (had per-

Abbreviations: CI, confidence interval; H, high-volume; L, low-volume; M, mid-volume; OR, odds ratio.

formed intracranial monitoring) and those that were not. It

is promising that with routine lobectomy similar outcomes
are seen when comparing Level 4 Centers and non–Level 4
Mid-volume hospital

Centers, most of which are urban teaching hospitals. This

may be because routine lobectomy surgery is part of a neu-
4.24%
0.00%

0.00%
0.00%

rosurgeon's standard armamentarium. This finding, however,

should be interpreted with caution, as some true Level 4
T A B L E 2   Discharge disposition comparing hospital volumes

93.18%

6.82%
0.00%

0.00%
0.00%

Centers could be incorrectly misidentified as not performing

intracranial monitoring, which would bias our results. Future
studies can help parse the interplay between volume and level
of accreditation in delivery of high-value care to epilepsy sur-
gery candidates.
Low-volume

This study is unique in that it uses a representative na-

hospitala 
86.40%

13.60%

tional sample of hospital discharges to show that rates of po-

0.00%

0.00%
0.00%

tentially curative epilepsy surgery are decreasing over time.

Low-volume hospital as reference level.

This study, however, has several possible limitations. First, it

Discharged home/routine care

assessed the US population during 2003-2014, and may not

reflect the current experience, including the recent increase in
against medical advice

teaching status of hospital.

Destination unknown

neuromodulatory therapies such as responsive neuromodula-

tion, although we have included deep brain, responsive neu-
Died in hospital

rostimulation, and vagus nerve stimulation within this study.

Discharge

Second, although total number of comorbidities are not sig-

Transfer

nificant when comparing across volume of centers, there may

be some impact on complications. We see that a significantly
a
8     
| KWON et al.

T A B L E 3   Log transformation of length of stay

Unadjusted model Adjusted model

% change 95% CI P % change 95% CI P

Low-volume hospital, 7.59 mean Reference Reference
days
Mid-volume hospital, 7.46 mean 6.82% −13.25% to 31.55% .53 3.05% −17.10% to 28.09% .79
days
High-volume hospital, 7.35 mean −0.73% −23.17% to 28.27% .96 −4.78% −26.18% to 22.84% .70
days
Note: Unadjusted model tests association between length of stay and hospital volume without controlling for any other factors. Adjusted model adjusts for the
following factors: age, expected primary payer, location, and teaching status of hospital.
Abbreviation: CI, confidence interval.

T A B L E 4   Log transformation of total mean charge

Unadjusted model Adjusted model

% change 95% CI P % change 95% CI P

Low-volume hospital, $96,623 0.92% −24.55% to 34.98% .95 10.46% −16.32% to 45.83% .48
Mid-volume hospital, $103,244 16.35% −10.75% to 51.68% .26 19.18% −6.13% to 51.31% .15
High-volume hospital, $89,914 Reference Reference
Note: Unadjusted model tests association between total mean charge and hospital volume without controlling for any other factors. Adjusted model adjusts for the
following factors: age, expected primary payer, location, and teaching status of hospital.
Abbreviation: CI, confidence interval.

T A B L E 5   Surgical complications

Unadjusted model Adjusted model

Low-volume Mid-volume High-volume
hospitala  hospital hospital OR (95% CI) P OR (95% CI) P
No 87.31% 93.20% 87.99% M:L: 1.99 (1.00-4.39) .02 M:L: 2.20 (1.01-5.09) .02
H:L: 1.07 (0.48-2.35) .34 H:L: 1.23 (0.52-2.92) .55
Yes 12.69% 6.80% 12.01% Ref Ref Ref Ref
Note: Unadjusted model tests association between surgical complications and hospital volume without controlling for any other factors. Adjusted model adjusts for the
following factors: age, expected primary payer, location, teaching status of hospital.
Abbreviations: CI, confidence interval; H, high-volume; L, low-volume; M, mid-volume; OR, odds ratio.
a
Low-volume hospital as reference level.

T A B L E 6   In-hospital medical complications

Unadjusted model Adjusted model

Low-volume Mid-volume High-volume
hospitala  hospital hospital OR (95% CI) P OR (95% CI) P
No 95.63% 98.13% 96.76% M:L: 2.40 (0.65-8.80) .19 M:L: 2.89 (0.74-11.20) .16
H:L: 1.37 (0.35-5.35) .83 H:L: 1.76 (0.45-6.88) .95
Yes 4.37% 1.87% 3.24% Ref Ref Ref Ref
Note: Unadjusted model tests association between medical complications and hospital volume without controlling for any other factors. Adjusted model adjusts for the
following factors: age, expected primary payer, location, and teaching status of hospital.
Abbreviations: CI, confidence interval; H, high-volume; L, low-volume; M, mid-volume; OR, odds ratio.
a
Low-volume hospital as reference level.

greater number of patients on Medicare (who are thus older additional limitation of this kind of study is that there is no in-
and more likely to have medical comorbidities) are operated formation on disease severity; thus, we do not know whether,
in LV hospitals, which may account for this as a proxy. An for example, LV centers have people with better-controlled
KWON et al.
comorbidities compared to HV centers. In addition, admin-
istrative claims data are produced for billing purposes, and
therefore do not allow for a detailed examination of socioeco-
nomic background, health care attitudes, medication adher-
ence, or functional status, all of which might impact decisions
as to whether/what type of surgery to perform and surgical
complications. In addition, we do not have data about long-
term outcomes, including seizure freedom, which is the ulti-
mate goal of these procedures. We used validated ICD-9-CM
codes for epilepsy, but despite being widely used, these codes
have not been specifically validated in this population.
We present data on declining epilepsy surgery rates over
an 11-year period in which there was robust and increasingly
publicized evidence for the efficacy of the surgical treatment
of epilepsy. This is a concerning finding that suggests that
drug-resistant epilepsy continues to be undertreated despite
evidence and recommendations by national societies includ-
ing the American Academy of Neurology and the American
Epilepsy Society. Our data also provide initial evidence
highlighting the potential importance of specialization for
epilepsy surgery with lower cost, and fewer complications
seen at HV centers. Our findings suggest that epilepsy sur-
gery may benefit from further specialization and reinforce
the need to direct significant resources to the identification
of potential epilepsy surgical candidates and to reduce the
existing gap between recommended and actual care.
ACKNOWLEDGMENTS
C-S.K. holds a Leon Levy Foundation Fellowship. N.J. is the
Bludhorn Professor of International Medicine at the Icahn
School of Medicine at Mount Sinai.
CONFLICT OF INTEREST
N.J. receives grant funding paid to her institution for
grants unrelated to this work from the National Institute of
Neurological Disorders and Stroke (NIH U24NS107201, NIH
IU54NS100064) and Patient-Centered Outcomes Research
Institute. She receives an honorarium for her work as an
Associate Editor of Epilepsia. None of the other authors has any
conflict of interest to disclose. We confirm that we have read the
Journal's position on issues involved in ethical publication and
affirm that this report is consistent with those guidelines.
ETHICAL PUBLICATION STATEMENT
We confirm that we have read the Journal's position on issues
involved in ethical publication and affirm that this report is
consistent with those guidelines.
STANDARD PROTOCOL APPROVAL S, REG-
ISTRATIONS, AND PATIENT CONSENT
Our Icahn School of Medicine at Mount Sinai Institutional
Review Board has reviewed and approved this project and
waived the need for human consent.
     9
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DATA AVAILABILIT Y STATEMENT
HCUP data are publicly accessible. The data user agree-
ment limits release of data, and any requests should be
made directly to HCUP. Analyses comply with HCUP
regulations.
ORCID
Churl-Su Kwon  https://orcid.org/0000-0001-9904-2240
Leah Blank  https://orcid.org/0000-0001-8719-6752
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SUPPORTING INFORMATION
Additional supporting information may be found online in
the Supporting Information section.
How to cite this article: Kwon C-S, Blank L, Mu L,
Jetté N. Trends in lobectomy/
amygdalohippocampectomy over time and the impact
of hospital surgical volume on hospitalization
outcomes: A population-based study. Epilepsia.
2020;00:1–10. https://doi.org/10.1111/epi.16664