Improving access to epilepsy surgery: a review of the global praxis, implementation science, and relevant policy frameworks.

Objective: In this review of experiences across the world, the authors aim to demonstrate a roadmap to success in initiating epilepsy surgery programs. The goal of closing the gap of underutilization and inequitable access to epilepsy surgery requires an understanding of potential solutions and evaluation of best practices from a broad range of literature.

Methods: The PubMed and Global Index Medicus databases were systematically queried for eligible articles relevant to the topic. Using a scoping review methodology, the authors described the available narratives of the global experiences of initiating epilepsy surgery centers on a summative basis and through the lens of implementation science and various frameworks. On the basis of relevant public health principles grounded on varied experiences, the authors put forth recommendations for implementing an epilepsy surgery program mainly on a national level.

Results: The results were stratified on the basis of thematic fit to the process stages of social health program implementation and the components of the Global Surgery and Flagship frameworks. Based on documented best practices, initial recommendations that can be applied to nascent programs included the following: organizational leadership at the outset, nuanced patient selection informed by workforce and equipment capacities, and a graduated and stepwise evolution in case selection and therefore capacity. Bellwether procedures for pediatric epilepsy surgery across the settings of different resource levels can include temporal lobectomy and amygdalohippocampectomy, lesional and multilobar resections, corpus callosotomy, and hemispheric disconnection procedures. Advocacy and formal policy work for improved financing and governance arrangements were deemed crucial in supporting the work of improving access to, and addressing the underutilization of, epilepsy surgery.

Conclusions: Working to address the global magnitude of the need for epilepsy surgery needs to be matched by what could be a thoughtful process of implementation that examines contextual challenges and resources. This review informs a roadmap to address the very substantial challenges posed when attempting to initiate epilepsy surgery programs, particularly in under-resourced settings and in low- and middle-income countries.