Worsening Trends in the Ambulatory Management of Headache

Session D4: Quality of Care/Patient Safety Moderator: Leora I. Horwitz, MD, MHS WORSENING TRENDS IN THE AMBULATORY MANAGEMENT OF HEADACHE John N. Mafi 1 ; Samuel T. Edwards 2 ; Nigel Pederson 3 ; Roger B. Davis 1 ; Ellen P. McCarthy 1,4 ; Bruce E. Landon 1,5 . 1 Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA; 2 Veterans Affairs Boston Healthcare System, Boston, MA; 3 Beth Israel Deaconess Medical Center and Massachusetts General Hospital, Boston, MA; 4 Harvard Medical School, Boston, MA; 5 Harvard Medical School, Boston, MA. (Tracking ID #1930868) BACKGROUND: Headache is a universal complaint and among the most common reasons for visiting a physician. Despite numerous headache practice guidelines published over the past decade, little is known about the extent to which U.S. physicians adhere to recommended therapies or how this has changed over time. In this context, we sought to characterize trends in the management and treatment of headache from 1999-2010. METHODS: Using nationally representative data from the National Ambulatory Medical Care Survey and the National Hospital Ambulatory Medical Care Survey we examined ambulatory visits for headache. Our primary outcomes included use of advanced imaging, referrals to other physicians, and use of opiates/barbiturates (guideline discordant indicators), as well as physician counseling on headache prevention and use of preventative therapies including verapamil, topiramate, amitriptyline, or propranolol (guideline concordant indicators). Other outcomes included abortive medications such as non-steroidal anti-inflammatory drugs (NSAIDs) or acetaminophen (APAP) and triptans/ergot alkaloids. We excluded visits with "red flags," such as neurologic deficit, cancer, or trauma. We used logistic regression models for each outcome focusing on a linear trend for each two-year interval, and adjusted for age, sex, race/ethnicity, insurance, symptom duration, geographic region, urban location, and whether the healthcare professional was the primary care physician (PCP), and weighted results to reflect U.S. population estimates. Additionally, we stratified findings by migraine versus non-migraine, acute versus chronic presentations, and visits to PCPs versus non-PCPs. RESULTS: We identified 9,110 visits for headache, which represented an estimated 139 million visits from 1999-2010. Nearly threequarters of patients were female and mean age remained stable at approximately 46 years. Our Table summarizes unadjusted use over time. Use of advanced imaging (computed tomography or magnetic resonance imaging) rose from 7.6% in 1999-2000 to 14.1% in 2009-2010 (unadjusted p<0.001) and referrals to other physicians increased from 7.7% to 12.9% (p=0.009). In contrast, physician counseling for headache prevention declined from 22.5% in 1999-2000 to 17.3% in 2009-2010 (p=0.034). Use of preventative medications increased from 8.3% to 15.0% (p=0.003) while opiates/barbiturates remained unchanged at approximately 18%. Adjusted trends (Figure) were similar as were results after stratifying by migraine versus non-migraine, acute versus chronic presentations, and visits to PCPs versus non-PCPs, with one important difference being that non-PCPs more frequently ordered advanced imaging (p<0.001). CONCLUSIONS: Contrary to numerous headache practice guidelines, physicians are increasingly ordering advanced imaging and referring to other physicians and less frequently offering first-line headache prevention counseling to their patients. Worsening adherence to headache guidelines represents an area of particular concern for our healthcare system and stands out as an important opportunity to improve the value of U.S. healthcare. Table. Unadjusted Use over Time (% of Visits) Year (sample n) 1999-2000 (n=1,287) 2001-2002 (n=1,694) 2003-2004 (n=1,647) 2005-2006 (n=1,453) 2007-2008 (n=1,515) 2009-2010 (n=1,514) Pvalue Advanced Imaging (CT/MRI) 7.6 7.3 8.0 10.7 13.5 14.1 <0.001 Referrals to Other Physicians 7.7 9.8 11.7 10.7 13.5 12.9 0.009 Headache Prevention Counseling 22.5 21.8 23.2 18.8 15.6 17.3 0.034