Scott Friedenberg

The demand for neurology services exceeds the current supply. We convened multiple stakeholders to learn what drives our primary care providers (PCPs) to refer patients with headache to our neurology practice. This information guided a collaborative effort to evaluate the impact of an electronic health record (EHR) headache tool on care delivery in our PCP clinics. Neurology referrals and MRI ordering declined by 77% and 35%, respectively, after the release of the EHR tool for an estimated savings of $207,600 over 3 months. PCPs prescribing habits minimally changed. Electronically embedding a neurologist's knowledge in our PCP office was an effective way to shape the demand for headache consultation. By further leveraging stakeholder collaboration, we plan to improve the tool and disseminate it across our health system to reduce headache burden and health care costs.

The combination of inadequate financial training, limited benchmarks, and mindset contribute to many physicians prioritizing revenue below quality, outcomes, and safety. This creates a challenge as hospital administrators aim to motivate clinicians to improve RVU generation and increase revenue. Creating physician/administrator teams that defines and explores the gap between observed and expected financial performance in parallel with appreciating the physician's practice preferences can create new opportunities for billing. The proposed 3 phase approach emphasizes nonjudgmental communication, education and partnership. The most common and effective opportunities for improvement include billing optimization, scheduling and system infrastructure modifications. As reimbursement decrease, balancing revenue generation with physician satisfaction has become paramount. Promoting data drive bidirectional communication can lead to identifying previously unrecognized billing opportunities where change is driven by providers rather than by 1-dimensional institutional goals.

Background: Headaches, including migraines, are one of the most common causes of disability and account for nearly 20%‐30% of referrals from primary care to neurology. In primary care, electronic health record–based alerts offer a mechanism to influence health care provider behaviors, manage neurology referrals, and optimize headache care. Objective: This project aimed to evaluate the impact of an electronic alert implemented in primary care on patients’ overall headache management. Methods: We conducted a stratified cluster-randomized study across 38 primary care clinic sites between December 2021 to December 2022 at a large integrated health care delivery system in the United States. Clinics were stratified into 6 blocks based on region and patient-to–health care provider ratios and then 1:1 randomized within each block into either the control or intervention. Health care providers practicing at intervention clinics received an interruptive alert in the electronic health record. The primary end point was a change in headache burden, measured using the Headache Impact Test 6 scale, from baseline to 6 months. Secondary outcomes included changes in headache frequency and intensity, access to care, and resource use. We analyzed the difference-in-differences between the arms at follow-up at the individual patient level. Results: We enrolled 203 adult patients with a confirmed headache diagnosis. At baseline, the average Headache Impact Test 6 scores in each arm were not significantly different (intervention: mean 63, SD 6.9; control: mean 61.8, SD 6.6; P=.21). We observed a significant reduction in the headache burden only in the intervention arm at follow-up (3.5 points; P=.009). The reduction in the headache burden was not statistically different between groups (difference-in-differences estimate –1.89, 95% CI –5 to 1.31; P=.25). Similarly, secondary outcomes were not significantly different between groups. Only 11.32% (303/2677) of alerts were acted upon. Conclusions: The use of an interruptive electronic alert did not significantly improve headache outcomes. Low use of alerts by health care providers prompts future alterations of the alert and exploration of alternative approaches.

BACKGROUND Headaches including migraines are one of the most common causes of disability and account for nearly 20-30% of referrals from primary care to neurology. Electronic health record-based alerts have been used in the past within primary care with varying degree of success to influence provider behaviors in multiple disease states except for headaches. OBJECTIVE The aim of this project was to evaluate the impact of an electronic alert implemented in primary care on patients’ overall headache management. METHODS We conducted a stratified cluster-randomized study across 38 primary care clinic sites between December 2021 to December 2022 at a large integrated healthcare delivery system in the United States. Clinics were stratified into six blocks based on region and patient-to-provider ratios and then 1:1 randomized within each block into either control or intervention. Providers practicing at intervention clinics received an interruptive alert in the electronic health record. The primary endpoint was a change in headache burden, measured using the Headache Impact Test 6 (HIT-6) scale, from baseline to six months. Secondary outcomes included change in headache frequency and intensity, access to care, and resource utilization. The analysis was performed to assess the difference in difference outcomes between the arms at follow up at the individual patient level. RESULTS We enrolled 203 adult patients with a confirmed headache diagnosis. At baseline the average HIT-6 scores (standard deviation) in each arm were not significantly different (Intervention – 63 (+- 6.9) vs. Control - 61.8 (+- 6.6), P= .21). We observed a significant reduction in the headache burden only in the intervention arm at follow-up (3.5-point, P= .009). The reduction in the headache burden was not statistically different between groups (difference-in-difference estimate: -1.89 (95% confidence interval -5.0, 1.31; P= .25). Similarly, secondary outcomes were not significantly different between groups. Only 11% of alerts were acted upon. CONCLUSIONS The use of an interruptive electronic alert did not significantly improve headache outcomes. Low use of alerts by providers prompts future alterations of the alert and exploration of alternative approaches. CLINICALTRIAL Registered at clinicaltrials.gov as registration number NCT05067725.

A cohort of 106 patients with electrodiagnostically confirmed long thoracic neuropathy (50 patients) or spinal accessory neuropathy (56 patients) seen at the Mayo Clinic over a 22‐year period were retrospectively studied to better understand the natural history of these disorders and to determine the role of electrodiagnostic testing in predicting prognosis. Mean follow‐up was 48 and 50 months, respectively. Good functional recovery was generally observed regardless of the results of electrodiagnostic studies, but improvement in the amplitude of the spinal accessory compound muscle action potential on serial nerve conduction studies tended to predict a good outcome. No electrodiagnostic findings correlated with poor outcome. Traumatic neuropathies generally did worse than neuropathies of other causes. In spinal accessory neuropathies, involvement of the dominant limb, scapular winging, and impaired arm elevation were associated with a poor outcome. Our data suggest that, contrary to other focal neuropathies, the electrodiagnostic findings do not predict functional outcome in these neuropathies. © 2002 Wiley Periodicals, Inc. Muscle Nerve 25: 000–000, 2002