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Measuring Migraine-Related Quality of Care Across 10 Health Plans
Valerie P. Pracilio, MPH; Stephen Silberstein, MD; Joseph Couto, PharmD, MBA; Jon Bumbaugh, MA; Mary Hopkins, RN; Daisy Ng-Mak, PhD; Cary Sennett, MD, PhD; and Neil I. Goldfarb, BA
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Measuring Migraine-Related Quality of Care Across 10 Health Plans

Valerie P. Pracilio, MPH; Stephen Silberstein, MD; Joseph Couto, PharmD, MBA; Jon Bumbaugh, MA; Mary Hopkins, RN; Daisy Ng-Mak, PhD; Cary Sennett, MD, PhD; and Neil I. Goldfarb, BA
Standardized measurement of migraine, an underdiagnosed and perhaps underrecognized condition, is necessary for health plans to understand utilization of costly diagnostic and treatment services.
The final 2 RX measures examined multiple prescriptions for opioids and butalbital products in the migraine population. More than one-third (35%) of the migraine population were dispensed an average of 10 doses of opioids per month over a 6-month period (RX.10). Ten percent of the migraine population were given an average of 10 doses of butalbital-containing products per month over a 6-month period (RX.11). Considerable variability was observed for RX.10 between plans, but variability was more modest for RX.11

DISCUSSION

This study demonstrates several potential quality concerns associated with migraine care and the potential utility of the measurement set in helping health plans examine care for their members with migraine.

Migraine is significantly underdiagnosed and undercoded, with 42% of the migraine population in this study identified by means other than a diagnosis code or visit for migraine in the measurement year. The identified population prevalence (4.7%-4.9%) using the measurement specifications was significantly lower than the 10% to 12% population prevalence rates derived from survey and chart review studies,2,4 suggesting that many people with migraine may not seek out treatment, or may be misdiagnosed and/or undertreated.

The findings for the identified population nonetheless show that migraineurs are utilizing a considerable number of healthcare services related to their condition. About 20% of migraineurs had a CT scan or MRI scan in the measurement year (2% had multiple scans), close to 18% went to the ED or an urgent care center, and 38% utilized an abortive medication (triptan, ergot alkaloid/derivative, or butalbital-containing product). The data presented in this study represent a sample of 10 plans with broad variability. The migraine quality of care measures provide guidance for the establishment of national benchmarks for utilization of healthcare services and medications for migraine care. This study represents initial efforts to identify benchmarks and provide evidence of how health plans can use them to classify and manage their migraine patients.

This assessment also highlights a number of opportunities for improvement in migraine treatment and management. Initial identification of migraineurs and documentation through claims are key elements of managing migraine pain. As a chronic, episodic condition, migraine must be well controlled to keep utilization of medical services low. Given the generic availability of many migraine abortive and preventive medications, medical services are the primary driver of migraineur cost from a payer perspective. Pain control also has a profound effect on ED and urgent care center visits. Because almost three-fourths of CT scans are completed within 48 hours of an emergent visit, better outpatient management might keep patients out of the ED and reduce neuroimaging rates. Based on the low rate of follow-up subsequent to an ED/urgent care visit, there is great opportunity to improve patient communication and long-term outcomes by encouraging follow-up with a primary care physician or neurologist after emergent visits.

The pharmaceutical results also indicate several opportunities for improvement and further investigation. The great variability in findings across health plans suggests opportunities for improved implementation of care standards and monitoring of appropriate utilization of migraine medications. For instance, triptan utilization (RX.2) varied considerably among plans, as the highest rate of utilization was more than double the lowest rate. The mean triptan utilization rate observed (37.74%) was higher than that reported by a recent population-based study (20%).18 This higher rate may be due to the way we defined the migraine population, or to the fact that prior work relied on patient self-report.18

In the migraine population as a whole, extremely high utilization of opioids as demonstrated by the RX.4 and RX.10 measures was concerning, as opioids are often implicated in medication overuse headaches. Although they are used less frequently than the opioids, butalbital-containing products can also be responsible for medication overuse headaches, and their utilization is not trivial, as shown by measure RX.11. The incidence of high use of triptan (measure RX.6) was encouraging, although individual health plan utilization management controls and our definition (which was designed only to capture the most egregious overusers throughout the measurement year) may have kept the incidence artificially low. However, the use of a migraine preventive (measure RX.7) in this population was not encouraging. Only 70% of these individuals had a prescription for a migraine preventive in the measurement year, and our definition of a preventive was rather generous. In the entire migraine population, 42% used a migraine preventive (measure RX.5), a rate considerably higher than the approximately 17% that was self-reported in a recent publication by Bigal and colleagues.18 This difference may indicate that our definition of a preventive was too generous.

Based on the results observed with measure RX.9, it appears that migraineurs are not being denied care based on their use of other serotonergic medications. Although more caution appears to be used in treating patients aged 50 to 64 years, measure RX.8 deserves further investigation because the proportion of triptan users who have cardiac contraindications is not insignificant. Finally, given the black box warning carried by rapid-acting fentanyl products, it was reassuring to see extremely low utilization of these products in measure RX.4c, although every health plan should strive for zero utilization of these products. For many of these measures, greater insight into patient compliance and adherence would be helpful to better understand additional opportunities for improvement.

Limitations

A number of limitations were realized while developing and testing the migraine quality of care measurement set. One of the early challenges was specifying the components to be included. Incorporating what we recognized as best practice based on the US Headache Consortium Guidelines (2000) and the evidence in the literature (2006-2010), we defined a measurement set based on elements known to be drivers of utilization. One limitation may be differences of opinion on how the numerators and denominators were defined. To mitigate disagreement, we enlisted the expertise of an advisory group of headache specialists and employer coalition representatives to review the measures.

The migraine prevalence rate in our study population was just under 5%, which is less than half the rate reported in the literature.2,4 This lower rate may have resulted from the use of only 12 months of data, as well as relying on claims data rather than chart review and patient report. Nonetheless, the measures should be generalizable to any health plan (other than Medicare), and the data presented provide grounds for any health plan using the measures to compare its performance with the medians and ranges presented here.

Future Directions

The data presented here represent early efforts to establish national benchmarks for migraine care at the health plan level and to validate a standardized approach to measurement. Although further refinement with consultation from the expert advisory group is expected, the measurement set presented in this study has the potential to advance migraine measurement activities.

The advisors provided a number of recommendations to strengthen the migraine quality of care measurement set. There was unanimous agreement that underreporting of migraine is significant and necessitates capture of potential migraineurs in the migraine population. Recurrent headache was defined as 2 or more episodes of headache >7 days apart in the measurement set (n = 21,718). Rather than identifying this group through a defined time period, the advisors suggested changing this component of the migraine population definition to “any visit where headache is listed as primary diagnosis” (n = 9177). This modification, representing a difference of 12,541 covered lives, would have an effect on most measures, since the migraine population serves as the denominator for a substantial portion of the measurement set.

Additional recommendations were made to modify numerator and denominator definitions to improve the mechanism used to capture elements of migraineur health service and pharmacy utilization. The details of these recommendations are presented in Table 5.

The migraine quality of care measurement set provides a framework for assessing migraine care. Additional assessments will be conducted and endorsement will be sought through the National Quality Forum to improve visibility and provide validation that the measures represent the interests of multiple healthcare stakeholders.

Acknowledgments
The analytic findings were reviewed with the following expert advisors in November 2010: Walter “Buzz” Stewart, PhD, MPH, Associate Chief Research Officer, Director, Center for Health Research, Geisinger Health System, Danville, PA; Roger Cady, MD, CEO, Banyan Group Inc, Springfield, MO, Director, Headache Care Center, Clinvest, Springfield, MO, Founder, Primary Care Network, Inc, Springfield, MO; David Dodick, MD, Professor of Neurology, Mayo Clinic, Phoenix, AZ; Fred Freitag, DO, Medical Director of the Comprehensive Headache Center, Director of Headache Medicine, Baylor Health Care System, Dallas, TX; Christopher Goff, JD, MA, CEO, and General Counsel, Employers Health Purchasing Corporation of Ohio, Canton, OH; and Richard Lipton, MD, FAAN, Professor and Vice Chair, Neurology, Montefiore Medical Center, Bronx, NY.

Author Affiliations: From Jefferson School of Population Health (VPP, JC, NIG), Philadelphia, PA; Jefferson Headache Center (SS, MH), Philadelphia, PA; Inovalon, Inc (JB, CS), Bowie, MD; Global Health Outcomes (DN-M), Merck Sharp & Dohme Corp, West Point, PA.

Funding Source: This study was funded by Merck Sharp & Dohme Corp.

Author Disclosures: Dr Ng-Mak reports former employment and stock ownership with Merck Sharp & Dohme Corp. Dr Sennett reports that he is now with IMPAQ International, Columbia, MD. The other authors (VPP, SS, JC, JB, MH, CS, NIG) report no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article.

Authorship Information: Concept and design (VPP, SS, JC, MH, DN-M, CS, NIG); acquisition of data (VPP, SS, JB, MH, NIG); analysis and interpretation of data (VPP, SS, JC, JB, MH, DN-M, CS, NIG); drafting of the manuscript (VPP, JC, DN-M, NIG); critical revision of the manuscript for important intellectual content (VPP, SS, JC, DN-M, NIG); statistical analysis (JB); obtaining funding (CS, NIG); administrative, technical, or logistic support (VPP, JB); and supervision (VPP, JB, DN-M, NIG).

Address correspondence to: Neil I. Goldfarb, BA, Executive Director, Greater Philadelphia Business Coalition on Health, c/o Public Health Management Corporation, 260 S Broad St, Philadelphia, PA 19102. E-mail: ngoldfarb@gpbch.org.
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