Population-based data on drug-resistant epilepsy (DRE) are lacking. This retrospective study aimed to determine the prevalence and incidence of pediatric epilepsy and DRE in South Korea using health insurance claims data from the Health Insurance Review and Assessment Service (2013–2022). Epilepsy and DRE prevalence and incidence in children <18 years old were estimated over time and by age and sex. Results showed that the age-standardized prevalence and incidence rates of epilepsy increased. The age-standardized prevalence rate of DRE increased, while the age-standardized incidence rate remained unchanged. The standardized prevalence rate of DRE was 0.26 per 1000 persons, and the average standardized incidence rate of DRE was 0.06 per 1000 persons. The prevalence rate of DRE gradually increased with age, with age 0 demonstrating the highest incidence rate. The prevalence of generalized DRE was the highest across all ages, and incidence was the highest at 0 years. Conversely, the incidence of focal DRE did not change with age. Our study revealed a stable incidence rate of DRE in Korea, despite increased prevalence. DRE incidence was the highest in the first year of life, with the generalized type being the most prevalent.

Pediatric drug-resistant epilepsy (DRE) affects 30–40% of children with epilepsy, resulting in medical costs significantly higher than those of controlled epilepsy. Cranial epilepsy surgery (CES) and vagus nerve stimulation (VNS) are key interventions; however, their long-term economic impact remains ambiguous. Using South Korea’s National Health Insurance claims data (2007–2022), we examined healthcare utilization and costs among children with DRE treated with antiseizure medications (ASM) only, CES, or VNS. Of the cohort included 6020 patients, of whom 5407 (89.8%) received ASM-only treatment, 396 (6.6%) underwent CES, and 217 (3.6%) received VNS. Post-CES, emergency department (ED) visits declined by 65%, overall length of stay (LOS) by 45%, epilepsy-specific admissions by 49% and epilepsy-specific LOS by 83%. Interrupted time series analysis revealed a sustained monthly reduction in total costs, consistent with fewer high-risk encounters. Post-VNS, ED visits fell by 41%, admissions by 39%, and LOS by 44%, with reductions in epilepsy-related admissions; however, outpatient visits remained unchanged. Both CES and VNS significantly reduce acute-care needs in pediatric DRE. CES yields the greatest and most durable benefits, while VNS shifts care from emergency and inpatient settings to scheduled outpatient follow-up, offering a valuable alternative when surgery is not feasible.