Missed opportunities for epilepsy surgery referrals in Bhutan: a cohort study

Abstract Objective To quantify the missed opportunities for epilepsy surgery referral and operationalize the Canadian Appropriateness of Epilepsy Surgery (CASES) tool for use in a lower income country without neurologists. Methods People with epilepsy were recruited from the Jigme Dorji Wangchuck National Referral Hospital from 2014-2016. Each participant was clinically evaluated, underwent at least one standard EEG, and was invited to undergo a free 1.5 Tesla brain MRI. Clinical variables required for CASES were operationalized for use in lower-income populations and entered into the free, anonymous website tool. Findings There were 209 eligible participants (mean age 28.4 years, 56% female, 179 with brain MRI data). Of the 179 participants with brain MRI, 43 (24.0%) were appropriate for an epilepsy surgery referral, 21 (11.7%) were uncertain, and 115 (64.3%) were inappropriate for referral. Among the 43 appropriate referral cases, 36 (83.7%) were “very high” and 7 (16.3%) were “high” priorities for referral. For every unit increase in surgical appropriateness, quality of life (QoL) dropped by 2.3 points (p-value 1 antiepileptic drug prior to enrollment, 42 (61.8%) were appropriate referrals, 14 (20.6%) were uncertain, and 12 (17.6%) were inappropriate. Conclusion Approximately a quarter of Bhutanese epilepsy patients who completed evaluation in this national referral-based hospital should have been evaluated for epilepsy surgery, sometimes urgently. Surgical services for epilepsy are an emerging priority for improving global epilepsy care and should be scaled up through international partnerships and clinician support algorithms like CASES to avoid missed opportunities.