{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,8,20]],"date-time":"2026-08-20T14:57:35Z","timestamp":1787237855857,"version":"build-2736575974"},"reference-count":31,"publisher":"Wiley","license":[{"start":{"date-parts":[[2026,8,20]],"date-time":"2026-08-20T00:00:00Z","timestamp":1787184000000},"content-version":"vor","delay-in-days":0,"URL":"http:\/\/onlinelibrary.wiley.com\/termsAndConditions#vor"},{"start":{"date-parts":[[2026,8,20]],"date-time":"2026-08-20T00:00:00Z","timestamp":1787184000000},"content-version":"tdm","delay-in-days":0,"URL":"http:\/\/doi.wiley.com\/10.1002\/tdm_license_1.1"}],"content-domain":{"domain":["onlinelibrary.wiley.com"],"crossmark-restriction":true},"short-container-title":["Epilepsia"],"abstract":"Abstract<\/jats:title>\n \n Objective<\/jats:title>\n Surgery is an effective, yet underutilized treatment for children with drug\u2010resistant epilepsy. Although predictors of surgical outcomes are well described, the decision to recommend surgery varies by institution. We aim to evaluate the rates of not recommending surgery, identify associated patient characteristics, and quantify variability across centers.<\/jats:p>\n <\/jats:sec>\n \n Methods<\/jats:title>\n We queried the Pediatric Epilepsy Research Consortium Surgery database, a prospective multicenter cohort of children (0\u201318\u2009years) undergoing initial evaluation for epilepsy surgery. Patients with documented surgical decisions were included. Demographic, clinical, and presurgical evaluation variables were compared by surgical recommendation status. Logistic regression identified factors associated with not recommending surgery. Mixed\u2010effects models quantified between\u2010center variability.<\/jats:p>\n <\/jats:sec>\n \n Results<\/jats:title>\n \n Among 2480 patients across 29 centers, 532 (21%) were not recommended epilepsy surgery (median center rate 17%, interquartile range [IQR] 10%\u201328%). After accounting for patient characteristics associated with surgical candidacy, substantial variation in decision\u2010making remained across centers, with a median twofold difference in the odds of not recommending surgery between otherwise similar patients evaluated at different institutions (Median Odds Ratio\u2009=\u20092.25; Intraclass Correlation Coefficient\u2009=\u2009.18). The clinical characteristics most strongly associated with not recommending surgery included monthly or less frequent seizures (odds ratio [OR] 2.17, 95% confidence interval [CI] 1.75\u20132.69), non\u2010structural etiology (OR 2.02, 95% CI 1.56\u20132.61), and taking \u22642 anti\u2010seizure medications (ASMs) (OR 1.67, 95% CI 1.34\u20132.08, all\n p<\/jats:italic>\n 's\u2009<\u2009.01). These characteristics showed minimal clustering across centers (ICCs\u2009<\u2009.05).\n <\/jats:p>\n <\/jats:sec>\n \n Significance<\/jats:title>\n One in five children evaluated for epilepsy surgery are not recommended to pursue surgical treatment. Although clinical factors influence decision\u2010making, they do not explain the substantial variation in recommendations across pediatric epilepsy centers. Similar children evaluated at different institutions had significant differences in the odds of not being recommended surgery, suggesting that institutional decision\u2010making contributes importantly to surgical candidacy.<\/jats:p>\n <\/jats:sec>","DOI":"10.1002\/epi.70440","type":"journal-article","created":{"date-parts":[[2026,8,20]],"date-time":"2026-08-20T10:16:16Z","timestamp":1787220976000},"update-policy":"https:\/\/doi.org\/10.1002\/crossmark_policy","source":"Crossref","is-referenced-by-count":0,"title":["Variability in recommending epilepsy surgery across Level\n IV<\/scp>\n epilepsy centers in the United States"],"prefix":"10.1002","author":[{"ORCID":"https:\/\/orcid.org\/0009-0008-2957-9227","authenticated-orcid":false,"given":"Avery R.","family":"Caraway","sequence":"first","affiliation":[{"name":"Jane and John Justin Neurosciences Center Cook Children's Medical Center Fort Worth Texas USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Nancy A.","family":"McNamara","sequence":"additional","affiliation":[{"name":"Department of Pediatric Neurology Corewell Health William Beaumont University Hospital Royal Oak Michigan USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-7792-5384","authenticated-orcid":false,"given":"Andrew T.","family":"Knox","sequence":"additional","affiliation":[{"name":"Department of Neurology University of Wisconsin School of Medicine and Public Health Madison Wisconsin USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-5154-8717","authenticated-orcid":false,"given":"Debopam","family":"Samanta","sequence":"additional","affiliation":[{"name":"Department of Pediatrics University of Arkansas for Medical Sciences Little Rock Arkansas USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-7602-3474","authenticated-orcid":false,"given":"Steven M.","family":"Wolf","sequence":"additional","affiliation":[{"name":"Department of Child Neurology New York Medical College Hawthorne New York USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Edward J.","family":"Novotny","sequence":"additional","affiliation":[{"name":"Norcliffe Foundation Center for Integrative Brain Research Seattle Children's Hospital Seattle Washington USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-9994-6650","authenticated-orcid":false,"given":"Adam P.","family":"Ostendorf","sequence":"additional","affiliation":[{"name":"Department of Child Neurology Nationwide Children's Hospital Columbus Ohio USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-4249-338X","authenticated-orcid":false,"given":"Krista L.","family":"Eschbach","sequence":"additional","affiliation":[{"name":"The Neuroscience Institute Children's Hospital Colorado Aurora Colorado USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Dewi F.","family":"Depositario\u2010Cabacar","sequence":"additional","affiliation":[{"name":"Department of Pediatric Neurology, Children's National Hospital George Washington University Washington District of Columbia USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Cemal","family":"Karakas","sequence":"additional","affiliation":[{"name":"Department of Pediatric Neurology, Children's National Hospital George Washington University Washington District of Columbia USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Pilar D.","family":"Pichon","sequence":"additional","affiliation":[{"name":"Department of Child Neurology Children's Hospital Orange County Orange California USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Kurtis I.","family":"Auguste","sequence":"additional","affiliation":[{"name":"Weill Institute for Neurosciences University of California San Francisco California USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-1077-2963","authenticated-orcid":false,"given":"Danilo R.","family":"Bernardo","sequence":"additional","affiliation":[{"name":"Weill Institute for Neurosciences University of California San Francisco California USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Pradeep K.","family":"Javarayee","sequence":"additional","affiliation":[{"name":"Department of Neurology Medical College of Wisconsin Milwaukee Wisconsin USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Rani K.","family":"Singh","sequence":"additional","affiliation":[{"name":"Department of Pediatrics Atrium Health\u2010Levine Children's Hospital Charlotte North Carolina USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Michael A.","family":"Ciliberto","sequence":"additional","affiliation":[{"name":"Child Neurology University of Iowa Iowa City Iowa USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Shilpa B.","family":"Reddy","sequence":"additional","affiliation":[{"name":"Division of Pediatric Neurology Monroe Carell Jr. Children's Hospital at Vanderbilt Nashville Tennessee USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Kristen H.","family":"Arredondo","sequence":"additional","affiliation":[{"name":"UT Health Austin Pediatric Neurosciences Dell Children's Austin Texas USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Ahmad","family":"Marashly","sequence":"additional","affiliation":[{"name":"Department of Neurology Johns Hopkins University School of Medicine Baltimore Maryland USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Fernando N.","family":"Galan","sequence":"additional","affiliation":[{"name":"Department of Child and Adolescent Neurology Nemours Children's Health Jacksonville Florida USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Dallas M.","family":"Armstrong","sequence":"additional","affiliation":[{"name":"Department of Pediatrics and Department of Neurology University of Texas Southwestern Medical Center Dallas Texas USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Janelle L.","family":"Wagner","sequence":"additional","affiliation":[{"name":"College of Medicine Medical University of South Carolina Charleston South Carolina USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Lily C.","family":"Wong\u2010Kisiel","sequence":"additional","affiliation":[{"name":"Department of Neurology Mayo Clinic Children's Rochester Minnesota USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jeffrey B.","family":"Bolton","sequence":"additional","affiliation":[{"name":"Department of Neurology Boston Children's Hospital Boston Massachusetts USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jenny J.","family":"Lin","sequence":"additional","affiliation":[{"name":"Department of Neurology Children's Healthcare of Atlanta Atlanta Georgia USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-6705-0932","authenticated-orcid":false,"given":"Zachary M.","family":"Grinspan","sequence":"additional","affiliation":[{"name":"Department of Pediatric Neurology Weill Cornell Medicine New York New York USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-5089-460X","authenticated-orcid":false,"given":"Taylor J.","family":"Abel","sequence":"additional","affiliation":[{"name":"Department of Pediatric Neurosurgery University of Pittsburgh Medical Center Pittsburgh Pennsylvania USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jason","family":"Coryell","sequence":"additional","affiliation":[{"name":"Department of Pediatric Neurology Intermountain Primary Children's Hospital Salt Lake City Utah USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-1825-846X","authenticated-orcid":false,"given":"M. Scott","family":"Perry","sequence":"additional","affiliation":[{"name":"Jane and John Justin Neurosciences Center Cook Children's Medical Center Fort Worth Texas USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"name":"the rest of the PERC Surgery Special Interest Group","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"311","published-online":{"date-parts":[[2026,8,20]]},"reference":[{"key":"e_1_2_13_2_1","doi-asserted-by":"crossref","first-page":"167","DOI":"10.1016\/S1059-1311(02)00320-5","article-title":"Epilepsy surgery, delays and referral patterns\u2014are all your epilepsy patients controlled?","volume":"12","author":"Benbadis SR","year":"2003","journal-title":"Seizure"},{"key":"e_1_2_13_3_1","doi-asserted-by":"crossref","first-page":"37","DOI":"10.1111\/j.1535-7597.2003.03201.x","article-title":"A greater role for surgical treatment of epilepsy: why and when?","volume":"3","author":"Engel J","year":"2003","journal-title":"Epilepsy Curr"},{"key":"e_1_2_13_4_1","doi-asserted-by":"crossref","first-page":"375","DOI":"10.1111\/epi.12912","article-title":"Increasing utilization of pediatric epilepsy surgery in the United States between 1997 and 2009","volume":"56","author":"Pestana\u2010Knight EM","year":"2015","journal-title":"Epilepsia"},{"key":"e_1_2_13_5_1","doi-asserted-by":"crossref","DOI":"10.1016\/j.yebeh.2021.107837","article-title":"Underutilization of epilepsy surgery: part I: a scoping review of barriers","volume":"117","author":"Samanta D","year":"2021","journal-title":"Epilepsy Behav"},{"key":"e_1_2_13_6_1","doi-asserted-by":"crossref","DOI":"10.1016\/j.yebeh.2025.110391","article-title":"Sociodemographic barriers in epilepsy surgery in the United States: a systematic review and meta\u2010analysis","volume":"167","author":"Karakas C","year":"2025","journal-title":"Epilepsy Behav"},{"key":"e_1_2_13_7_1","doi-asserted-by":"crossref","first-page":"2491","DOI":"10.1111\/epi.17350","article-title":"Timing of referral to evaluate for epilepsy surgery: expert consensus recommendations from the surgical therapies Commission of the International League against Epilepsy","volume":"63","author":"Jehi L","year":"2022","journal-title":"Epilepsia"},{"key":"e_1_2_13_8_1","doi-asserted-by":"crossref","first-page":"1835","DOI":"10.1002\/epi4.70144","article-title":"Current practices and trends in surgical decision\u2010making for children with Lennox\u2010Gastaut syndrome: a cross\u2010sectional survey by the pediatric epilepsy research consortium","volume":"10","author":"Chiu MY","year":"2025","journal-title":"Epilepsia Open"},{"key":"e_1_2_13_9_1","doi-asserted-by":"crossref","first-page":"106","DOI":"10.1016\/j.pediatrneurol.2023.03.001","article-title":"Responsive neurostimulation in drug\u2010resistant pediatric epilepsy: findings from the epilepsy surgery subgroup of the pediatric epilepsy research consortium","volume":"143","author":"Singh RK","year":"2023","journal-title":"Pediatr Neurol"},{"key":"e_1_2_13_10_1","doi-asserted-by":"crossref","first-page":"785","DOI":"10.1002\/epi4.12902","article-title":"Pediatric neuromodulation for drug\u2010resistant epilepsy: survey of current practices, techniques, and outcomes across US epilepsy centers","volume":"9","author":"Joshi CN","year":"2024","journal-title":"Epilepsia Open"},{"key":"e_1_2_13_11_1","doi-asserted-by":"crossref","first-page":"21","DOI":"10.1016\/j.pediatrneurol.2016.06.008","article-title":"Surgical management of pediatric epilepsy: decision\u2010making and outcomes","volume":"64","author":"Kellermann TS","year":"2016","journal-title":"Pediatr Neurol"},{"key":"e_1_2_13_12_1","first-page":"e96","article-title":"European trends in epilepsy surgery","volume":"91","author":"Baud MO","year":"2018","journal-title":"Neurology"},{"key":"e_1_2_13_13_1","doi-asserted-by":"crossref","DOI":"10.1016\/j.yebeh.2021.108263","article-title":"Parental experience and decision\u2010making for epilepsy surgery: a systematic review of qualitative and quantitative studies","volume":"123","author":"Samanta D","year":"2021","journal-title":"Epilepsy Behav"},{"key":"e_1_2_13_14_1","doi-asserted-by":"crossref","first-page":"83","DOI":"10.1016\/j.seizure.2022.08.013","article-title":"Barriers to epilepsy surgery in pediatric patients: a scoping review","volume":"102","author":"Hatoum R","year":"2022","journal-title":"Seizure"},{"key":"e_1_2_13_15_1","doi-asserted-by":"crossref","DOI":"10.1016\/j.spen.2021.100916","article-title":"Underrepresented populations in pediatric epilepsy surgery","volume":"39","author":"Armour EA","year":"2021","journal-title":"Semin Pediatr Neurol"},{"key":"e_1_2_13_16_1","doi-asserted-by":"crossref","first-page":"71","DOI":"10.1016\/j.pediatrneurol.2019.09.002","article-title":"Sociodemographic factors in pediatric epilepsy surgery","volume":"107","author":"Jackson HN","year":"2020","journal-title":"Pediatr Neurol"},{"key":"e_1_2_13_17_1","doi-asserted-by":"crossref","first-page":"E2","DOI":"10.3171\/2011.12.FOCUS11315","article-title":"Inequities in access to pediatric epilepsy surgery; a bioethical framework","volume":"32","author":"Ibrahim GM","year":"2012","journal-title":"Neurosurg Focus"},{"key":"e_1_2_13_18_1","doi-asserted-by":"crossref","first-page":"127","DOI":"10.1111\/epi.17452","article-title":"Epilepsy center characteristics and geographic region influence presurgical testing in the United States","volume":"64","author":"Ahrens SM","year":"2023","journal-title":"Epilepsia"},{"key":"e_1_2_13_19_1","first-page":"209","article-title":"Predictors for being offered epilepsy surgery: 5\u2010year experience of a tertiary referral centre","volume":"87","author":"Fois C","year":"2016","journal-title":"J Neurol Neurosurg Psychiatry"},{"key":"e_1_2_13_20_1","first-page":"268","article-title":"Barreras de acceso a la cirugia de la epilepsia: revision de la bibliografia [Barriers impeding access to epilepsy surgery: a review of the literature]","volume":"65","author":"Ladino LD","year":"2017","journal-title":"Rev Neurol"},{"key":"e_1_2_13_21_1","article-title":"Epilepsy surgery: factors that affect patient decision\u2010making in choosing or deferring a procedure","volume":"2013","author":"Anderson CT","year":"2013","journal-title":"Epilepsy Res Treat"},{"key":"e_1_2_13_22_1","doi-asserted-by":"crossref","first-page":"e719","DOI":"10.1212\/WNL.0000000000201526","article-title":"Association between characteristics of National Association of epilepsy centers and reported utilization of specific surgical techniques","volume":"100","author":"Arredondo KH","year":"2023","journal-title":"Neurology"},{"key":"e_1_2_13_23_1","doi-asserted-by":"crossref","first-page":"510","DOI":"10.1001\/jamasurg.2019.0090","article-title":"Variation in surgical outcomes across networks of the highest\u2010rated US hospitals","volume":"154","author":"Sheetz KH","year":"2019","journal-title":"JAMA Surg"},{"key":"e_1_2_13_24_1","doi-asserted-by":"crossref","DOI":"10.1212\/WNL.0000000000208087","article-title":"Guidelines for specialized epilepsy centers: executive summary of the report of the National Association of Epilepsy Centers guideline panel","volume":"102","author":"Lado FA","year":"2024","journal-title":"Neurology"},{"key":"e_1_2_13_25_1","doi-asserted-by":"crossref","first-page":"821","DOI":"10.1111\/epi.17512","article-title":"Associations between testing and treatment pathways in lesional temporal or extratemporal epilepsy: a census survey of NAEC center directors","volume":"64","author":"Beatty 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