To improve the quality and lower the cost of care, guidelines recommend conservative treatment for most cases of headache, which accounts for more than 12 million visits to US clinicians and more than $31 billion in lost productivity and medical costs annually. Despite these guidelines, the treatment of headache has become less conservative. Fewer physicians are counseling patients on lifestyle modification, and advanced imaging (eg, CT and MRI) and referrals to specialists are increasing, according to the results of a study published online ahead of print January 8 in the Journal of General Internal Medicine.
Researchers from Beth Israel Deaconess Medical Center (BIDMC) in Boston identified 9,362 visits for headache using data from the National Ambulatory Medical Care Survey (NAMCS) and the National Hospital Ambulatory Medical Care Survey (NHAMCS). The data represent an estimated 144 million visits from 1999 through 2010. The researchers found substantial increases in the use of low-value, high-cost services. CT and MRI were ordered in 6.7% of visits from 1999 to 2000, compared with 13.9% of visits from 2009 to 2010. Requests for imaging increased more rapidly for patients who presented with acute symptoms rather than chronic headache. The rate of referrals rose from 6.9% to 13.2% of visits in the same time frame, even as patient counseling decreased from 23.5% to 18.5% of visits. Medication use also increased.
“The assessment of headache depends on identifying the relatively rare instances when serious underlying causes are suspected,” said lead author John N. Mafi, MD, a research fellow in general medicine at BIDMC. The researchers excluded cases with red flags such as neurologic signs and symptoms, cancer, head trauma, or seizures, from the study. Noting that evidence-based guidelines from the American Academy of Neurology, among other groups, call for counseling on lifestyle modification for routine headache, Dr. Mafi said he was “particularly alarmed about the overall trend of more imaging tests, medications, and referrals alongside less counseling.”
The use of prescription and over-the-counter nonsteroidal anti-inflammatory drugs and acetaminophen barely changed during the study period. The drugs were used in approximately 16% of visits over the course of the study, while use of triptans and ergot alkaloids increased from 9.8% during 1999–2000 to 15.4% of visits during 2009–2010. The use of recommended preventive therapies, including anticonvulsants, antidepressants, beta blockers, and calcium channel blockers increased from 8.5% of visits during 1999–2000 to 15.9% of visits during 2009–2010. The use of opioids and barbiturates, which is discouraged, remained at 18% of visits.
“These findings seem to reflect a larger trend in the US health care system beyond just headache,” Dr. Mafi observed, adding that “overhurried doctors seem to be spending less time connecting with their patients and more time ordering tests and treatments. This study suggests that the current 20-minute visit-based model of health care is broken and that we need to move toward promoting and reimbursing innovative solutions such as doctors and patients electronically collaborating on their health care outside the office visit.”
Senior author Bruce Landon, MD, MSc, a staff physician at BIDMC and Professor of Health Care Policy at Harvard Medical School, cited particular concern about the consequences of overuse of imaging, both in terms of cost and treatment. CT head or brain scans are “most frequently ordered inappropriately for chronic headache,” Dr. Landon said, adding that “incidental findings provoke unnecessary patient anxiety, can lead to more invasive procedures, and often require follow-up testing.”