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• Key reasons were identified causing physician-related barriers to epilepsy surgery. • Physicians may have suboptimum awareness and ambivalent attitude about epilepsy surgery. • Identification and referral of patients for surgery are insufficient. • Physician-specific barriers also include communication and coordination challenges. The epilepsy surgery treatment gap is well defined and secondary to a broad range of issues, including healthcare professionals' (HCPs') knowledge, attitude, and perception (KAP) toward epilepsy surgery. However, no previous systematic reviews investigated this important topic. The systematic review was conducted according to Preferred Reporting Items for the Systematic Reviews and Meta-Analyses (PRISMA) guidelines. We identified a total of 652 articles from multiple databases using database-specific queries and included 65 articles for full-text review after screening the titles and abstracts of the articles. Finally, we selected 11 papers for qualitative analysis. We critically appraised the quality of the studies using the Joanna Briggs critical appraisal tool. The qualitative analysis of the content identified several key reasons causing healthcare professional-related barriers to epilepsy surgery: inadequate knowledge and awareness about the role of epilepsy surgery in drug-resistant epilepsy (DRE), poor identification and referral of patients with DRE, insufficient selection of candidates for presurgical workup, negative or ambivalent attitudes and perceptions regarding epilepsy surgery, deficient communication practices with patients regarding risk–benefit analysis of epilepsy surgery, and challenging coordination issues with the surgical referral. Neurologists with formal instruction in epilepsy, surgical exposure during training, participation in high volume epilepsy practice, or prior experience in surgical referral may refer more patients for surgical evaluation. While significant work has been conducted in a limited number of studies to explore HCPs' knowledge gap and educational need regarding epilepsy surgery, further research is needed in defining the learning goals, assessing and validating specific learning gaps among providers, defining the learning outcomes, optimizing the educational format, content, and outcome measures, and appraising the achieved results following the educational intervention. [ABSTRACT FROM AUTHOR]

• Appetite disturbances and growth abnormalities are common in Dravet syndrome (DS). • Fenfluramine reduces seizure frequency in DS and has known effects on appetite. • After ≥12 months or ≥24 months of fenfluramine treatment in children with DS: • Impact on growth was minimal as measured by Z -score analysis. • Weight gain and height were comparable to growth curves in historical controls with DS. Appetite disturbance and growth abnormalities are commonly reported in children with Dravet syndrome (DS). Fenfluramine (Fintepla) has demonstrated profound reduction in convulsive seizure frequency in DS and was recently approved for use in DS in the US and EU. Prior to its use in epilepsy, fenfluramine was approved to suppress appetite in obese adults. Here, we evaluated the impact of fenfluramine on weight and growth in patients with DS treated for ≥12 months or ≥24 months and compared the results with growth curves in normative reference populations and published historical controls among patients with DS. Historical control data from a recent study of 68 patients with DS show decreases in height and weight Z -scores of ∼0.1 standard deviation (SD) for every 12-month increase in age (Eschbach K. Seizure. 2017;52:117–22). Anthropometric data for fenfluramine were extracted from an open-label extension (OLE) study of eligible patients with DS (2–18 y/o; fenfluramine dose: 0.2–0.7 mg/kg/day). Z -score analyses were based on the Boston Children's Hospital algorithm and assessed potential impact of fenfluramine on growth at OLE baseline, at Month 12, and at Month 24. A mixed-effect model for repeated measures (MMRM) estimated changes in height and weight over time. Height and weight Z -scores were also analyzed by dose group (0.2–<0.3 mg/kg/day, 0.3–<0.5 mg/kg/day, and 0.5–0.7 mg/kg/day), averaged over time. At the time of analysis, 279 patients were treated with fenfluramine for ≥12 months; 128 were treated for ≥24 months. Relative to the reference population with DS, fenfluramine treatment for ≥12 months or for ≥24 months had minimal impact on height or weight over time as assessed by Z -score analyses. No substantial dose-dependent changes from baseline were observed at Month 12 nor at Month 24. MMRM showed that patients treated with fenfluramine for ≥12 months (N = 262) had an estimated change in Z -score per year of −0.056 for height and −0.166 for weight. For patients with data from all three time points (baseline, 12 months, and 24 months; N = 110), estimated changes in Z -scores per year were −0.025 for height and −0.188 for weight. MMRM projections based on normative reference growth curves were comparable to growth data from historical control populations with DS. Long-term treatment with fenfluramine had minimal impact on the growth of patients with DS as demonstrated by differences in Z -scores for height and weight at 12 months and at 24 months. Changes in Z -scores for height and weight were consistent with published reports on patients with DS. [ABSTRACT FROM AUTHOR]

• Multifaceted interventions are necessary to tackle underutilization of epilepsy surgery. • Educational interventions can be useful for both patients and providers. • Targeted coordination and communication strategies promote efficient evaluation. • Innovative technology and supportive policies improve access to epilepsy surgery. • Specific strategies for epilepsy centers ensure appropriate surgical evaluation. Interventions focused on utilization of epilepsy surgery can be divided into groups: those that improve patients' access to surgical evaluation and those that facilitate completion of the surgical evaluation and treatment. Educational intervention, technological innovation, and effective coordination and communication can significantly improve patients' access to surgery. Patient and public facing, individualized (analog and/or digital) communication can raise awareness and acceptance of epilepsy surgery. Educational interventions aimed at providers may mitigate knowledge gaps using practical and concise consensus statements and guidelines, while specific training can improve awareness around implicit bias. Innovative technology, such as clinical decision-making toolkits within the electronic medical record (EMR), machine learning techniques, online decision-support tools, nomograms, and scoring algorithms can facilitate timely identification of appropriate candidates for epilepsy surgery with individualized guidance regarding referral appropriateness, postoperative seizure freedom rate, and risks of complication after surgery. There are specific strategies applicable for epilepsy centers' success: building a multidisciplinary setup, maintaining/tracking volume and complexity of cases, collaborating with other centers, improving surgical outcome with reduced complications, utilizing advanced diagnostics tools, and considering minimally invasive surgical techniques. Established centers may use other strategies, such as multi-stage procedures for multifocal epilepsy, advanced functional mapping with tailored surgery for epilepsy involving the eloquent cortex, and generation of fresh hypotheses in cases of surgical failure. Finally, improved access to epilepsy surgery can be accomplished with policy changes (e.g., anti-discrimination policy, exemption in transportation cost, telehealth reimbursement policy, patient-centered epilepsy care models, pay-per-performance models, affordability and access to insurance, and increased funding for research). Every intervention should receive regular evaluation and feedback-driven modification to ensure appropriate utilization of epilepsy surgery. [ABSTRACT FROM AUTHOR]

• Epilepsy surgery is an effective and safe treatment for drug-resistant epilepsy. • It remains one of the most underutilized treatments in modern medicine. • Underutilization of epilepsy surgery may have patient and/or health system components. • Misconception about epilepsy surgery is prevalent among patients and providers. • Other barriers include inadequate access and complex presurgical evaluations. One-third of persons with epilepsy have seizures despite appropriate medical therapy. Drug resistant epilepsy (DRE) is associated with neurocognitive and psychological decline, poor quality of life, increased risk of premature death, and greater economic burden. Epilepsy surgery is an effective and safe treatment for a subset of people with DRE but remains one of the most underutilized evidence-based treatments in modern medicine. The reasons for this quality gap are insufficiently understood. In this comprehensive review, we compile known significant barriers to epilepsy surgery, originating from both patient/family-related factors and physician/health system components. Important patient-related factors include individual and epilepsy characteristics which bias towards continued preferential use of poorly effective medications, as well as patient perspectives and misconceptions of surgical risks and benefits. Health system and physician-related barriers include demonstrable knowledge gaps among physicians, inadequate access to comprehensive epilepsy centers, complex presurgical evaluations, insufficient research, and socioeconomic bias when choosing appropriate surgical candidates [ABSTRACT FROM AUTHOR]