Implementing evidence-based practices consistent with the AAN Headache Quality Measures has the potential to improve the quality of care in this patient population, however, additional study is required to determine if better process performance produces better outcomes.
Scott Turner, DNP
A large-scale quality improvement (QI) project found that team-based strategies and electronic medical record integration can improve performance on American Academy of Neurology Headache Quality Measures, however, it might be difficult to demonstrate improvement of patient outcomes.
The project, which focused on a large pediatric neurology practice serving children across 5 states in the US Mountain-West, sought to determine if improved performance on the American Academy of Neurology Headache Quality Measures would lead to better outcomes in children and adolescents seen in an existing clinical care pathway ages 8—17 seen for a primary headache disorder including migraine and tension-type headache.
“Healthcare consumers often use quality measures as a means of assessing value in healthcare,” Scott Turner, DNP, assistant professor in pediatric neurology, at the University of Alabama at Birmingham, told NeurologyLive. “We wondered if improved performance on the American Academy of Neurology’s Headache Quality Measures would lead to improved patient outcomes. Our project showed that significant improvements in process measures did not necessarily translate into better patient-centered outcomes.”
QI interventions focused on the use of Pediatric Migraine Disability Assessment (PedMIDAS), headache action plans, nurse triage, and infusion center (IC) order sets.
The interdisciplinary workgroup used PedMIDAS to measure headache disability and encourage clinicians to treat headaches more aggressively when needed. A seminar was held to teach providers strategies to improve patients’ functional capacity and were encouraged to recommend behavioral interviews emphasizing healthy behaviors, active coping skills, goal setting, pacing, normalization of routine, and clarification of parental roles to improve patient outcomes.
The headache nurse coordinator created a piloted a nurse telephone triage script reinforcing each step of the headache action plan and screening infusion candidates for signs of secondary headache.
The primary outcome included a decrease in the number of patients visiting the emergency department (ED) for acute headache from a baseline of 1.42% to a target of 0.90% or better, while the secondary outcome was the change in PedMIDAS disability grade.
During the 12-month comparison period, researchers found that the percentage of patients using the ED for acute treatment decreased from 0.83% to 0.54% (P <.0001). The monthly number of ED visits decreased from 23 in 2014—2015 to 19 in 2015–2016 while the use of the IC increased from an average of 4 patients per month to 11 patients per month in the same period.
“We expected that more consistent use of Headache Action Plans would lead to more effective home treatment and thereby reduce the need for headache-related infusions,” Turner added. “While we were able to significantly decrease the number of ED visits, the total number of infusions increased slightly during the intervention period suggesting that infusion recipients simply changed the location of their infusion from the ED to the infusion center.”
Turner explains that this project opens up additional questions on whether improvement in the quality of care, measured by performance on quality measures, actually leads to improved patient outcomes.
Even though a sizable decrease was reported in the number of established patients visiting the ED for acute treatment, the researchers think that it’s unlikely that this is attributed to the increased use of headache action plans because of small increase (5% above baseline and 15% of the total patients). It’s suspected that the reduction in the number of visits is attributed to changes in the nurse triage system and a streamlined infusion order entry and insurance verification process. The triage and referall practices shifted away from sending established patients to the ED for migraine management in favor of the IC. The cost savings of treating a patient in the IC as opposed to the ED was an estimated $1808.75 per visit; a total of 358 patients received infusions between March 2015 and February 2016, 37% (n=132) in the IC and 63% (n=226) in the ED.
Additionally, administering PedMIDAS assessments and a 1-time training for providers on how to address disability did not result in any improvement in disability grades; the researchers suggest that ongoing training may be better to address both the medical and behavioral health factors contributing to functional disability.
“We still do not know if the use of Headache Action Plans leads to better outcomes such as a reduction in the number of ED visits and fewer school absences,” Turner concluded. “Though we were not able to reduce the overall number of headache infusions or improve the average disability level of our headache population, we were able to reduce the number of ED visits which ultimately saved payers nearly $150,000 during the intervention period.”
Turner, S, Foss-Barratt A, Malmberg J, et al. Minding the gap in pediatric headache care. Neurology: Clinical Practice. 2019;1—7.