Quality Improvement Strategies Benefit Care Delivery in Pediatric Headache

child with headache
child with headache
Although it may be difficult to demonstrate improved patient outcomes, quality improvement efforts using team-based strategies and electronic medical record integration can improve performance on headache quality measures.

Using Pediatric Migraine Disability Assessment (PedMIDAS) and headache action plans (HAPs), key quality measures in the treatment of pediatric headache were improved and provided measurable cost savings, according to a study published in Neurology: Clinical Practice.

In 2014, the American Academy of Neurology identified 10 areas of underperformance in the prevention and treatment of headache, in which 7 of 10 problem areas applied to children or adolescents. The investigators of this study sought to improve performance measures in the delivery of care and outcomes in a pediatric population with primary headache disorder.

The study was designed by an interdisciplinary team of providers, neurology nurses, and emergency department and infusion center personnel using the Institute for Healthcare Improvement’s Model for Improvement as the study framework. Quality improvement interventions included the use of PedMIDAS to assess disability grade and to measure clinician utilization; customization and generation of HAP letters; and nurse triage and infusion center order sets using electronic medical records (EMR).

Primary outcomes included the reduction in emergency department visits and improvement in average disability grade of pediatric patients with headache. Process measures included the percentage of patients for which PedMIDAS data were collected, and HAP letters were generated during a 12-month comparison period (March 2014 to February 2015 vs March 2015 to February 2016).

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During the comparison period, PedMIDAS collection rates from patient visits increased from 15% to 55% (P <.0001), and HAP letter generation increased from 9% to 15% (P <.0003). However, when the HAP letter template was changed, this gain was not sustained. The average number of monthly emergency department visits decreased from 23 to 19 over the comparison period, whereas the use of infusion center order sets increased from 4 to 11 patient visits per month on average. Patients’ average PedMIDAS disability grade did not show significant improvement from baseline during the comparison period.

Limitations to the study included the inability to evaluate the association between PedMIDAS use with the providers’ improved use of appropriate prevention and treatment tactics. A lack of data on established patients seen outside the emergency department for acute headache care was another limitation, as was the lack of non-English PedMIDAS translations. In addition, the increased demand for infusions often exceeded the infusion center capacity, possibly diminishing the effect size. Finally, the study time frame and disability assessment strategy were likely insufficient to detect a change in disability.

The researchers concluded that, motivated by individual feedback, quality improvement strategies to collect PedMIDAS and increase HAP use improved practice performance. However, the time to detect change in patient outcome was insufficient. The investigators suggest optimizing nurse triage and streamlining EMR workflows to enable more patients with established headache status to receive treatment in the infusion center rather than the emergency department, which could ultimately benefit hospital revenue strategies.

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Turner S, Foss-Barratt A, Malmberg J, Disabato J. Minding the gap in pediatric headache care: can a focus on quality measures improve outcomes? [published online March 5, 2019]. Neurol Clin Pract. doi:10.1212/CPJ.0000000000000614

This article originally appeared on Neurology Advisor