Abstract
Effects of an Inpatient Rehabilitation Program After Temporal Lobe Epilepsy Surgery and Other Factors on Employment 2 Years After Epilepsy Surgery.
Thorbecke R, May TW, Koch-Stoecker S, Ebner A, Bien CG, Specht U. Epilepsia 2014;55:725–733.
OBJECTIVE: To evaluate the effects of a postsurgical rehabilitation program on employment status two years after temporal lobe epilepsy surgery in relation to other predictors. METHODS: Employment outcome 2 years after temporal lobe resection in a group of 232 adult patients with the offer of a 3-week inpatient rehabilitation program immediately after surgery (“Reha group”) was compared to a group of 119 patients who had surgery before such a rehabilitation program existed. One hundred thirty-nine (59.9%) of the Reha group patients attended the rehabilitation program. Further predictors for employment outcome were analyzed using multivariate logistic regression analysis. RESULTS: Preoperatively, the groups did not differ significantly in variables relevant for employment, including employment rate. Two years after surgery, the rate of those not being employed had decreased in the Reha group from 38.4% to 27.6% (p < 0.001, McNemar test), and slightly increased in the control group (37.8–42.0%; n.s.), resulting in a difference of 14.4% in favor of the Reha group (p = 0.008). General unemployment rates during the two observation periods were similar. In addition to the offer of rehabilitation support (Reha group) and preoperative employment, the following other variables were shown as significant predictors of employment post surgery in multivariate regression analysis: seizure outcome, diagnosis of a personality disorders preoperatively, and age at surgery (all, p < 0.01; Nagelkerkes R(2) = 0.59). SIGNIFICANCE: Independently from other factors, a 3-week inpatient rehabilitation program after temporal lobe epilepsy surgery seems to improve employment status 2 years after surgery.
Commentary
Seizures are not the only relevant outcome measure for epilepsy surgery. Other outcomes—such as cognition, psychosocial functioning, and quality of life—are increasingly considered equally relevant (1). However, these outcome measures are more difficult to quantify. A surrogate outcome measure for psychosocial outcome is employment status. It is assumed that being employed is equal to the ability to lead a relatively normal life without being restricted. Employment status is directly related to quality of life after epilepsy surgery (2). Only a few studies have quantified employment outcome after epilepsy surgery (2–4). A systematic review identified 14 studies that measured employment outcome, 7 of which found an increased proportion of employed patients after surgery, 5 reported no change (3). Employment gains were considered “modest” by the authors. A randomized controlled trial of epilepsy surgery did not report significant gains in employment at 1 year (5). In summary, employment outcomes are lacking behind seizure outcomes.
Thorbecke et al. report an interesting approach to improve employment outcomes after epilepsy surgery. The patients were admitted for 3 weeks to a specialized inpatient rehabilitation following surgery. Patients who received this intervention were three times more likely to be employed 2 years after surgery than historical controls, even after controlling for preoperative employment status.
The program included medical monitoring, epilepsy nurse counseling, sports therapy, neuropsychological interview and counseling, psychological counseling, social work support, occupational therapy, and postsurgical education for epilepsy. Physical therapy, psychiatric treatment, cognitive rehabilitation, speech therapy, and training in job-seeking skills were only offered if indicated. The program distinctly included some vocational and rehabilitation components as well as psychiatric care and self-management (6).
The rehabilitation program was supported by the German social security and retirement system, with the goal to reduce disability payments. The entire inpatient program cost €4,000 per patient. This certainly raises the question about the utilization of health care dollars in various health systems and countries. A similar program in the United States would cost considerably more (7). However, if only a few patients gain employment and, therefore, their need for decades of disability payments is alleviated, the intervention will still be cost effective even with a significantly higher price tag attached to it.
Employment is a difficult outcome measure as it is influenced by various other factors such as the state of the economy, the country in which the patient lives, availability of social services, health care systems, and cultural norms. Many of these factors are quite diverse in different countries and continents, as demonstrated by a study from India in which employment was not considered an important motivation for epilepsy surgery (8). In addition, employment is influenced by patient specific factors, such as income and educational status (6).
The most significant factor affecting employment was being employed before surgery. Further, Thorbecke et al. found seizure outcome, the absence of a personality disorder, and younger age at surgery to be positive predictors for gaining or maintaining employment after surgery. A correlation of seizure outcome and a younger age with post-surgical employment is consistent with previous studies (3, 4). It seems intuitive that being seizure free as well as being younger gives patient a greater chance of gaining employment.
A personality disorder was negatively associated with obtaining gainful employment. This again stresses the need for greater focus on the psychiatric comorbidities, although the authors distinguish between personality disorders and psychiatric disease, which they feel is easier to treat. Surgery does eliminate seizures but other manifestations of epilepsy, such as the psychiatric comorbidities and cognitive impairment, persist and may prevent gains in employment and quality of life. As a crude measure for cognition, the authors included IQ, which was significant only as a factor affecting employment in univariate and not multivariate analysis. IQ measures may be too insensitive to quantify the effect of impaired cognition on employment.
Not all patients with surgery were offered rehabilitation, which introduced some selection bias. Using historical controls as well as the retrospective nature of the study certainly adds further bias. Nevertheless, the study demonstrates that additional interventions focused on psychosocial support contribute significantly more than surgery alone to achieving gainful employment. An increasing focus on similar interventions, including a greater focus on self-management, will increase our success in treating epilepsy and add to what we can achieve with AED, stimulation devices, and epilepsy surgery.
Publicly sponsored programs with a focus on self-management and comorbidities, such as the Managing Epilepsy Well Network, will hopefully raise awareness about the necessity to shift focus from seizures alone and develop interventions based on evidence-based research (9). The content of psychosocial rehabilitation and the form of delivery whether ambulatory or inpatient is certainly disputable and needs study in greater depth (10). Ambulatory outpatient programs may be as effective as inpatient rehabilitation and could contain costs. Patient preferences, costs, and feasibility certainly may play an important role (10). A greater focus on psychosocial function and self-management will hopefully make such programs more widely available and reimbursable.
This study nicely demonstrates that simple measures can have a great effect in the day-to-day life of patients. Although short-term costs may be frightening initially, it may be well worthwhile investing in such interventions as they assure long-term positive outcomes.