Marginal decision-making in the treatment of refractory epilepsy

Abstract

Objective: Epilepsy surgery is one of the most effective treatments in modern medicine. Yet, it remains largely under-utilized, in spite of its proven efficacy. The referrals for epilepsy surgery are often delayed until it is too late to prevent the detrimental psychosocial effects of refractory seizures. The reluctance towards epilepsy surgery is influenced by the perceived risks of the procedure by practitioners and patients. This review discusses how, in general decision-making processes, one faces a natural tendency towards emphasizing the risks of the most immediate and operational decision (surgery), at times without contrasting these risks with the alternative (uncontrolled epilepsy).

Methods: In the field of economics, this bias is well recognized and can be overcome through marginal analysis, formally defined as focusing on incremental changes as opposed to absolute levels.

Results: Regarding epilepsy surgery, the risks and benefits of surgery are considered separately from the risks of uncontrolled epilepsy. For instance, even though surgery carries an ∼0.1–0.5% risk of perioperative mortality, the chance of sudden unexpected death with refractory epilepsy can be as high as 0.6–0.9% per year. It is suggested that the inadequate way of phrasing clinical questions can be a crucial contributing factor for the under-utilization of epilepsy surgery.

Significance: It is proposed that examining decision-making for epilepsy surgery in the context of marginal analysis may enable providers and patients to make more accurate informed decisions.

Keywords:

• Marginal
• epilepsy
• surgery
• neurology

Transparency

Declaration of funding

This manuscript was not funded.

Declaration of financial/other relationships

LB’s laboratory has received research support from Medtronic. This research support does not overlap with the contents of this manuscript and there are no conflicts of interest related to this article. LB receives salary support for research projects funded by the National Institutes of Health and by the American Heart Association. JCE and RSS have no conflicts of interest to disclose. JME peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Acknowledgment

We would like to thank the Comprehensive Epilepsy Center at the Medical University of South Carolina for supporting this research. We also want to express our appreciation to the editor and reviewers for their careful review and insightful comments.