Mafi John N, Edwards Samuel T, Pedersen Nigel P, Davis Roger B, McCarthy Ellen P, Landon Bruce E
Division of General Medicine and Primary Care, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Avenue, CO-1309, Boston, MA, 02215, USA,
J Gen Intern Med. 2015 May;30(5):548-55. doi: 10.1007/s11606-014-3107-3. Epub 2015 Jan 8.
Headache is a frequent complaint and among the most common reasons for visiting a physician.
To characterize trends from 1999 through 2010 in the management of headache.
Longitudinal trends analysis.
Nationally representative sample of visits to clinicians for headache from the National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey, excluding visits with "red flags," such as neurologic deficit, cancer, or trauma.
Use of advanced imaging (CT/MRI), opioids/barbiturates, and referrals to other physicians (guideline-discordant indicators), as well as counseling on lifestyle modifications and use of preventive medications including verapamil, topiramate, amitriptyline, or propranolol (guideline-concordant during study period). We analyzed results using logistic regression, adjusting for patient and clinician characteristics, and weighted to reflect U.S. population estimates. Additionally, we stratified findings based on migraine versus non-migraine, acute versus chronic symptoms, and whether the clinician self-identified as the primary care physician.
We identified 9,362 visits for headache, representing an estimated 144 million visits during the study period. Nearly three-quarters of patients were female, and the mean age was approximately 46 years. Use of CT/MRI rose from 6.7% of visits in 1999-2000 to 13.9% in 2009-2010 (unadjusted p < 0.001), and referrals to other physicians increased from 6.9 % to 13.2% (p = 0.005). In contrast, clinician counseling declined from 23.5 % to 18.5% (p = 0.041). Use of preventive medications increased from 8.5 % to 15.9% (p = 0.001), while opioids/barbiturates remained unchanged, at approximately 18%. Adjusted trends were similar, as were results after stratifying by migraine versus non-migraine and acute versus chronic presentation. Primary care clinicians had lower odds of ordering CT/MRI (OR 0.56 [0.42, 0.74]).
Contrary to numerous guidelines, clinicians are increasingly ordering advanced imaging and referring to other physicians, and less frequently offering lifestyle counseling to their patients. The management of headache represents an important opportunity to improve the value of U.S. healthcare.
头痛是一种常见的主诉，也是就医的最常见原因之一。
描述1999年至2010年期间头痛治疗的趋势。
纵向趋势分析。
来自国家门诊医疗调查和国家医院门诊医疗调查的全国代表性头痛患者就诊样本，排除伴有“红旗”症状（如神经功能缺损、癌症或创伤）的就诊。
先进成像检查（CT/MRI）、阿片类药物/巴比妥类药物的使用以及转介给其他医生（不符合指南的指标），以及关于生活方式调整的咨询和预防性药物（包括维拉帕米、托吡酯、阿米替林或普萘洛尔）的使用（在研究期间符合指南）。我们使用逻辑回归分析结果，对患者和临床医生特征进行调整，并加权以反映美国人口估计数。此外，我们根据偏头痛与非偏头痛、急性与慢性症状以及临床医生是否自我认定为初级保健医生对结果进行分层。
我们确定了9362例头痛就诊病例，估计在研究期间有1.44亿次就诊。近四分之三的患者为女性，平均年龄约为46岁。CT/MRI的使用从1999 - 2000年就诊病例的6.7%上升至2009 - 2010年的13.9%（未调整p < 0.001），转介给其他医生的比例从6.9%增至13.2%（p = 0.005）。相比之下，临床医生的咨询比例从23.5%降至18.5%（p = 0.041）。预防性药物的使用从8.5%增至15.9%（p = 0.001），而阿片类药物/巴比妥类药物的使用保持不变，约为18%。调整后的趋势相似，按偏头痛与非偏头痛以及急性与慢性表现分层后的结果也相似。初级保健临床医生开具CT/MRI的几率较低（OR 0.56 [0.42, 0.74]）。
与众多指南相反，临床医生越来越多地开具先进成像检查并转介给其他医生，而向患者提供生活方式咨询的频率则越来越低。头痛的治疗是提高美国医疗保健价值的一个重要契机。
