Rationale:
Epilepsy affects approximately 1% of the general population, with one-third developing drug-resistant epilepsy (DRE). For pediatric DRE patients, surgical interventions offer potential treatment when medications fail. Previous studies demonstrate that patients with Medicaid insurance are less likely to receive epilepsy surgery compared to those with private insurance. However, whether these disparities are changing over time, particularly as surgical techniques evolve and utilization increases, remains unclear. This study examines national trends in pediatric epilepsy surgery from 2016-2022 to determine if insurance-based access disparities persist and whether gaps are widening or narrowing. Methods:
We analyzed the Kids' Inpatient Database (KID) from the Healthcare Cost and Utilization Project for 2016, 2019, and 2022, the largest publicly-available all-payer pediatric inpatient database in the United States. Pediatric patients aged < 21 years with drug-resistant epilepsy were identified using ICD-10 diagnostic codes, and epilepsy surgical procedures were identified using procedural ICD-10 codes including neurostimulation, laser interstitial thermal therapy (LITT), and resective surgeries (lobectomy, hemispherectomy). Survey-weighted logistic regression models examined factors associated with procedure receipt, adjusting for age, sex, race/ethnicity, hospital teaching status, and region. Models included interaction terms between year and insurance status to assess temporal changes in access patterns.
Results:
Of the 74,975 pediatric hospitalizations with intractable epilepsy, 3,779 (5.0%) underwent epilepsy surgery. Higher proportions of surgical procedures were observed among older patients (P< 0.001), White patients (P< 0.001), privately insured patients (P< 0.001), and those at urban teaching hospitals (P< 0.001). Surgical rates increased from 4.6% in 2016 to 5.1% in 2019 and 5.5% in 2022. Brain resection declined from 3.1% to 2.9%, while neurostimulator implantation increased from 1.5% to 2.3% and LITT increased from 0.3% to 0.5%. Urban teaching hospitals performed 99-100% of procedures. Privately insured patients had consistently higher surgical rates than government-insured patients across all years: 5.9% vs 3.3% (2016), 6.7% vs 3.5% (2019), and 8.1% vs 3.6% (2022). Privately insured patients had annual increases in surgery probability of 0.113 percentage points (p=0.003), while government-insured patients showed no significant change (0.016 percentage points annually, p=0.573) when adjusting for the variables in our model. The insurance-based difference was most pronounced for neurostimulator procedures (interaction OR 1.09, 95% CI 1.02-1.16, p=0.011).
Conclusions:
Pediatric epilepsy surgery utilization increased 19.6% from 2016-2022, with a notable increase in less invasive procedures such as neurostimulation. However, temporal trends differed significantly by insurance type. Privately insured patients experienced annual increases in surgery rates while government-insured patients showed stable rates, resulting in widening access gaps despite overall surgical advances.
Funding: James Barnett was awarded the 2025 Children's Hospital at Montefiore Resident Research Award.