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Rahimi F, Rabiei R, Seddighi AS, Roshanpoor A, Seddighi A, Moghaddasi H. Features and functions of decision support systems for appropriate diagnostic imaging: a scoping review. Diagnosis (Berl) 2024; 11:4-16. [PMID: 37795534 DOI: 10.1515/dx-2023-0083] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2023] [Accepted: 09/10/2023] [Indexed: 10/06/2023]
Abstract
BACKGROUND Diagnostic imaging decision support (DI-DS) systems could be effective tools for reducing inappropriate diagnostic imaging examinations. Since effective design and evaluation of these systems requires in-depth understanding of their features and functions, the present study aims to map the existing literature on DI-DS systems to identify features and functions of these systems. METHODS The search was performed using Scopus, Embase, PubMed, Web of Science, and Cochrane Central Registry of Controlled Trials (CENTRAL) and was limited to 2000 to 2021. Analytical studies, descriptive studies, reviews and book chapters that explicitly addressed the functions or features of DI-DS systems were included. RESULTS A total of 6,046 studies were identified. Out of these, 55 studies met the inclusion criteria. From these, 22 functions and 22 features were identified. Some of the identified features were: visibility, content chunking/grouping, deployed as a multidisciplinary program, clinically valid and relevant feedback, embedding current evidence, and targeted recommendations. And, some of the identified functions were: displaying an appropriateness score, recommending alternative or more appropriate imaging examination(s), providing recommendations for next diagnostic steps, and providing safety alerts. CONCLUSIONS The set of features and functions obtained in the present study can provide a basis for developing well-designed DI-DS systems, which could help to improve adherence to diagnostic imaging guidelines, minimize unnecessary costs, and improve the outcome of care through appropriate diagnosis and on-time care delivery.
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Affiliation(s)
- Fatemeh Rahimi
- Department of Health Information Technology and Management, Medical Informatics, School of Allied Medical Sciences, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Reza Rabiei
- Department of Health Information Technology and Management, Medical Informatics, School of Allied Medical Sciences, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Amir Saied Seddighi
- Functional Neurosurgery Research Center, Shohada Tajrish Comprehensive Neurosurgical Center of Excellence, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Arash Roshanpoor
- Department of computer, Yadegar-e-Imam Khomeini (RAH), Janat-abad Branch, Islamic Azad University, Tehran, Iran
| | - Afsoun Seddighi
- Functional Neurosurgery Research Center, Shohada Tajrish Comprehensive Neurosurgical Center of Excellence, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Hamid Moghaddasi
- Department of Health Information Technology and Management, Health Information Management & Medical Informatics, School of Allied Medical Sciences, Shahid Beheshti University of Medical Sciences, Darband St., Tehran, Iran
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Beltramone M, Redon S, Fernandes S, Ducros A, Avouac A, Donnet A. The teaching of headache medicine in France: A questionnaire-based study. Headache 2022; 62:1177-1186. [PMID: 36200808 PMCID: PMC9828409 DOI: 10.1111/head.14395] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2022] [Revised: 07/05/2022] [Accepted: 07/05/2022] [Indexed: 11/06/2022]
Abstract
BACKGROUND The treatment of patients with headache represents an important part of a neurologist's activity. It requires sufficient training for neurology residents. In France, residents in neurology can complete this training by attending specialized consultations or by participating in a postgraduate training program called "Diplôme Inter-Universitaire Migraine et Céphalées" (DIUMC). OBJECTIVE The objective of this cross-sectional study was to investigate the French residents' knowledge in headache medicine and the impact of different types of training in headache medicine that are available in France. METHODS An anonymous survey was carried out among 548 French residents in neurology. RESULTS The questionnaires of 121 residents (22.1%) were analyzed. Among them, 54.5% (66/121) had no complementary training apart from the internship (Group 1), 21.5% (26/121) had attended only specialized consultations (Group 2), and 24% (29/121) had participated in the DIUMC (Group 3). There was no difference between all groups regarding the knowledge of the prevalence of primary or chronic headaches. There was almost no difference between the groups in the management of episodic migraine. In contrast, the management of tension-type headache and chronic headache was better known by residents of Group 3 than residents of Group 1. In these two diseases, residents of Group 3 offered prophylactic treatment more often. Almost 29% of the residents (35/121) had read the French guidelines for the diagnosis and management of migraine. In Group 3, residents had read them significantly more often (1.6% in Group 1, 38.5% in Group 2 and 62.1% in Group 3, p < 0.001). CONCLUSION This study shows the lack of knowledge among French neurology residents regarding headache medicine. It highlights the interest of specific training programs that could improve the practical and theoretical knowledge of future neurologists.
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Affiliation(s)
- Marion Beltramone
- Department of Evaluation and Treatment of PainFHU INOVPAIN, CHU Timone, AP‐HMMarseilleFrance
| | - Sylvain Redon
- Department of Evaluation and Treatment of PainFHU INOVPAIN, CHU Timone, AP‐HMMarseilleFrance
| | - Sara Fernandes
- Service d'Epidémiologie et d'Economie de la Santé, Unité de Recherche Clinique, Direction de la Recherche en SantéAix Marseille Univ, APHM, Hôpital de la TimoneMarseilleFrance
| | - Anne Ducros
- Neurology DepartmentCHU de MontpellierMontpellierFrance
| | - Alexandre Avouac
- Department of Evaluation and Treatment of PainFHU INOVPAIN, CHU Timone, AP‐HMMarseilleFrance
| | - Anne Donnet
- Department of Evaluation and Treatment of PainFHU INOVPAIN, CHU Timone, AP‐HMMarseilleFrance,INSERM U‐1107, CHU de Clermont‐FerrandClermont‐FerrandFrance
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3
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Reynolds EL, Burke JF, Evans L, Syed FI, Liao E, Lobo R, Cooper W, Charleston L, Callaghan BC. Headache neuroimaging: A survey of current practice, barriers, and facilitators to optimal use. Headache 2022; 62:36-56. [PMID: 35041218 PMCID: PMC9053599 DOI: 10.1111/head.14249] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2021] [Revised: 09/15/2021] [Accepted: 10/07/2021] [Indexed: 09/02/2023]
Abstract
OBJECTIVE The objective of this study was to understand current practice, clinician understanding, attitudes, barriers, and facilitators to optimal headache neuroimaging practices. BACKGROUND Headaches are common in adults, and neuroimaging for these patients is common, costly, and increasing. Although guidelines recommend against routine headache neuroimaging in low-risk scenarios, guideline-discordant neuroimaging is still frequently performed. METHODS We administered a 60-item survey to headache clinicians at the Veterans Affairs health system to assess clinician understanding and attitudes on headache neuroimaging and to determine neuroimaging practice patterns for three scenarios describing hypothetical patients with headaches. Descriptive statistics were used to summarize responses, stratified by clinician type (physicians or advanced practice clinicians [APCs]) and specialty (neurology or primary care). RESULTS The survey was successfully completed by 431 of 1426 clinicians (30.2% response rate). Overall, 317 of 429 (73.9%) believed neuroimaging was overused for patients with headaches. However, clinicians would utilize neuroimaging a mean (SD) 30.9% (31.7) of the time in a low-risk scenario without red flags, and a mean 67.1% (31.9) of the time in the presence of minor red flags. Clinicians had stronger beliefs in the potential benefits (268/429, 62.5%) of neuroimaging compared to harms (181/429, 42.2%) and more clinicians were bothered by harms stemming from the omission of neuroimaging (377/426, 88.5%) compared to commission (329/424, 77.6%). Additionally, APCs utilized neuroimaging more frequently than physicians and were more receptive to potential interventions to improve neuroimaging utilization. CONCLUSIONS Although a majority of clinicians believed neuroimaging was overused for patients with headaches, many would utilize neuroimaging in low-risk scenarios with a small probability of changing management. Future studies are needed to define the role of currently used red flags given their importance in neuroimaging decisions. Importantly, APCs may be an ideal target for future optimization efforts.
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Affiliation(s)
- Evan L Reynolds
- Department of Neurology, University of Michigan, Ann Arbor, Michigan, USA
| | - James F Burke
- Department of Neurology, University of Michigan, Ann Arbor, Michigan, USA
- VA Center for Clinical Management Research, Ann Arbor, Michigan, USA
| | - Lacey Evans
- VA Center for Clinical Management Research, Ann Arbor, Michigan, USA
| | - Faiz I Syed
- Department of Radiology, University of Michigan, Ann Arbor, Michigan, USA
- Department of Radiology, VA Ann Arbor Health System, Ann Arbor, Michigan, USA
| | - Eric Liao
- Department of Radiology, University of Michigan, Ann Arbor, Michigan, USA
| | - Remy Lobo
- Department of Radiology, University of Michigan, Ann Arbor, Michigan, USA
| | - Wade Cooper
- Department of Neurology, University of Michigan, Ann Arbor, Michigan, USA
| | - Larry Charleston
- College of Human Medicine, Michigan State University, East Lansing, Michigan, USA
- Jefferson Headache Center, Philadelphia, Pennsylvania, USA
| | - Brian C Callaghan
- Department of Neurology, University of Michigan, Ann Arbor, Michigan, USA
- VA Center for Clinical Management Research, Ann Arbor, Michigan, USA
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Kristoffersen ES, Faiz KW, Hansen JM, Tronvik EA, Frich JC, Lundqvist C, Winsvold BS. The management and clinical knowledge of headache disorders among general practitioners in Norway: a questionnaire survey. J Headache Pain 2021; 22:136. [PMID: 34763647 PMCID: PMC8582095 DOI: 10.1186/s10194-021-01350-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2021] [Accepted: 10/28/2021] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND General practitioners (GPs) diagnose and manage a majority of headache patients seeking health care. With the aim to understand the potential for clinical improvement and educational needs, we performed a study to investigate Norwegian GPs knowledge about headache and its clinical management. METHODS We invited GPs from a random sample of 130 Norwegian continuous medical education (CME) groups to respond to an anonymous questionnaire survey. RESULTS 367 GPs responded to the survey (73% of invited CME groups, 7.6% of all GPs in Norway). Mean age was 46 (SD 11) years, with an average of 18 (SD 10) years of clinical experience. In general the national treatment recommendations were followed, while the International Classification of Headache Disorders and other international guidelines were rarely used. Overall, 80% (n = 292) of the GPs suggested adequate prophylactic medication for frequent episodic migraine, while 28% (n = 101) suggested adequate prophylactic medication for chronic tension-type headache (CTTH). Half (52%, n = 191)) of the respondents were aware that different types of acute headache medication can lead to medication-overuse headache (MOH), and 59% (n = 217) knew that prophylactic headache medication does not lead to MOH. GPs often used MRI in the diagnostic work-up. GPs reported that lack of good treatment options was a main barrier to more optimized treatment of headache patients. CONCLUSION The knowledge of management of CTTH and MOH was moderate compared to migraine among Norwegian GPs.
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Affiliation(s)
- Espen Saxhaug Kristoffersen
- Department of General Practice, University of Oslo, PO Box 1130, Blindern, 0318, Oslo, Norway. .,Department of Neurology, Akershus University Hospital, Lørenskog, Norway. .,Department of Research and Innovation, Division of Clinical Neuroscience, Oslo University Hospital, Oslo, Norway.
| | - Kashif Waqar Faiz
- Department of Neurology, Akershus University Hospital, Lørenskog, Norway
| | - Jakob Møller Hansen
- Danish Knowledge Centre on Headache Disorders, Rigshospitalet-Glostrup, University, of Copenhagen, Glostrup, Denmark
| | - Erling Andreas Tronvik
- Department of Neuromedicine and Movement Science, NTNU Norwegian University of Science and Technology, Trondheim, Norway.,Department of Neurology, National Advisory Unit on Headaches, St. Olavs Hospital, Trondheim, Norway
| | - Jan C Frich
- Department of Health Management and Health Economics, Institute of Health and Society, University of Oslo, Oslo, Norway
| | - Christofer Lundqvist
- Department of Neurology, Akershus University Hospital, Lørenskog, Norway.,Health Services Research Unit, Akershus University Hospital, Lørenskog, Norway.,Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Bendik Slagsvold Winsvold
- Department of Research and Innovation, Division of Clinical Neuroscience, Oslo University Hospital, Oslo, Norway.,Department of Neurology, Oslo University Hospital, Oslo, Norway
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Mueller B, Sweetnam C, Klenofsky B, Pace A, Grant J, Natbony L, Robinson-Papp J, Kummer B. A retrospective cohort study of clinical factors, visit patterns, and demographic factors associated with use of remote communications in patients with headache. Headache 2021; 61:1521-1528. [PMID: 34713896 DOI: 10.1111/head.14226] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2021] [Revised: 07/07/2021] [Accepted: 08/04/2021] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To identify the characteristics associated with high utilization of remote communications (RCs) in patients with headache. BACKGROUND Patients with headache frequently communicate with their providers using secure portal messaging and telephone calls. However, clinical and demographic factors as well as visit patterns associated with RC utilization remain poorly characterized. METHODS We retrospectively analyzed data from patients with headache who were evaluated in the ambulatory neurology faculty practice at the Icahn School of Medicine at Mount Sinai in New York between January 1 and June 30, 2019. We extracted clinical and demographic characteristics, total office visits, secure MyChart portal messages, and telephone encounters from our institutional data warehouse. We defined high RC and MyChart utilization as the top tertile of RC and MyChart message volume, respectively, and assessed the relationship between patient characteristics and high RC (primary outcome), as well as high MyChart utilization (secondary outcome). We characterized the relationship between clinicodemographic characteristics and the ratio of MyChart messages to total RCs (secondary outcome). RESULTS We identified 1390 patients, of whom 477 (34.3%) were high RC utilizers and 321 (23.1%) were high MyChart utilizers. High RC utilizers generated 3306/3921 (84.3%) RCs. The presence of chronic headache (aOR 2.31, 95% CI 1.75-3.03, p < 0.0001), cluster headache (aOR 18.3, 95% CI 5.0-71.7, p = 0.001), and migraine (aOR 3.82, 95% CI 1.93-9.3, p = 0.011) was associated with high RC utilization. Patients ≥65 years of age were less likely to engage in MyChart messaging as a proportion of RC (191/680, 28.1%) compared with patients 18-30 years of age (243/620, 39.2%, p = 0.049) and 30-64 years of age (1172/2721, 43.1%, p < 0.0001). CONCLUSIONS A minority of patients with headache (477/1390; 34.3%) generated the majority (3306/3921; 84.3%) of RCs. Our findings should be validated in external patient cohorts with the objective of developing strategies to optimize RC utilization.
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Affiliation(s)
- Bridget Mueller
- Center for Headache and Facial Pain, Department of Neurology, Icahn School of Medicine at Mount Sinai, New York City, New York, USA
| | - Chloe Sweetnam
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York City, New York, USA
| | - Britany Klenofsky
- Center for Headache and Facial Pain, Department of Neurology, Icahn School of Medicine at Mount Sinai, New York City, New York, USA
| | - Anna Pace
- Center for Headache and Facial Pain, Department of Neurology, Icahn School of Medicine at Mount Sinai, New York City, New York, USA
| | - Jihan Grant
- Center for Headache and Facial Pain, Department of Neurology, Icahn School of Medicine at Mount Sinai, New York City, New York, USA
| | - Lauren Natbony
- Center for Headache and Facial Pain, Department of Neurology, Icahn School of Medicine at Mount Sinai, New York City, New York, USA
| | - Jessica Robinson-Papp
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York City, New York, USA
| | - Benjamin Kummer
- Department of Neurology, Clinical Informatics, Icahn School of Medicine at Mount Sinai, Mount Sinai Health System, New York City, New York, USA
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Tabeeva G, Katsarava Z, Dmitriev G, Lyubovnaya Y, Kovalchuk N. Migraine in the real-life clinical practice: results of the observational study of diagnosis and treatment patterns in the urban population of the Russian Federation. Zh Nevrol Psikhiatr Im S S Korsakova 2021; 121:40-50. [DOI: 10.17116/jnevro202112112140] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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7
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Rua T, Mazumder A, Akande Y, Margariti C, Ochulor J, Turville J, Razavi R, Peacock JL, McCrone P, Goh V, Shearer J, Afridi S. Management of chronic headache with referral from primary care to direct access to MRI compared with Neurology services: an observational prospective study in London. BMJ Open 2020; 10:e036097. [PMID: 33067273 PMCID: PMC7569948 DOI: 10.1136/bmjopen-2019-036097] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
OBJECTIVES To evaluate the cost, accessibility and patient satisfaction implications of two clinical pathways used in the management of chronic headache. INTERVENTION Management of chronic headache following referral from Primary Care that differed in the first appointment, either a Neurology appointment or an MRI brain scan. DESIGN AND SETTING A pragmatic, non-randomised, prospective, single-centre study at a Central Hospital in London. PARTICIPANTS Adult patients with chronic headache referred from primary to secondary care. PRIMARY AND SECONDARY OUTCOME MEASURES Participants' use of healthcare services and costs were estimated using primary and secondary care databases and questionnaires quarterly up to 12 months postrecruitment. Cost analyses were compared using generalised linear models. Secondary outcomes assessed: access to care, patient satisfaction, headache burden and self-perceived quality of life using headache-specific (Migraine Disability Assessment Scale and Headache Impact Test) and a generic questionnaire (5-level EQ-5D). RESULTS Mean (SD) cost up to 6 months postrecruitment per participant was £578 (£420) for the Neurology group (n=128) and £245 (£172) for the MRI group (n=95), leading to an estimated mean cost difference of £333 (95% CI £253 to £413, p<0.001). The mean cost difference at 12 months increased to £518 (95% CI £401 to £637, p<0.001). When adjusted for baseline and follow-up imbalances between groups, this remained statistically significant. The utilisation of brain MRI improved access to care compared with the Neurology group (p<0.001). Participants in the Neurology group reported higher levels of satisfaction associated with the pathway and led to greater change in care management. CONCLUSION Direct referral to brain MRI from Primary Care led to cost-savings and quicker access to care but lower satisfaction levels when compared with referral to Neurology services. Further research into the use of brain MRI for a subset of patient population more likely to be reassured by a negative brain scan should be considered. TRIAL REGISTRATION NUMBER NCT02753933.
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Affiliation(s)
- Tiago Rua
- King's Health Economics, King's College London, London, UK
- Clinical Imaging and Medical Physics, Guy's and Saint Thomas' NHS Foundation Trust, London, UK
| | - Asif Mazumder
- Neuroradiology Group, Department of Radiology, Lambeth Wing, Guy's and St Thomas' Hospitals NHS Foundation Trust, London, UK
| | - Yvonne Akande
- Clinical Imaging and Medical Physics, Guy's and Saint Thomas' NHS Foundation Trust, London, UK
| | - Charikleia Margariti
- Clinical Imaging and Medical Physics, Guy's and Saint Thomas' NHS Foundation Trust, London, UK
| | - Juliana Ochulor
- Neurology Department, Guy's and Saint Thomas' NHS Foundation Trust, London, UK
| | - Joanna Turville
- Clinical Imaging and Medical Physics, Guy's and Saint Thomas' NHS Foundation Trust, London, UK
| | - Reza Razavi
- Imaging Science Division, King's College London, London, UK
| | - Janet L Peacock
- Division of Primary Care and Public Health Sciences, King's College London, London, UK
| | - Paul McCrone
- King's Health Economics, King's College London, London, UK
| | - Vicky Goh
- School of Biomedical Engineering and Imaging Sciences, King's College London, London, UK
| | - James Shearer
- Division of Primary Care and Public Health Sciences, King's College London, London, UK
| | - Shazia Afridi
- Neurology Department, Guy's and Saint Thomas' NHS Foundation Trust, London, UK
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Kamtchum-Tatuene J, Kenteu B, Fogang YF, Zafack JG, Nyaga UF, Noubiap JJ. Neuroimaging findings in headache with normal neurologic examination: Systematic review and meta-analysis. J Neurol Sci 2020; 416:116997. [DOI: 10.1016/j.jns.2020.116997] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Revised: 05/25/2020] [Accepted: 06/15/2020] [Indexed: 01/16/2023]
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9
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Onder H, Kisbet T. Neuroimaging findings in patients with idiopathic intracranial hypertension and cerebral venous thrombosis, and their association with clinical features. Neurol Res 2020; 42:141-147. [PMID: 31910744 DOI: 10.1080/01616412.2019.1710408] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Objective: To investigate the frequency of neuroimaging findings of intracranial hypertension in patients with idiopathic intracranial hypertension (IIH) and cerebral venous thrombosis (CVT). We also aimed to compare these findings in two patient groups and investigate the association of these findings with some clinical parameters.Methods: Patients with IIH and CVT admitted to the neurology, neuro-ophthalmology outpatient clinics, and emergency services between 2017 and 2019 were enrolled in this study. The presence of eight previously defined neuroimaging signs of intracranial hypertension were evaluated on MRIs. The values of total MRI scores were formed to use in the analyses investigating the association between neuroimaging findings and clinical parameters.Results: Twenty-three patients with proven IIH and seven patients with CVT with signs of intracranial hypertension were included in this study. Body mass index (BMI) values were higher in the IIH group than in the CVT group (31.0/25.9; p = 0.022). There were no differences in terms of gender distribution, age, ortotal MRI scores between the patient groups. The most common neuroimaging parameters found in the IIH group were the following: increased peri-optic cerebrospinal fluid (CSF) (n = 20) and optic nerve tortuosity (n = 12). There were no significant correlations between values of total MRI scores, lumbar puncture opening pressure, and BMI.Conclusion: Neuroimaging findings are useful tools with high diagnostic sensitivity in IIH. The most sensitive finding was increased peri-optic CSF. The utility of these neuroimaging correlates and their potential significance as solely diagnostic markers in IIH should be investigated in future large-scale studies.
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Affiliation(s)
- Halil Onder
- Neurology Clinic, Yozgat City Hospital, Yozgat, Turkey
| | - Tanju Kisbet
- Radiology Clinic, Yozgat City Hospital, Yozgat, Turkey
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10
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Kim BS, Kim SK, Kim JM, Moon HS, Park KY, Park JW, Sohn JH, Song TJ, Chu MK, Cha MJ, Kim BK, Cho SJ. Factors Associated with Incidental Neuroimaging Abnormalities in New Primary Headache Patients. J Clin Neurol 2020; 16:222-229. [PMID: 32319238 PMCID: PMC7174120 DOI: 10.3988/jcn.2020.16.2.222] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2019] [Revised: 10/24/2019] [Accepted: 10/24/2019] [Indexed: 12/12/2022] Open
Abstract
Background and Purpose Deciding whether or not to perform neuroimaging in primary headache is a dilemma for headache physicians. The aim of this study was to identify clinical predictors of incidental neuroimaging abnormalities in new patients with primary headache disorders. Methods This cross-sectional study was based on a prospective multicenter headache registry, and it classified 1,627 consecutive first-visit headache patients according to the third edition (beta version) of the International Classification of Headache Disorders (ICHD-3β). Primary headache patients who underwent neuroimaging were finally enrolled in the analysis. Serious intracranial pathology was defined as serious neuroimaging abnormalities with a high degree of medical urgency. Univariable and multivariable logistic regression analyses were conducted to identify factors associated with incidental neuroimaging abnormalities. Results Neuroimaging abnormalities were present in 170 (18.3%) of 927 eligible patients. In multivariable analysis, age ≥40 years [multivariable-adjusted odds ratio (aOR)=3.37, 95% CI=2.07–6.83], male sex (aOR=1.61, 95% CI=1.12–2.32), and age ≥50 years at headache onset (aOR=1.86, 95% CI=1.24–2.78) were associated with neuroimaging abnormalities. In univariable analyses, age ≥40 years was the only independent variable associated with serious neuroimaging abnormalities (OR=3.37, 95% CI=1.17–9.66), which were found in 34 patients (3.6%). These associations did not change after further adjustment for neuroimaging modality. Conclusions Incidental neuroimaging abnormalities were common and varied in a primary headache diagnosis. A small proportion of the patients incidentally had serious neuroimaging abnormalities, and they were predicted by age ≥40 years. These findings can be used to guide the performing of neuroimaging in primary headache disorders.
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Affiliation(s)
- Byung Su Kim
- Department of Neurology, Bundang Jesaeng General Hospital, Daejin Medical Center, Seongnam, Korea
| | - Soo Kyoung Kim
- Department of Neurology, Gyeongsang National University College of Medicine, Jinju, Korea
| | - Jae Moon Kim
- Department of Neurology, Chungnam National University College of Medicine, Daejeon, Korea
| | - Heui Soo Moon
- Department of Neurology, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Kwang Yeol Park
- Department Neurology, Chung-Ang University Hospital, Chung-Ang University College of Medicine, Seoul, Korea
| | - Jeong Wook Park
- Department of Neurology, Uijeongbu St.Mary's Hospital, The Catholic University of Korea College of Medicine, Uijeongbu, Korea
| | - Jong Hee Sohn
- Department of Neurology, Chuncheon Sacred Heart Hospital, Hallym University College of Medicine, Chuncheon, Korea
| | - Tae Jin Song
- Department of Neurology, Ewha Womans University Seoul Hospital, Ewha Womans University College of Medicine, Seoul, Korea
| | - Min Kyung Chu
- Department of Neurology, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Myoung Jin Cha
- Department of Neurology, National Police Hospital, Seoul, Korea
| | - Byung Kun Kim
- Department of Neurology, Eulji Hospital, Eulji University, Seoul, Korea
| | - Soo Jin Cho
- Department of Neurology, Dongtan Sacred Heart Hospital, Hallym University College of Medicine, Hwaseong, Korea.
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11
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Systematic review and meta-analysis of MRI signs for diagnosis of idiopathic intracranial hypertension. Eur J Radiol 2019; 116:106-115. [DOI: 10.1016/j.ejrad.2019.04.023] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2019] [Revised: 04/06/2019] [Accepted: 04/29/2019] [Indexed: 01/02/2023]
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12
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Kristoffersen ES, Faiz KW, Winsvold BS. Neurology residents' knowledge of the management of headache. Cephalalgia 2019; 39:1396-1406. [PMID: 31067081 DOI: 10.1177/0333102419847973] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND In Norway, as in most other countries, the training program for clinical neurology has no mandatory headache program. Knowledge in headache management must therefore be acquired during everyday clinical training. The objectives of this study were to investigate neurology residents' knowledge of headache. METHODS A questionnaire survey was undertaken among neurology residents in Norway. RESULTS All 17 neurological departments in Norway participated, and 143 residents responded (86%). Sixty percent were women, mean age was 32.5 years, and the respondents had an average of 28 months clinical training in neurology. Fifty-six percent knew the approximate prevalence of migraine and chronic headache. Thirty-seven percent asked their patients about disability, quality of life, and social functioning at every consultation. Further, 72% would prescribe prophylaxis for chronic tension-type headache and 97% for very frequent migraine. One third wrongly stated that use of the most common headache prophylactics could lead to medication-overuse headache. Headache diaries were used regularly by 63% for diagnostic purposes, and 73% requested an MRI for all long-lasting headaches referred to neurological outpatient clinics. CONCLUSION Although a major public health problem, headache knowledge is moderate at best, and its management clearly varies. There is an unmet need for a better and more structured headache training program in Norway.
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Affiliation(s)
- Espen Saxhaug Kristoffersen
- Department of Neurology, Akershus University Hospital, Lørenskog, Norway.,Department of General Practice, HELSAM, University of Oslo, Oslo, Norway.,FORMI, Oslo University Hospital, Oslo, Norway
| | - Kashif Waqar Faiz
- Department of Neurology, Akershus University Hospital, Lørenskog, Norway.,Research Centre, Akershus University Hospital, Lørenskog, Norway
| | - Bendik Slagsvold Winsvold
- FORMI, Oslo University Hospital, Oslo, Norway.,Department of Research, Innovation and Education, Division of Clinical Neuroscience, Oslo University Hospital, Oslo, Norway
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13
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Carey MR, Callaghan BC, Kerber KA, Skolarus LE, Burke JF. Impact of early headache neuroimaging on time to malignant brain tumor diagnosis: A retrospective cohort study. PLoS One 2019; 14:e0211599. [PMID: 30707721 PMCID: PMC6358089 DOI: 10.1371/journal.pone.0211599] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2018] [Accepted: 01/16/2019] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Neuroimaging for headaches is both common and costly. While the costs are well quantified, little is known about the benefit in terms of diagnosing pathology. Our objective was to determine the role of early neuroimaging in the identification of malignant brain tumors in individuals presenting to healthcare providers with headaches. METHODS This was a retrospective cohort study using administrative claims data (2001-2014) from a US insurer. Individuals were included if they had an outpatient visit for headaches and excluded for prior headache visits, other neurologic conditions, neuroimaging within the previous year, and cancer. The exposure was early neuroimaging, defined as neuroimaging within 30 days of the first headache visit. A propensity score-matched group that did not undergo early neuroimaging was then created. The primary outcome was frequency of malignant brain tumor diagnoses and median time to diagnosis within the first year after the incident headache visit. The secondary outcome was frequency of incidental findings. RESULTS 22.2% of 180,623 individuals had early neuroimaging. In the following year, malignant brain tumors were found in 0.28% (0.23-0.34%) of the early neuroimaging group and 0.04% (0.02-0.06%) of the referent group (P<0.001). Median time to diagnosis in the early neuroimaging group was 8 (3-19) days versus 72 (39-189) days for the referent group (P<0.001). Likely incidental findings were discovered in 3.17% (3.00-3.34%) of the early neuroimaging group and 0.66% (0.58-0.74%) of the referent group (P<0.001). CONCLUSIONS Malignant brain tumors in individuals presenting with an incident headache diagnosis are rare and early neuroimaging leads to a small reduction in the time to diagnosis.
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Affiliation(s)
- Matthew R. Carey
- University of Michigan Medical School, University of Michigan, Ann Arbor, Michigan, United States of America
- * E-mail:
| | - Brian C. Callaghan
- Department of Neurology, University of Michigan, Ann Arbor, Michigan, United States of America
| | - Kevin A. Kerber
- Department of Neurology, University of Michigan, Ann Arbor, Michigan, United States of America
| | - Lesli E. Skolarus
- Department of Neurology, University of Michigan, Ann Arbor, Michigan, United States of America
| | - James F. Burke
- Department of Neurology, University of Michigan, Ann Arbor, Michigan, United States of America
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14
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Young NP, Elrashidi MY, McKie PM, Ebbert JO. Neuroimaging utilization and findings in headache outpatients: Significance of red and yellow flags. Cephalalgia 2018; 38:1841-1848. [DOI: 10.1177/0333102418758282] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Background Neuroimaging for headache commonly exceeds published guideline recommendations and may be overutilized. Methods We conducted a retrospective cross-sectional study of all outpatient community patients at Mayo Clinic Rochester who underwent a neuroimaging study for a headache indication in 2015. We assessed the neuroimaging utilization pattern, clinical application of red flags, and concordance with neuroimaging guidelines. Results We identified 190 outpatients who underwent 304 neuroimaging studies for headache. The median age was 46.5 years (range 18–91 years), 65% were female, and most reported no prior history of headache (n = 97, 51%). A minority of patients had prior brain imaging studies (n = 44, 23%) and neurological consultations for headache (n = 29, 15%). Few studies were ordered after consultation with a neurologist (n = 14, 7%). Seventy-seven percent of patients were documented to have a “red flag” justifying the imaging study. Abnormal neuroimaging findings were found in 3.1% of patients with warning flags (5/161); carotid dissection (n = 3) and reversible cerebral vasoconstrictive syndrome (n = 2). An estimated 35% of patients were imaged against guidelines. Conclusions The prevalence of serious causes of headache in a community practice was low despite the presence of a documented red flag symptom. Inadequate understanding or application of red flags may be contributing to recommendations to image patients against current guidelines. Interventions to reduce unnecessary neuroimaging of patients with headache need to be designed and implemented.
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Affiliation(s)
- Nathan P Young
- Department of Neurology, Mayo Clinic, Rochester, MN, USA
| | - Muhamad Y Elrashidi
- Division of Primary Care Internal Medicine, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Paul M McKie
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| | - Jon O Ebbert
- Division of Primary Care Internal Medicine, Department of Medicine, Mayo Clinic, Rochester, MN, USA
- Robert D and Patricia E Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA
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15
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Cote DJ, Laws ER. The Ethics of "Choosing Wisely": The Use of Neuroimaging for Uncomplicated Headache. Neurosurgery 2018; 80:816-819. [PMID: 28327977 DOI: 10.1093/neuros/nyw180] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2016] [Accepted: 12/22/2016] [Indexed: 11/14/2022] Open
Abstract
The use of magnetic resonance imaging (MRI) for evaluation of headache remains excessive among physicians across many specialties according to both the American Headache Society and the American College of Radiology, despite recent attempts at limiting overuse of imaging and procedures. As part of the Choosing Wisely campaign, both of these organizations have explicitly recommended against imaging in patients with uncomplicated or typical migraine headaches. Yet, the practice nevertheless remains prevalent, with estimates ranging from 12.4% to 15.9% of patients with uncomplicated headache receiving MRI in outpatient practices. The low prevalence of serious pathological findings on imaging in patients who present without other indicative symptoms and the high cost of such exams necessitates a thorough evaluation of appropriate use of MRI for headache. Here, we debate the problematic use of MRI for uncomplicated headache and put forth a discussion of possible interventions that could promote more efficient use of imaging. Overuse of imaging has the potential to open a box that cannot readily be closed, and physicians upstream of surgical decision making must remain aware of the downstream effects of their clinical choices.
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16
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Callaghan BC, Burke JF, Kerber KA, Skolarus LE, Ney JP, Magliocco B, Esper GJ. The association of neurologists with headache health care utilization and costs. Neurology 2018; 90:e525-e533. [PMID: 29321226 DOI: 10.1212/wnl.0000000000004925] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2017] [Accepted: 10/27/2017] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To determine the association of a neurologist visit with headache health care utilization and costs. METHODS Utilizing a large privately insured health care claims database, we identified patients with an incident headache diagnosis (ICD-9 codes 339.xx, 784.0x, 306.81) with at least 5 years follow-up. Patients with a subsequent neurologist visit were matched to controls without a neurologist visit using propensity score matching, accounting for 54 potential confounders and regional variation in neurologist density. Co-primary outcomes were emergency department (ED) visits and hospitalizations for headache. Secondary outcomes were quality measures (abortive, prophylactic, and opioid prescriptions) and costs (total, headache-related, and non-headache-related). Generalized estimating equations assessed differences in longitudinal outcomes between cases and controls. RESULTS We identified 28,585 cases and 57,170 controls. ED visits did not differ between cases and controls (p = 0.05). Hospitalizations were more common in cases in year 0-1 (0.2%, 95% confidence interval [CI] 0.2%-0.3% vs 0.01%, 95% CI 0.01%-0.02%; p < 0.01), with minimal differences in subsequent years. Costs (including non-headache-related costs) and high-quality and low-quality medication utilization were higher in cases in the first year and decreased toward control costs in subsequent years with small differences persisting over 5 years. Opioid prescriptions increased over time in both cases and controls. CONCLUSION Compared with those without a neurologist, headache patients who visit neurologists had a transient increase in hospitalizations, but the same ED utilization. Confounding by severity is the most likely explanation given the non-headache-related cost trajectory. Claims-based risk adjustment will likely underestimate disease severity of headache patients seen by neurologists.
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Affiliation(s)
- Brian C Callaghan
- From the Health Services Research Program, Department of Neurology (B.C.C., J.F.B., K.A.K., L.E.S.), University of Michigan; Veterans Affairs Healthcare System (B.C.C., J.F.B.), Ann Arbor, MI; Boston University School of Medicine (J.P.N.), MA; American Academy of Neurology (B.M.), Minneapolis, MN; and Department of Neurology (G.J.E.), Emory University, Atlanta.
| | - James F Burke
- From the Health Services Research Program, Department of Neurology (B.C.C., J.F.B., K.A.K., L.E.S.), University of Michigan; Veterans Affairs Healthcare System (B.C.C., J.F.B.), Ann Arbor, MI; Boston University School of Medicine (J.P.N.), MA; American Academy of Neurology (B.M.), Minneapolis, MN; and Department of Neurology (G.J.E.), Emory University, Atlanta
| | - Kevin A Kerber
- From the Health Services Research Program, Department of Neurology (B.C.C., J.F.B., K.A.K., L.E.S.), University of Michigan; Veterans Affairs Healthcare System (B.C.C., J.F.B.), Ann Arbor, MI; Boston University School of Medicine (J.P.N.), MA; American Academy of Neurology (B.M.), Minneapolis, MN; and Department of Neurology (G.J.E.), Emory University, Atlanta
| | - Lesli E Skolarus
- From the Health Services Research Program, Department of Neurology (B.C.C., J.F.B., K.A.K., L.E.S.), University of Michigan; Veterans Affairs Healthcare System (B.C.C., J.F.B.), Ann Arbor, MI; Boston University School of Medicine (J.P.N.), MA; American Academy of Neurology (B.M.), Minneapolis, MN; and Department of Neurology (G.J.E.), Emory University, Atlanta
| | - John P Ney
- From the Health Services Research Program, Department of Neurology (B.C.C., J.F.B., K.A.K., L.E.S.), University of Michigan; Veterans Affairs Healthcare System (B.C.C., J.F.B.), Ann Arbor, MI; Boston University School of Medicine (J.P.N.), MA; American Academy of Neurology (B.M.), Minneapolis, MN; and Department of Neurology (G.J.E.), Emory University, Atlanta
| | - Brandon Magliocco
- From the Health Services Research Program, Department of Neurology (B.C.C., J.F.B., K.A.K., L.E.S.), University of Michigan; Veterans Affairs Healthcare System (B.C.C., J.F.B.), Ann Arbor, MI; Boston University School of Medicine (J.P.N.), MA; American Academy of Neurology (B.M.), Minneapolis, MN; and Department of Neurology (G.J.E.), Emory University, Atlanta
| | - Gregory J Esper
- From the Health Services Research Program, Department of Neurology (B.C.C., J.F.B., K.A.K., L.E.S.), University of Michigan; Veterans Affairs Healthcare System (B.C.C., J.F.B.), Ann Arbor, MI; Boston University School of Medicine (J.P.N.), MA; American Academy of Neurology (B.M.), Minneapolis, MN; and Department of Neurology (G.J.E.), Emory University, Atlanta
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17
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Little RD. Emergency Department Evaluation and Management of Children With Headaches. CLINICAL PEDIATRIC EMERGENCY MEDICINE 2017. [DOI: 10.1016/j.cpem.2017.09.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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18
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Kullgren JT, Krupka E, Schachter A, Linden A, Miller J, Acharya Y, Alford J, Duffy R, Adler-Milstein J. Precommitting to choose wisely about low-value services: a stepped wedge cluster randomised trial. BMJ Qual Saf 2017; 27:355-364. [DOI: 10.1136/bmjqs-2017-006699] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2017] [Revised: 09/08/2017] [Accepted: 10/07/2017] [Indexed: 11/04/2022]
Abstract
BackgroundLittle is known about how to discourage clinicians from ordering low-value services. Our objective was to test whether clinicians committing their future selves (ie, precommitting) to follow Choosing Wisely recommendations with decision supports could decrease potentially low-value orders.MethodsWe conducted a 12-month stepped wedge cluster randomised trial among 45 primary care physicians and advanced practice providers in six adult primary care clinics of a US community group practice.Clinicians were invited to precommit to Choosing Wisely recommendations against imaging for uncomplicated low back pain, imaging for uncomplicated headaches and unnecessary antibiotics for acute sinusitis. Clinicians who precommitted received 1–6 months of point-of-care precommitment reminders as well as patient education handouts and weekly emails with resources to support communication about low-value services.The primary outcome was the difference between control and intervention period percentages of visits with potentially low-value orders. Secondary outcomes were differences between control and intervention period percentages of visits with possible alternate orders, and differences between control and 3-month postintervention follow-up period percentages of visits with potentially low-value orders.ResultsThe intervention was not associated with a change in the percentage of visits with potentially low-value orders overall, for headaches or for acute sinusitis, but was associated with a 1.7% overall increase in alternate orders (p=0.01). For low back pain, the intervention was associated with a 1.2% decrease in the percentage of visits with potentially low-value orders (p=0.001) and a 1.9% increase in the percentage of visits with alternate orders (p=0.007). No changes were sustained in follow-up.ConclusionClinician precommitment to follow Choosing Wisely recommendations was associated with a small, unsustained decrease in potentially low-value orders for only one of three targeted conditions and may have increased alternate orders.Trial registration numberNCT02247050; Pre-results.
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Ong JJY, Chan YC. Medical Undergraduate Survey on Headache Education in Singapore: Knowledge, Perceptions, and Assessment of Unmet Needs. Headache 2017; 57:967-978. [DOI: 10.1111/head.13110] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2017] [Revised: 03/17/2017] [Accepted: 03/17/2017] [Indexed: 01/03/2023]
Affiliation(s)
- Jonathan Jia Yuan Ong
- Division of Neurology; Department of Medicine, National University Hospital; Singapore
| | - Yee Cheun Chan
- Division of Neurology; Department of Medicine, National University Hospital; Singapore
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20
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Burke JF, Callaghan BC. Author response: Neuroimaging overuse is more common in Medicare compared with the VA. Neurology 2017; 88:607-608. [DOI: 10.1212/wnl.0000000000003581] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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21
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Evers S. Welche Faktoren beeinflussen die Indikation zur zerebralen Bildgebung bei Kopfschmerzen? ACTA ACUST UNITED AC 2016. [DOI: 10.1007/s15202-016-1419-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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22
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Burke JF, Kerr EA, McCammon RJ, Holleman R, Langa KM, Callaghan BC. Neuroimaging overuse is more common in Medicare compared with the VA. Neurology 2016; 87:792-8. [PMID: 27402889 DOI: 10.1212/wnl.0000000000002963] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2016] [Accepted: 05/12/2016] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To inform initiatives to reduce overuse, we compared neuroimaging appropriateness in a large Medicare cohort with a Department of Veterans Affairs (VA) cohort. METHODS Separate retrospective cohorts were established in Medicare and in VA for headache and neuropathy from 2004 to 2011. The Medicare cohorts included all patients enrolled in the Health and Retirement Study (HRS) with linked Medicare claims (HRS-Medicare; n = 1,244 for headache and 998 for neuropathy). The VA cohorts included all patients receiving services in the VA (n = 93,755 for headache and 183,642 for neuropathy). Inclusion criteria were age over 65 years and an outpatient visit for incident neuropathy or a primary headache. Neuroimaging use was measured with Current Procedural Terminology codes and potential overuse was defined using published criteria for use with administrative data. Increasingly specific appropriateness criteria excluded nontarget conditions for which neuroimaging may be appropriate. RESULTS For both peripheral neuropathy and headache, potentially inappropriate imaging was more common in HRS-Medicare compared with the VA. Forty-nine percentage of all headache patients received neuroimaging in HRS-Medicare compared with 22.1% in the VA (p < 0.001) and differences persist when analyzing more specific definitions of overuse. A total of 23.7% of all HRS-Medicare incident neuropathy patients received neuroimaging compared with 9.0% in the VA (p < 0.001), and the difference persisted after excluding nontarget conditions. CONCLUSIONS Overuse of neuroimaging is likely less common in the VA than in a Medicare population. Better understanding the reasons for the more selective use of neuroimaging in the VA could help inform future initiatives to reduce overuse of diagnostic testing.
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Affiliation(s)
- James F Burke
- From the Department of Neurology (J.F.B., B.C.C.), Department of Internal Medicine (E.A.K., R.J.M., K.M.L.), Institute for Healthcare Policy and Innovation (J.F.B., E.A.K., K.M.L., B.C.C.), and Institute for Social Research (K.M.L.), University of Michigan, Ann Arbor; and Neurology Section (J.F.B., B.C.C.) and Center for Clinical Management and Research (E.A.K., R.H., K.M.L.), VA Ann Arbor Healthcare System, MI.
| | - Eve A Kerr
- From the Department of Neurology (J.F.B., B.C.C.), Department of Internal Medicine (E.A.K., R.J.M., K.M.L.), Institute for Healthcare Policy and Innovation (J.F.B., E.A.K., K.M.L., B.C.C.), and Institute for Social Research (K.M.L.), University of Michigan, Ann Arbor; and Neurology Section (J.F.B., B.C.C.) and Center for Clinical Management and Research (E.A.K., R.H., K.M.L.), VA Ann Arbor Healthcare System, MI
| | - Ryan J McCammon
- From the Department of Neurology (J.F.B., B.C.C.), Department of Internal Medicine (E.A.K., R.J.M., K.M.L.), Institute for Healthcare Policy and Innovation (J.F.B., E.A.K., K.M.L., B.C.C.), and Institute for Social Research (K.M.L.), University of Michigan, Ann Arbor; and Neurology Section (J.F.B., B.C.C.) and Center for Clinical Management and Research (E.A.K., R.H., K.M.L.), VA Ann Arbor Healthcare System, MI
| | - Rob Holleman
- From the Department of Neurology (J.F.B., B.C.C.), Department of Internal Medicine (E.A.K., R.J.M., K.M.L.), Institute for Healthcare Policy and Innovation (J.F.B., E.A.K., K.M.L., B.C.C.), and Institute for Social Research (K.M.L.), University of Michigan, Ann Arbor; and Neurology Section (J.F.B., B.C.C.) and Center for Clinical Management and Research (E.A.K., R.H., K.M.L.), VA Ann Arbor Healthcare System, MI
| | - Kenneth M Langa
- From the Department of Neurology (J.F.B., B.C.C.), Department of Internal Medicine (E.A.K., R.J.M., K.M.L.), Institute for Healthcare Policy and Innovation (J.F.B., E.A.K., K.M.L., B.C.C.), and Institute for Social Research (K.M.L.), University of Michigan, Ann Arbor; and Neurology Section (J.F.B., B.C.C.) and Center for Clinical Management and Research (E.A.K., R.H., K.M.L.), VA Ann Arbor Healthcare System, MI
| | - Brian C Callaghan
- From the Department of Neurology (J.F.B., B.C.C.), Department of Internal Medicine (E.A.K., R.J.M., K.M.L.), Institute for Healthcare Policy and Innovation (J.F.B., E.A.K., K.M.L., B.C.C.), and Institute for Social Research (K.M.L.), University of Michigan, Ann Arbor; and Neurology Section (J.F.B., B.C.C.) and Center for Clinical Management and Research (E.A.K., R.H., K.M.L.), VA Ann Arbor Healthcare System, MI
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Minen M, Shome A, Halpern A, Tishler L, Brennan KC, Loder E, Lipton R, Silbersweig D. A migraine management training program for primary care providers: An overview of a survey and pilot study findings, lessons learned, and considerations for further research. Headache 2016; 56:725-40. [PMID: 27037903 PMCID: PMC4890700 DOI: 10.1111/head.12803] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2015] [Revised: 01/23/2016] [Accepted: 01/23/2016] [Indexed: 01/27/2023]
Abstract
BACKGROUND There are five to nine million primary care office visits a year for migraine in the United States. However, migraine care is often suboptimal in the primary care setting. A prior study indicated that primary care physicians (PCPs) wanted direct contact with headache specialists to improve the migraine care they provide. OBJECTIVE We sought to further examine PCPs' knowledge of migraine management and assess the feasibility of a multimodal migraine education program for PCPs. METHODS We conducted a survey assessing PCPs' knowledge about migraine. We then held three live educational sessions and developed an email consultative service for PCPs to submit questions they had about migraine. We report both quantitative and qualitative findings. RESULTS Twenty-one PCPs completed the survey. They were generally familiar with the epidemiology of migraine (mean prevalence of migraine reported was 12.6% ± 10.1), the psychiatric comorbidities (mean prevalence of comorbid depression was 24.5% ± 16.7, mean prevalence of comorbid anxiety was 24.6% ± 18.3), and evidence-based behavioral treatments. Fifty-six percent cited cognitive behavioral therapy, 78% cited biofeedback, and 61% cited relaxation therapy as evidence based treatments. Though most were aware of the prevalence of psychiatric comorbidities, they did not routinely assess for them (43% did not routinely assess for anxiety, 29% did not routinely assess for depression). PCPs reported frequently referring patients for non-level A evidence based treatments: special diets (60%), acupuncture (50%), physical therapy (30%), and psychoanalysis (20%). Relaxation therapy was a therapy recommended by 40% of the PCPs. Only 10% reported referring for cognitive behavioral therapy or biofeedback. Nineteen percent made minimal or no use of migraine preventive medications. Seventy-two percent were unaware of or only slightly aware of the American Academy of Neurology guidelines for migraine. There was variable attendance at the educational sessions (N=22 at 1st session, 6 at 2nd session, 15 at 3rd session). Very few PCPs used the email consultative service (N=4). CONCLUSIONS Though PCPs are familiar with many aspects of migraine care, there is a need and opportunity for improvement. The three live sessions were poorly attended and the email consultative service was rarely used. We provide an in depth discussion of targeted areas for educational intervention, of the challenges in developing a migraine educational program for PCPs, and areas for future study.
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Affiliation(s)
| | | | | | | | | | | | | | - David Silbersweig
- Brigham and Women's Hospital
- Brigham and Women's Faulkner Hospital
- Harvard Medical School
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24
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Evans RW, Timm JS, Baskin DS. Imaging the Patient With Migraine: A Response. Headache 2015; 55:1444-5. [PMID: 26445076 DOI: 10.1111/head.12700] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Randolph W Evans
- Department of Neurology, Baylor College of Medicine, Houston, TX, USA
| | | | - David S Baskin
- Neurosurgery Residency Training Program, Department of Neurological Surgery, Methodist Neurological Institute, Houston, TX, USA.,Neurological Surgery, Weill Medical College, Cornell University, New York, NY, USA.,Houston Methodist Kenneth R. Peak Brain & Pituitary Tumor Treatment Center, Houston, TX, USA
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25
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Callaghan BC, De Lott LB, Kerber KA, Burke JF, Skolarus LE. Neurology Choosing Wisely recommendations: 74 and growing. Neurol Clin Pract 2015; 5:439-447. [PMID: 26526342 DOI: 10.1212/cpj.0000000000000189] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
To increase neurologist awareness and inform future efficiency efforts, we identified all neurology-related Choosing Wisely items. Items were categorized by neurologic specialty, disease/symptom, and test/treatment. Of 370 items provided by 65 medical societies, 74 (20%) items were relevant to neurologists. Twelve were duplicated by multiple societies. Items pertaining to 10 neurologic subspecialties were identified, but none for movement disorders and neuromuscular disease. While many recommendations question the use of imaging, few address other high-cost neurologic tests such as EMG/nerve conduction studies and EEG. A rapidly growing number of neurology-related Choosing Wisely recommendations exist including areas of consensus and areas with few recommendations despite high costs. Consensus items should be prioritized for near-term interventions, while areas with few recommendations represent opportunities for future research.
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Affiliation(s)
- Brian C Callaghan
- Health Services Research Program (BCC, LDL, KAK, JFB, LES), Department of Neurology, University of Michigan; and VA Center for Clinical Management Research (BCC, JFB), Ann Arbor, MI
| | - Lindsey B De Lott
- Health Services Research Program (BCC, LDL, KAK, JFB, LES), Department of Neurology, University of Michigan; and VA Center for Clinical Management Research (BCC, JFB), Ann Arbor, MI
| | - Kevin A Kerber
- Health Services Research Program (BCC, LDL, KAK, JFB, LES), Department of Neurology, University of Michigan; and VA Center for Clinical Management Research (BCC, JFB), Ann Arbor, MI
| | - James F Burke
- Health Services Research Program (BCC, LDL, KAK, JFB, LES), Department of Neurology, University of Michigan; and VA Center for Clinical Management Research (BCC, JFB), Ann Arbor, MI
| | - Lesli E Skolarus
- Health Services Research Program (BCC, LDL, KAK, JFB, LES), Department of Neurology, University of Michigan; and VA Center for Clinical Management Research (BCC, JFB), Ann Arbor, MI
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Zebenholzer K, Andree C, Lechner A, Broessner G, Lampl C, Luthringshausen G, Wuschitz A, Obmann SM, Berek K, Wöber C. Prevalence, management and burden of episodic and chronic headaches--a cross-sectional multicentre study in eight Austrian headache centres. J Headache Pain 2015; 16:531. [PMID: 25990699 PMCID: PMC4437990 DOI: 10.1186/s10194-015-0531-7] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2015] [Accepted: 05/10/2015] [Indexed: 11/10/2022] Open
Abstract
Background Episodic and chronic headaches (EH, CH) are highly prevalent disorders. Severely affected patients are usually referred to headache centres. In Austria, at least one headache centre is available in seven of nine states, but detailed multicentre data are missing. Therefore we studied prevalence rates, use of medication and health care services, impact of headaches, and comorbid depression and anxiety. Methods We included consecutive patients from eight Austrian outpatient headache centres. The patients filled-in the Eurolight questionnaire. In addition, the treating neurologist completed a questionnaire on clinical diagnoses and ever-before prophylactic medications. Results Of 598 patients screened, 441 questionnaires were analysed (79 % female, mean age 41.1 years). According to the Eurolight algorithm, 56.4 % of the patients had EH, 38.3 % had CH and 5.2 % did not give their headache frequency. The prevalence rates of migraine, tension-type headache, and probable medication overuse headache (pMOH) were 48.5 %, 6.3 % and 15.9 %, respectively. The concordance between clinical and Eurolight diagnoses was good for EH and moderate for CH. During the preceding month, acute medication was used by 90.9 % of the patients and prophylactic medication by 34 %. Ever-before use of five standard prophylactic drugs was recorded in 52.3 %. The proportion of patients with current pharmacoprophylaxis did not differ in EH and CH, whereas ever-before use was more common in CH (62.5 % was 45,3 %, p = 0.02). Patients with CH significantly more often consulted general practitioners and emergency departments, had a lower quality of life and more often signs of depression and anxiety. Conclusion This study provides comprehensive data from eight Austrian headache centres for the first time. We found a substantial number of patients with CH including pMOH and its association with more common utilization of health care facilities and greater burden. The low use of prophylactic medication requires further examination.
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Affiliation(s)
- Karin Zebenholzer
- Department of Neurology, Medical University of Vienna, Vienna, Austria,
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