Neuroimaging still is “substantially overused” for the outpatient treatment of headache, and its use is increasing despite the publication of numerous guidelines recommending against it in this patient population, according to a data analysis published online ahead of print March 17 in JAMA Internal Medicine.
Brian C. Callaghan, MD, Assistant Professor of Neurology at the University of Michigan in Ann Arbor, and his associates analyzed data from the National Ambulatory Medical Care Survey to characterize recent trends in the use of CT or MRI for routine headache visits to primary care physicians, neurologists, other specialists, and nonprimary care generalists from 2007 through 2010. The researchers identified 51.1 million headache visits, including 25.4 million for migraine.
Of all visits, 88% were by patients younger than 65. Approximately 78% of patients were female. Most visits were to primary care physicians (54.8%), followed by neurologists (20%), other specialists (12.9%), and nonprimary care generalists (12.4%).
Rate of Neuroimaging Has Nearly Tripled Since 1995
Clinicians ordered neuroimaging for 12.4% of outpatient headache visits and 9.8% of migraine visits annually. Headache neuroimaging use was higher if the headache or migraine diagnosis was listed as the primary diagnosis for the visit. The total cost of this imaging was approximately $1 billion each year. “Total neuroimaging expenditures were estimated at $3.9 billion over four years, including $1.5 billion from migraine visits,” said Dr. Callaghan.
The researchers found that the rate of neuroimaging increased from 5.1% of all annual headache visits in 1995 to 14.7% in 2010. This increase occurred despite the fact that since 2000, “multiple guidelines have recommended against routine neuroimaging in patients with headache because a serious intracranial pathologic condition is an uncommon cause.” Moreover, the yield of significant abnormalities on neuroimaging of headache patients ranges from 1% to 3%—a rate that is comparable to that in patients without headaches. As part of the American Board of Internal Medicine’s Choose Wisely campaign, the American College of Radiology listed imaging for uncomplicated headache as one of the top five things that physicians and patients should question.
“Perhaps guidelines have not curbed utilization because patients, as opposed to health care providers, may be the primary drivers of utilization,” said Dr. Callaghan. If so, efforts to better inform patients about unwarranted testing or to shift the costs of expensive, low-yield tests to patients may be more effective, he added.
“Given that headache neuroimaging is common, costly, and likely substantially overused, interventions to curb utilization of these tests have the potential to substantially reduce health care expenditures while improving guideline concordance. Therefore, optimizing headache neuroimaging practices should be a major national priority,” Dr. Callaghan concluded.
Physicians May Discuss With Patients the Dangers of Neuroimaging
The financial costs of unwarranted neuroimaging are substantial, “but the costs we should care most about as physicians are the unnecessary radiation ... and incidental findings that lead to unnecessary medical procedures and great anxiety on the part of our patients,” said Mitchell H. Katz, MD, Director of the Los Angeles County Department of Health Services and deputy editor of JAMA Internal Medicine, in an accompanying editorial.
Because professional guidelines appear to have a limited effect on the use of neuroimaging, “we need to focus more on educating our patients about headaches and the dangers of neuroimaging,” said Dr. Katz. “Signs to us that the headache does not require further evaluation (ie, no change in the nature of headache for multiple years) may mean to the patient that the headache is serious (ie, it must be serious because I have had these pains for many years). If a physician simply says, ‘You don’t need a scan,’ patients may think that the physician does not understand how great the pain is, or worse yet, that the physician is saving money for an insurance company.”
The clinician first should acknowledge that headaches are frightening, can be disabling, and can afflict patients for their entire lives, he explained. This reassures patients that their symptoms are taken seriously and makes them less fearful when the symptoms recur. The clinician also should explain that he or she does not want patients to have neuroimaging because of the dangers of radiation and incidental findings. “Most patients are reassured when they feel that their physician understands their condition and is working with them to develop a strategy for coping with the problem,” said Dr. Katz.
—Mary Ann Moon