A Mixed-Method Approach to Assessing the Need and Capacity for Epilepsy Surgery in a National Referral Hospital in Uganda

Abstract

AbstractBackground: An estimated 80% of patients with epilepsy reside in LMICs, where surgical options for treating medication refractory epilepsy (MRE) may not be readily available. This study assesses the need for an epilepsy surgery program in Uganda and evaluates the current capacity for implementing such a program at the nation’s largest hospital, the Mulago National Referral Hospital (MNRH).Methods: Medical records of 183 adult patients receiving care for epilepsy at the Bosa Psychiatric Clinic between January and April 2021 were retrospectively reviewed to determine patterns of medical management of epilepsy. 13 clinicians across Psychiatry, Neurology, and Neurosurgery were interviewed; these interviews were analyzed thematically to address the subjects of need and capacity for epilepsy surgery at MNRH. 41 patients and 63 caregivers were surveyed on their perceptions and attitudes toward surgery as a potential treatment for epilepsy.Results: Nearly half (49%) of patients receiving care at the Bosa Clinic had been treated on two or more anti-epileptic drugs (AEDs) over the course of their disease, with Carbamazepine, Sodium Valproate, and Phenytoin being the most commonly prescribed medications. Only few patients had records of prior brain imaging (8.2%) and EEG (21%) in their medical charts, and no patient had prior referral for surgical evaluation. The interviewed clinicians noted that there is a need for an epilepsy surgery program to augment the current medical practice. They identified infrastructure, cost, further specialized training, and public perception as factors to address in implementing a sustainable epilepsy surgery program locally. 53.3% of patients and 58.5% of caregivers would consider epilepsy surgery only after they had tried 5 or more AEDs without resolution of seizures, citing complications and cost as deterrents. Conclusions: Both clinical records and clinician interviews demonstrated a need for a surgical option for treating idiopathic epilepsy among Ugandans with medication refractory epilepsy. Investigative modalities such as EEG, CT, and MRI are locally accessible for preliminary evaluation of surgical candidacy. A future pilot program could serve as a platform for training personnel to sustain an epilepsy surgery program at MNRH, and patients and caregivers would subscribe to surgical treatment if a local program is affordable and has a low complication rate.