title: Critical determinants of the epilepsy treatment gap: a cross-national analysis in resource-limited settings.
abstract: OBJECTIVE
  Epilepsy is one of the most common serious neurologic disorders worldwide. Our objective was to determine which economic, health care, neurology, and epilepsy-specific resources were associated with untreated epilepsy in resource-constrained settings.
  
  
  METHODS
  A systematic review of the literature identified community-based studies in resource-constrained settings that calculated the epilepsy treatment gap, the proportion with untreated epilepsy, from prevalent active epilepsy cases. Economic, health care, neurology, and epilepsy-specific resources were taken from existing datasets. Poisson regression models with jackknifed standard errors were used to create bivariate and multivariate models comparing the association between treatment status and economic and health resource indicators. Relative risks were reported.
  
  
  RESULTS
  Forty-seven studies of 8,285 individuals from 24 countries met inclusion criteria. Bivariate analysis demonstrated that individuals residing in rural locations had significantly higher risks of untreated epilepsy (relative risk [RR] 1.63; 95% confidence interval [CI] 1.26-2.11). Significantly lower risks of untreated epilepsy were observed for higher physician density (RR 0.65, 95% CI 0.55-0.78), presence of a lay (RR 0.74, 95% CI 0.60-0.91) or professional association for epilepsy (RR 0.73, 95% CI 0.59-0.91), or postgraduate neurology training program (RR 0.67, 95% CI 0.55-0.82). In multivariate models, higher physician density maintained significant effects (RR 0.67; 95% CI 0.52-0.88).
  
  
  CONCLUSIONS
  Even among resource-limited regions, people with epilepsy in countries with fewer economic, health care, neurology, and epilepsy-specific resources are more likely to have untreated epilepsy. Community-based epilepsy care programs have improved access to treatment, but in order to decrease the epilepsy-treatment gap, poverty and inequalities of health care, neurology, and epilepsy resources must be dealt with at the local, national, and global levels.
authors.affiliation: Department of Neurology, University of California, San Francisco, California, USA. meyerac@sfgh.ucsf.edu
authors.forename: Ana-Claire L
authors.initials: AC
authors.lastname: Meyer
authors.forename: Tarun
authors.initials: T
authors.lastname: Dua
authors.forename: W John
authors.initials: WJ
authors.lastname: Boscardin
authors.forename: José J
authors.initials: JJ
authors.lastname: Escarce
authors.forename: Shekhar
authors.initials: S
authors.lastname: Saxena
authors.forename: Gretchen L
authors.initials: GL
authors.lastname: Birbeck
mesh_terms: D018672:Community Health Planning; D003430:Cross-Sectional Studies; D016208:Databases, Factual / Q000706:statistics & numerical data; D003695:Delivery of Health Care / Q000379:methods* / Q000706:statistics & numerical data; D004827:Epilepsy / Q000453:epidemiology / Q000628:therapy; D005260:Female; D006295:Health Resources / Q000706:statistics & numerical data*; D006301:Health Services Needs and Demand; D006801:Humans; D008297:Male