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Online tool could streamline surgical referrals for epilepsy.

BOSTON -- An online decision-support tool may help to close the protracted gap between seizure onset and referral for surgery in patients with medically intractable epilepsy, based on results obtained by an expert panel.

The user-friendly tool is designed for use by clinicians who treat epilepsy patients but may not be epilepsy specialists, according to Dr. Nathalie Jette, who developed the tool with her colleagues at the University of Calgary (Alta.)

The tool rates the appropriateness and necessity of referring individual patients for a surgery evaluation based on factors such as age, epilepsy duration, seizure type, frequency and severity of seizures, the number of adequate epilepsy drug trials, and EEG and MRI findings, Dr. Jette said at the annual meeting of the American Epilepsy Society.

Despite surgical success rates as high as 90% for patients with medically intractable temporal lobe epilepsy, the average time between seizure onset and surgery for these patients is 9 years for children and 19 years for adults, according to Dr. Jette.

Based on a literature review and on discussion during a face-to-face meeting, an expert panel rated clinical scenarios for their appropriateness for an epilepsy surgery evaluation, Dr. Jette said.

"The scenarios were rated on a scale from 1 to 9, where 1 was the most inappropriate and 9 was the most appropriate. After extensive discussion, all of the scenarios were re-rated, and those that were appropriate for referral [rated a 7 or higher] were re-rated for necessity," she said.

For rating purposes, referral was considered a necessity if the presumed benefits exceeded the risks by a sufficient margin; if failing to refer the patient would be improper care; if there was a reasonable chance the referral would benefit the patient; and if the magnitude of the expected benefit "was not small," she said.

Of 2,646 clinical scenarios, nearly 21% received a rating of at least 7 and were considered appropriate for surgical referral. About 17% were considered uncertain for appropriateness because they were rated 4-6, and nearly 62% were deemed inappropriate because they were rated 1-3, Dr. Jette said.

In practice, a patient who failed one antiepileptic drug (AED) would be inappropriate for referral, but a patient who failed two AEDs and had an abnormal MRI and EEG would typically be an appropriate candidate for surgical evaluation, she explained. With respect to necessity, "'none of the appropriate cases were rated as unnecessary," she said.

VITALS

Major Findings: Using a decision-support tool, nearly 21% of 2,646 clinical scenarios created from different combinations of patient-level factors were considered appropriate for evaluation for epilepsy surgery. None of the surgeries was rated as unnecessary.

Data Source: An expert panel's use of a decision-support tool.

Disclosures: The investigator had no relevant disclosures or conflicts of interest.

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Title Annotation:NEUROLOGIC DISORDERS
Author:Mahoney, Diana
Publication:Family Practice News
Geographic Code:1USA
Date:Jan 1, 2010
Words:458
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