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EFFECTIVE CARE FOR HEADACHE MEANS GETTING WITH THE PROGRAM
SEATTLE—If any condition can benefit from better diagnosis and treatment, it is headache. Though headache in its many forms is common and sometimes debilitating, consultation rates for it are low, training on how to manage it is insufficient, and effective diagnostic tests to help evaluate patients with it are lacking. Moreover, headache is not often considered a high priority in the medical community.
However, according to one expert, we do not have to look far to find examples of effective headache management. The Migraine Headache Quintessentials™ Program, created by the American Academy of Neurology (AAN), and the Kaiser Permanente California approach to headache care are both excellent headache management models, said Richard B. Lipton, MD.
Dr. Lipton, who is a Professor in the Saul R. Korey Department of Neurology at Albert Einstein College of Medicine in the Bronx, New York, presented his views on headache management at the 44th Annual Scientific Meeting of the American Headache Society.
SEVEN STEPS TO HEADACHE MANAGEMENT
The Quintessentials program was designed for individual practices and is as appropriate for primary care physicians as it is for neurologists, stated Dr. Lipton; Kaiser’s strategy applies more to organizations as a whole. Both programs incorporate seven basic steps that are crucial to successful headache management, he said. These include:
Step 1: Defining the Frame
of Reference. The frame of reference for clinicians
might be an individual practice, whereas for the medical
director of a health plan it would be the entire membership
of that plan. It is necessary to create case-finding strategies
within a frame of reference—that is, devise a way to
target patients. “If your frame [of reference] is your
practice, then your case-finding strategy is relatively
straightforward because you are the person providing medical
care,” Dr. Lipton pointed out.
Step 2: Specifying Desired
Outcomes. Controlling pain may be the most important
outcome to headache sufferers, but employers may be more
concerned with minimizing lost work time owing to headache.
A good headache- management program will identify all individuals
with a stake in the program and balance their competing
needs and priorities, he said.
Step 3: Identifying Critical
Influence Points. Accurate diagnosis is one influence
point that is particularly important because it affects subsequent
intervention. Efficient use of the available diagnostic tools
and encouragement of patient self-management are other examples.
Headache guidelines such as those created by the US Headache
Consortium are often useful for identifying critical influence
points, noted Dr. Lipton.
Step
4: Measuring Critical Influence Points.
For any critical influence point, a reliable measurement
may be best achieved by examining three elements—structure,
process, and outcome. Structure refers to the systems that
are in place to deliver care, such as magnetic resonance
imaging for headache sufferers when appropriate. Process
is the systematic delivery of care—a disability assessment
for all headache patients, for example, or offering preventive
medication to every patient with frequent headaches. “When
we evaluate quality using process measures, that assumes
that we have already done research to know what works,”
Dr. Lipton related.
He defined outcome measures as the consequences of medical care that the patient, physician, or health plan desire. “So outcome measure might include reduction in disability or improved health-related quality of life,” he said. “It might be cost of care for patients with particular levels of headache-related disability.”
Step 5: Managing Critical
Influence Points. Treatment guidelines and patterns of
care in specialized chronic headache care centers can provide
insight into how to manage critical influence points. These
centers usually have explicit protocols, stress patient self-management,
and closely monitor medication selection and compliance and
comorbidities. Many employ nonphysician practitioners, a strategy
often considered vital to cost-effective care.
Steps
6 and 7: Measuring the Impact of and Assessing and Revising Headache
Management Programs. Clinical trials often contain useful
lessons on how to improve headache management in daily practice,
because there is usually a specific plan for providing care,
systematic assessment of medication compliance and outcome,
and delegation of key functions to nonphysicians. In addition,
trial participants sometimes receive self-management instruction
and, very often, telephone follow-up.
THE QUINTESSENTIALS PROGRAM
The Quintessentials program, available from the AAN at its Web site (www.aan.com) or in print, meets the Residency Review Committee requirements for education on practice improvements. The program has four phases, starting with several case simulations and a test to assess baseline knowledge about headache management. The second phase involves 60 days of intervention in which knowledge deficits are identified and the practitioner receives specific suggestions on how to improve headache management. Phase three is follow-up, essentially a repeat of the baseline assessment to determine the degree of improvement. The final phase consists of further feedback and a summary of the practitioner’s improvement. “The Quintessentials Program is an excellent tool for the neurologist or general practitioner interested in improving the care of headache patients by making specific changes in the way they practice,” said Dr. Lipton.
THE KAISER PROGRAM
At Kaiser Permanente, the first goal in headache management is identifying cases. Specifically, researchers at Kaiser watch for all patients who visit the emergency department for headaches, who overutilize triptans, or, according to their primary care physician, who require subspecialty headache management. These patients are referred for group education on various aspects of headache, such as diagnosis, triggers, and how to improve management.
A physician, registered nurse practitioner, or health care educator may run the sessions, which are also designed to provide a positive atmosphere that makes patients feel understood and in control of their headaches. The patients subsequently receive individual consultation and follow-up, often in only one or two visits. The main goal at that juncture is to implement a specific treatment plan. Patients are then referred back to their primary care physician.
An analysis of data for the first 250 participants suggested that the Kaiser program is effective. Although triptan costs for these patients increased by about 20% after six months in the program, a large decline occurred in headache-related physician and emergency department visits and in headache frequency among patients with severe headaches two or more days per week.
Furthermore, the increased costs for triptans actually reflected more appropriate use of those drugs, he said. Patients with less severe headaches who had been taking triptans at baseline markedly decreased their use, and patients with disabling headaches who had never taken triptans substantially increased their use.
“So from an aggregate cost of care perspective and from a ‘patientcentric’ outcome perspective, this program was a huge success with a relatively minor change in the structure of care,” Dr. Lipton concluded.
NR
—Timothy Begany
Suggested Reading
Evans RW, Lipton RB. Topics in migraine management: a survey of headache specialists highlights some controversies. Neurol Clin. 2001;19:1-21.
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