Clinical Neurology News

Health insurers that cover millions of seniors have overcharged Medicare by nearly $30 billion the past 3 years alone, but federal officials say they are moving ahead with long-delayed plans to recoup at least part of the money.

Officials have known for years that some Medicare Advantage plans overbill the government by exaggerating how sick their members are or by charging Medicare for treatment of serious medical conditions they cannot prove their members have.

Getting refunds from the health plans has proved daunting, however. Officials with the Centers for Medicare & Medicaid Services repeatedly have postponed, or backed off, efforts to crack down on billing abuses and mistakes by the increasingly popular Medicare Advantage health plans offered by private health insurers under contract with Medicare. Today, such plans treat over 22 million seniors, more than 1 in 3 people on Medicare.

Now CMS is trying again, proposing a series of enhanced audits tailored to claw back $1 billion in Medicare Advantage overpayments by 2020 – just a tenth of what it estimates the plans overcharge the government in a given year.

At the same time, the Department of Health and Human Services Inspector General’s Office has launched a separate nationwide round of Medicare Advantage audits.

As in past years, such scrutiny faces an onslaught of criticism from the insurance industry, which argues the CMS audits especially are technically unsound and unfair and could jeopardize medical services for seniors.

America’s Health Insurance Plans, an industry trade group, blasted the CMS audit design when details emerged last fall, calling it “fatally flawed.”

Insurer Cigna Corp. warned in a May financial filing: “If adopted in its current form, [the audits] could have a detrimental impact” on all Medicare Advantage plans and “affect the ability of plans to deliver high quality care.”

But former Sen. Claire McCaskill, a Missouri Democrat who now works as a political analyst, said officials must move past powerful lobbying efforts to hold health insurers accountable and demand refunds for “inappropriate” billings.

“There’s a lot of things that could cause Medicare to go broke. This would be one of the contributing factors,” she said. “Ten billion dollars a year is real money.”
 

Catching overbilling with a wider net

In the overpayment dispute, health plans want CMS to scale back – if not kill off – an enhanced audit tool that, for the first time, could force insurers to cough up millions in improper payments they’ve received.

For over a decade, audits have been little more than an irritant to insurers because most plans go years without being chosen for review and often pay only a few hundred thousand dollars in refunds as a consequence. When auditors uncover errors in the medical records of patients they paid the companies to treat, CMS has simply required a rebate for those patients for just the year audited – relatively small sums for plans with thousands of members.

The latest CMS proposal would raise those stakes enormously by extrapolating error rates found in a random sample of 200 patients to the plan’s full membership – a technique expected to trigger many multimillion-dollar penalties. Though controversial, extrapolation is common in medical fraud investigations – except for investigations into Medicare Advantage. Since 2007, the industry has successfully challenged the extrapolation method and, as a result, largely avoided accountability for pervasive billing errors.

“The public has a substantial interest in the recoupment of millions of dollars of public money improperly paid to health insurers,” CMS wrote in a Federal Register notice late last year announcing its renewed attempt at using extrapolation.
 

Penalties in limbo

In a written response to questions posed by Kaiser Health News, CMS officials said the agency has already conducted 90 of those enhanced audits for payments made in 2011, 2012 and 2013 – and expects to collect $650 million in extrapolated penalties as a result.

Though that figure reflects only a minute percentage of actual losses to taxpayers from overpayments, it would be a huge escalation for CMS. Previous Medicare Advantage audits have recouped a total of about $14 million, far less than it cost to conduct them, federal records show.

Though CMS has disclosed the names of the health plans in the crossfire, it has not yet told them how much each owes, officials said. CMS declined to say when, or if, they would make the results public.

This year, CMS is starting audits for 2014 and 2015, 30 per year, targeting about 5% of the 600 plans annually.

This spring, CMS announced it would extend until the end of August the audit proposal’s public comment period, which was supposed to end in April. That could be a signal the agency might be looking more closely at industry objections.

Health care industry consultant Jessica Smith said CMS might be taking additional time to make sure the audit protocol can pass muster. “Once they have their ducks in a row, CMS will come back hard at the health plans. There is so much money tied to this.”

But Sean Creighton, a former senior CMS official who now advises the industry for health care consultant Avalere Health, said payment error rates have been dropping because many health plans “are trying as hard as they can to become compliant.”

Still, audits are continuing to find mistakes. The first HHS inspector general audit, released in late April, found that Missouri-based Essence Healthcare Inc. had failed to justify fees for dozens of patients it had covered for strokes or depression. Essence denied any wrongdoing but agreed it should refund $158,904 in overcharges for those patients and ferret out any other errors.

Essence also faces a pending whistle-blower suit filed by Charles Rasmussen, a Branson, Mo., doctor who alleges the health plan illegally boosted profits by overstating the severity of patients’ medical conditions. Essence has called the allegations “wholly without merit” and “baseless.”

Essence started as a St. Louis physician group, then grew into a broader holding company backed by prominent Silicon Valley venture capitalist John Doerr with his brother, St. Louis doctor and software designer Thomas Doerr, in 2007. Neither would comment on the allegations.
 

How we got here

CMS uses a billing formula called a “risk score” to pay for each Medicare Advantage member. The formula pays higher rates for sicker patients than for people in good health.

Congress approved risk scoring in 2003 to ensure health plans did not shy away from taking sick patients who could incur higher-than-usual costs from hospitals and other medical facilities. But some insurers quickly found ways to boost risk scores – and their revenues.

In 2007, after several years of running Medicare Advantage as what one CMS official dubbed an “honor system,” the agency launched “Risk Adjustment Data Validation,” or RADV, audits. The idea was to cut down on undeserved payments that cost CMS nearly $30 billion over the past 3 years.

The audits of 37 health plans revealed that on average auditors could confirm just 60% of the more than 20,000 medical conditions CMS had paid the plans to treat.

Extra payments to plans that had claimed some of its diabetic patients had complications, such as eye or kidney problems, were reduced or invalidated in nearly half the cases. The overpayments exceeded $10,000 a year for more than 150 patients, though health plans disputed some of the findings.

But CMS kept the findings under wraps until the Center for Public Integrity sued the agency under the Freedom of Information Act to make them public.

Despite the alarming results, CMS conducted no audits for payments made during 2008, 2009 and 2010 as they faced industry backlash over CMS’ authority to conduct them, and the threat of extrapolated repayments. Some inside the agency also worried that health plans would abandon the Medicare Advantage program if CMS pressed them too hard, records released through the FOIA lawsuit show.

CMS officials resumed the audits for 2011 and expected to finish them and assess penalties by the end of 2016. That has yet to happen amid the continuing protests from the industry. Insurers want CMS to adjust downward any extrapolated penalties to account for coding errors that exist in standard Medicare. CMS stands behind its method – at least for now.

At a minimum, argues AHIP, the health insurers association, CMS should back off extrapolation for the 90 audits for 2011-13 and apply it for 2014 and onward. Should CMS agree, it would write off more than half a billion dollars that could be recovered for the U.S. Treasury.
 

Kaiser Health News is a nonprofit national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation that is not affiliated with Kaiser Permanente.

Health insurers that cover millions of seniors have overcharged Medicare by nearly $30 billion the past 3 years alone, but federal officials say they are moving ahead with long-delayed plans to recoup at least part of the money.

Officials have known for years that some Medicare Advantage plans overbill the government by exaggerating how sick their members are or by charging Medicare for treatment of serious medical conditions they cannot prove their members have.

Getting refunds from the health plans has proved daunting, however. Officials with the Centers for Medicare & Medicaid Services repeatedly have postponed, or backed off, efforts to crack down on billing abuses and mistakes by the increasingly popular Medicare Advantage health plans offered by private health insurers under contract with Medicare. Today, such plans treat over 22 million seniors, more than 1 in 3 people on Medicare.

Now CMS is trying again, proposing a series of enhanced audits tailored to claw back $1 billion in Medicare Advantage overpayments by 2020 – just a tenth of what it estimates the plans overcharge the government in a given year.

At the same time, the Department of Health and Human Services Inspector General’s Office has launched a separate nationwide round of Medicare Advantage audits.

As in past years, such scrutiny faces an onslaught of criticism from the insurance industry, which argues the CMS audits especially are technically unsound and unfair and could jeopardize medical services for seniors.

America’s Health Insurance Plans, an industry trade group, blasted the CMS audit design when details emerged last fall, calling it “fatally flawed.”

Insurer Cigna Corp. warned in a May financial filing: “If adopted in its current form, [the audits] could have a detrimental impact” on all Medicare Advantage plans and “affect the ability of plans to deliver high quality care.”

But former Sen. Claire McCaskill, a Missouri Democrat who now works as a political analyst, said officials must move past powerful lobbying efforts to hold health insurers accountable and demand refunds for “inappropriate” billings.

“There’s a lot of things that could cause Medicare to go broke. This would be one of the contributing factors,” she said. “Ten billion dollars a year is real money.”
 

Catching overbilling with a wider net

In the overpayment dispute, health plans want CMS to scale back – if not kill off – an enhanced audit tool that, for the first time, could force insurers to cough up millions in improper payments they’ve received.

For over a decade, audits have been little more than an irritant to insurers because most plans go years without being chosen for review and often pay only a few hundred thousand dollars in refunds as a consequence. When auditors uncover errors in the medical records of patients they paid the companies to treat, CMS has simply required a rebate for those patients for just the year audited – relatively small sums for plans with thousands of members.

The latest CMS proposal would raise those stakes enormously by extrapolating error rates found in a random sample of 200 patients to the plan’s full membership – a technique expected to trigger many multimillion-dollar penalties. Though controversial, extrapolation is common in medical fraud investigations – except for investigations into Medicare Advantage. Since 2007, the industry has successfully challenged the extrapolation method and, as a result, largely avoided accountability for pervasive billing errors.

“The public has a substantial interest in the recoupment of millions of dollars of public money improperly paid to health insurers,” CMS wrote in a Federal Register notice late last year announcing its renewed attempt at using extrapolation.
 

Penalties in limbo

In a written response to questions posed by Kaiser Health News, CMS officials said the agency has already conducted 90 of those enhanced audits for payments made in 2011, 2012 and 2013 – and expects to collect $650 million in extrapolated penalties as a result.

Though that figure reflects only a minute percentage of actual losses to taxpayers from overpayments, it would be a huge escalation for CMS. Previous Medicare Advantage audits have recouped a total of about $14 million, far less than it cost to conduct them, federal records show.

Though CMS has disclosed the names of the health plans in the crossfire, it has not yet told them how much each owes, officials said. CMS declined to say when, or if, they would make the results public.

This year, CMS is starting audits for 2014 and 2015, 30 per year, targeting about 5% of the 600 plans annually.

This spring, CMS announced it would extend until the end of August the audit proposal’s public comment period, which was supposed to end in April. That could be a signal the agency might be looking more closely at industry objections.

Health care industry consultant Jessica Smith said CMS might be taking additional time to make sure the audit protocol can pass muster. “Once they have their ducks in a row, CMS will come back hard at the health plans. There is so much money tied to this.”

But Sean Creighton, a former senior CMS official who now advises the industry for health care consultant Avalere Health, said payment error rates have been dropping because many health plans “are trying as hard as they can to become compliant.”

Still, audits are continuing to find mistakes. The first HHS inspector general audit, released in late April, found that Missouri-based Essence Healthcare Inc. had failed to justify fees for dozens of patients it had covered for strokes or depression. Essence denied any wrongdoing but agreed it should refund $158,904 in overcharges for those patients and ferret out any other errors.

Essence also faces a pending whistle-blower suit filed by Charles Rasmussen, a Branson, Mo., doctor who alleges the health plan illegally boosted profits by overstating the severity of patients’ medical conditions. Essence has called the allegations “wholly without merit” and “baseless.”

Essence started as a St. Louis physician group, then grew into a broader holding company backed by prominent Silicon Valley venture capitalist John Doerr with his brother, St. Louis doctor and software designer Thomas Doerr, in 2007. Neither would comment on the allegations.
 

How we got here

CMS uses a billing formula called a “risk score” to pay for each Medicare Advantage member. The formula pays higher rates for sicker patients than for people in good health.

Congress approved risk scoring in 2003 to ensure health plans did not shy away from taking sick patients who could incur higher-than-usual costs from hospitals and other medical facilities. But some insurers quickly found ways to boost risk scores – and their revenues.

In 2007, after several years of running Medicare Advantage as what one CMS official dubbed an “honor system,” the agency launched “Risk Adjustment Data Validation,” or RADV, audits. The idea was to cut down on undeserved payments that cost CMS nearly $30 billion over the past 3 years.

The audits of 37 health plans revealed that on average auditors could confirm just 60% of the more than 20,000 medical conditions CMS had paid the plans to treat.

Extra payments to plans that had claimed some of its diabetic patients had complications, such as eye or kidney problems, were reduced or invalidated in nearly half the cases. The overpayments exceeded $10,000 a year for more than 150 patients, though health plans disputed some of the findings.

But CMS kept the findings under wraps until the Center for Public Integrity sued the agency under the Freedom of Information Act to make them public.

Despite the alarming results, CMS conducted no audits for payments made during 2008, 2009 and 2010 as they faced industry backlash over CMS’ authority to conduct them, and the threat of extrapolated repayments. Some inside the agency also worried that health plans would abandon the Medicare Advantage program if CMS pressed them too hard, records released through the FOIA lawsuit show.

CMS officials resumed the audits for 2011 and expected to finish them and assess penalties by the end of 2016. That has yet to happen amid the continuing protests from the industry. Insurers want CMS to adjust downward any extrapolated penalties to account for coding errors that exist in standard Medicare. CMS stands behind its method – at least for now.

At a minimum, argues AHIP, the health insurers association, CMS should back off extrapolation for the 90 audits for 2011-13 and apply it for 2014 and onward. Should CMS agree, it would write off more than half a billion dollars that could be recovered for the U.S. Treasury.
 

Kaiser Health News is a nonprofit national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation that is not affiliated with Kaiser Permanente.

Health insurers that cover millions of seniors have overcharged Medicare by nearly $30 billion the past 3 years alone, but federal officials say they are moving ahead with long-delayed plans to recoup at least part of the money.

Officials have known for years that some Medicare Advantage plans overbill the government by exaggerating how sick their members are or by charging Medicare for treatment of serious medical conditions they cannot prove their members have.

Getting refunds from the health plans has proved daunting, however. Officials with the Centers for Medicare & Medicaid Services repeatedly have postponed, or backed off, efforts to crack down on billing abuses and mistakes by the increasingly popular Medicare Advantage health plans offered by private health insurers under contract with Medicare. Today, such plans treat over 22 million seniors, more than 1 in 3 people on Medicare.

Now CMS is trying again, proposing a series of enhanced audits tailored to claw back $1 billion in Medicare Advantage overpayments by 2020 – just a tenth of what it estimates the plans overcharge the government in a given year.

At the same time, the Department of Health and Human Services Inspector General’s Office has launched a separate nationwide round of Medicare Advantage audits.

As in past years, such scrutiny faces an onslaught of criticism from the insurance industry, which argues the CMS audits especially are technically unsound and unfair and could jeopardize medical services for seniors.

America’s Health Insurance Plans, an industry trade group, blasted the CMS audit design when details emerged last fall, calling it “fatally flawed.”

Insurer Cigna Corp. warned in a May financial filing: “If adopted in its current form, [the audits] could have a detrimental impact” on all Medicare Advantage plans and “affect the ability of plans to deliver high quality care.”

But former Sen. Claire McCaskill, a Missouri Democrat who now works as a political analyst, said officials must move past powerful lobbying efforts to hold health insurers accountable and demand refunds for “inappropriate” billings.

“There’s a lot of things that could cause Medicare to go broke. This would be one of the contributing factors,” she said. “Ten billion dollars a year is real money.”
 

Catching overbilling with a wider net

In the overpayment dispute, health plans want CMS to scale back – if not kill off – an enhanced audit tool that, for the first time, could force insurers to cough up millions in improper payments they’ve received.

For over a decade, audits have been little more than an irritant to insurers because most plans go years without being chosen for review and often pay only a few hundred thousand dollars in refunds as a consequence. When auditors uncover errors in the medical records of patients they paid the companies to treat, CMS has simply required a rebate for those patients for just the year audited – relatively small sums for plans with thousands of members.

The latest CMS proposal would raise those stakes enormously by extrapolating error rates found in a random sample of 200 patients to the plan’s full membership – a technique expected to trigger many multimillion-dollar penalties. Though controversial, extrapolation is common in medical fraud investigations – except for investigations into Medicare Advantage. Since 2007, the industry has successfully challenged the extrapolation method and, as a result, largely avoided accountability for pervasive billing errors.

“The public has a substantial interest in the recoupment of millions of dollars of public money improperly paid to health insurers,” CMS wrote in a Federal Register notice late last year announcing its renewed attempt at using extrapolation.
 

Penalties in limbo

In a written response to questions posed by Kaiser Health News, CMS officials said the agency has already conducted 90 of those enhanced audits for payments made in 2011, 2012 and 2013 – and expects to collect $650 million in extrapolated penalties as a result.

Though that figure reflects only a minute percentage of actual losses to taxpayers from overpayments, it would be a huge escalation for CMS. Previous Medicare Advantage audits have recouped a total of about $14 million, far less than it cost to conduct them, federal records show.

Though CMS has disclosed the names of the health plans in the crossfire, it has not yet told them how much each owes, officials said. CMS declined to say when, or if, they would make the results public.

This year, CMS is starting audits for 2014 and 2015, 30 per year, targeting about 5% of the 600 plans annually.

This spring, CMS announced it would extend until the end of August the audit proposal’s public comment period, which was supposed to end in April. That could be a signal the agency might be looking more closely at industry objections.

Health care industry consultant Jessica Smith said CMS might be taking additional time to make sure the audit protocol can pass muster. “Once they have their ducks in a row, CMS will come back hard at the health plans. There is so much money tied to this.”

But Sean Creighton, a former senior CMS official who now advises the industry for health care consultant Avalere Health, said payment error rates have been dropping because many health plans “are trying as hard as they can to become compliant.”

Still, audits are continuing to find mistakes. The first HHS inspector general audit, released in late April, found that Missouri-based Essence Healthcare Inc. had failed to justify fees for dozens of patients it had covered for strokes or depression. Essence denied any wrongdoing but agreed it should refund $158,904 in overcharges for those patients and ferret out any other errors.

Essence also faces a pending whistle-blower suit filed by Charles Rasmussen, a Branson, Mo., doctor who alleges the health plan illegally boosted profits by overstating the severity of patients’ medical conditions. Essence has called the allegations “wholly without merit” and “baseless.”

Essence started as a St. Louis physician group, then grew into a broader holding company backed by prominent Silicon Valley venture capitalist John Doerr with his brother, St. Louis doctor and software designer Thomas Doerr, in 2007. Neither would comment on the allegations.
 

How we got here

CMS uses a billing formula called a “risk score” to pay for each Medicare Advantage member. The formula pays higher rates for sicker patients than for people in good health.

Congress approved risk scoring in 2003 to ensure health plans did not shy away from taking sick patients who could incur higher-than-usual costs from hospitals and other medical facilities. But some insurers quickly found ways to boost risk scores – and their revenues.

In 2007, after several years of running Medicare Advantage as what one CMS official dubbed an “honor system,” the agency launched “Risk Adjustment Data Validation,” or RADV, audits. The idea was to cut down on undeserved payments that cost CMS nearly $30 billion over the past 3 years.

The audits of 37 health plans revealed that on average auditors could confirm just 60% of the more than 20,000 medical conditions CMS had paid the plans to treat.

Extra payments to plans that had claimed some of its diabetic patients had complications, such as eye or kidney problems, were reduced or invalidated in nearly half the cases. The overpayments exceeded $10,000 a year for more than 150 patients, though health plans disputed some of the findings.

But CMS kept the findings under wraps until the Center for Public Integrity sued the agency under the Freedom of Information Act to make them public.

Despite the alarming results, CMS conducted no audits for payments made during 2008, 2009 and 2010 as they faced industry backlash over CMS’ authority to conduct them, and the threat of extrapolated repayments. Some inside the agency also worried that health plans would abandon the Medicare Advantage program if CMS pressed them too hard, records released through the FOIA lawsuit show.

CMS officials resumed the audits for 2011 and expected to finish them and assess penalties by the end of 2016. That has yet to happen amid the continuing protests from the industry. Insurers want CMS to adjust downward any extrapolated penalties to account for coding errors that exist in standard Medicare. CMS stands behind its method – at least for now.

At a minimum, argues AHIP, the health insurers association, CMS should back off extrapolation for the 90 audits for 2011-13 and apply it for 2014 and onward. Should CMS agree, it would write off more than half a billion dollars that could be recovered for the U.S. Treasury.
 

Kaiser Health News is a nonprofit national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation that is not affiliated with Kaiser Permanente.

Many of the personnel questions I receive concern the dreaded “marginal employee” – a person who has never done anything truly heinous to merit firing, but neither anything special to merit continued employment. I advise getting rid of such people and then changing the hiring criteria that bring you marginal employees in the first place.

katleho Seisa/Getty Images

Most bad hires come about because employers do not have a clear vision of the kind of employee they want. Many office manuals do not contain detailed job descriptions. If you don’t know exactly what you are looking for, your entire selection process will be inadequate from initial screening of applicants through assessments of their skills and personalities. Many physicians compound the problem with poor interview techniques and inadequate verification.

So now is the time, before a job vacancy occurs, to reevaluate your entire hiring process.. Take a hard look at your job descriptions, and update them if necessary. A good job description lists the major responsibilities of the position, with the relative importance of each duty and the critical knowledge, skills, and education levels necessary for each function. In other words, it describes, accurately and in detail, exactly what you expect from the employee you will hire to perform that job.

Once you have a clear job description in mind (and in print), take all the time you need to find the best possible match for it. This is not a place to cut corners. Screen your candidates carefully and avoid lowering your expectations. This is the point at which it might be tempting to settle for a marginal candidate, just to get the process over with.

It also is tempting to hire the candidate that you have the “best feeling” about, even though he or she is a poor match for the job, and then try to mold the job to that person. Every doctor knows that hunches are no substitute for hard data.


Be alert for red flags in résumés: significant time gaps between jobs; positions at companies that are no longer in business, or are otherwise impossible to verify; job titles that don’t make sense, given the applicant’s qualifications.

Background checks are a dicey subject, but publicly available information can be found, cheaply or free, on multiple websites created for that purpose. Be sure to tell applicants that you will be verifying facts in their résumés; it’s usually wise to get their written consent to do so.

Many employers skip the essential step of verification; many applicants know that. (I once actually overheard a new hire say, “I won’t be here long if they check my references.” And by golly, she was right!) If a reference is reluctant to tell you anything substantive, ask, “Would you hire this person again?” You can interpret a lot from the answer – or lack of one.

Interviews often get short shrift as well. Many doctors tend to do all the talking. The purpose of an interview is to allow you to size up the prospective employee, not to deliver a lecture on the sterling attributes of your office. Important interview topics include educational background, skills, experience, and unrelated job history.

By law, you cannot ask an applicant’s age, date of birth, sex, creed, color, religion, or national origin. Other forbidden subjects include disabilities, marital status, military record, number of children (or who cares for them), addiction history, citizenship, criminal record, psychiatric history, absenteeism, or workers’ compensation.

There are acceptable alternatives to some of those questions, however: You can ask if applicants have ever gone by another name (for your background check), for example. You can ask if they are legally authorized to work in this country, and whether they will be physically able to perform the duties specified in the job description. While past addictions are off limits, you do have a right to know about current addictions to illegal substances.

Once you have hired people whose skills and personalities best fit your needs, train them well, and then give them the opportunity to succeed. “The best executive,” wrote Theodore Roosevelt, “is the one who has sense enough to pick good [people] to do what he [or she] wants done, and self-restraint enough to keep from meddling with them while they do it.”
 

Dr. Eastern practices dermatology and dermatologic surgery in Belleville, N.J. He is the author of numerous articles and textbook chapters, and is a longtime monthly columnist for Dermatology News. Write to him at dermnews@mdedge.com.

Many of the personnel questions I receive concern the dreaded “marginal employee” – a person who has never done anything truly heinous to merit firing, but neither anything special to merit continued employment. I advise getting rid of such people and then changing the hiring criteria that bring you marginal employees in the first place.

katleho Seisa/Getty Images

Most bad hires come about because employers do not have a clear vision of the kind of employee they want. Many office manuals do not contain detailed job descriptions. If you don’t know exactly what you are looking for, your entire selection process will be inadequate from initial screening of applicants through assessments of their skills and personalities. Many physicians compound the problem with poor interview techniques and inadequate verification.

So now is the time, before a job vacancy occurs, to reevaluate your entire hiring process.. Take a hard look at your job descriptions, and update them if necessary. A good job description lists the major responsibilities of the position, with the relative importance of each duty and the critical knowledge, skills, and education levels necessary for each function. In other words, it describes, accurately and in detail, exactly what you expect from the employee you will hire to perform that job.

Once you have a clear job description in mind (and in print), take all the time you need to find the best possible match for it. This is not a place to cut corners. Screen your candidates carefully and avoid lowering your expectations. This is the point at which it might be tempting to settle for a marginal candidate, just to get the process over with.

It also is tempting to hire the candidate that you have the “best feeling” about, even though he or she is a poor match for the job, and then try to mold the job to that person. Every doctor knows that hunches are no substitute for hard data.


Be alert for red flags in résumés: significant time gaps between jobs; positions at companies that are no longer in business, or are otherwise impossible to verify; job titles that don’t make sense, given the applicant’s qualifications.

Background checks are a dicey subject, but publicly available information can be found, cheaply or free, on multiple websites created for that purpose. Be sure to tell applicants that you will be verifying facts in their résumés; it’s usually wise to get their written consent to do so.

Many employers skip the essential step of verification; many applicants know that. (I once actually overheard a new hire say, “I won’t be here long if they check my references.” And by golly, she was right!) If a reference is reluctant to tell you anything substantive, ask, “Would you hire this person again?” You can interpret a lot from the answer – or lack of one.

Interviews often get short shrift as well. Many doctors tend to do all the talking. The purpose of an interview is to allow you to size up the prospective employee, not to deliver a lecture on the sterling attributes of your office. Important interview topics include educational background, skills, experience, and unrelated job history.

By law, you cannot ask an applicant’s age, date of birth, sex, creed, color, religion, or national origin. Other forbidden subjects include disabilities, marital status, military record, number of children (or who cares for them), addiction history, citizenship, criminal record, psychiatric history, absenteeism, or workers’ compensation.

There are acceptable alternatives to some of those questions, however: You can ask if applicants have ever gone by another name (for your background check), for example. You can ask if they are legally authorized to work in this country, and whether they will be physically able to perform the duties specified in the job description. While past addictions are off limits, you do have a right to know about current addictions to illegal substances.

Once you have hired people whose skills and personalities best fit your needs, train them well, and then give them the opportunity to succeed. “The best executive,” wrote Theodore Roosevelt, “is the one who has sense enough to pick good [people] to do what he [or she] wants done, and self-restraint enough to keep from meddling with them while they do it.”
 

Dr. Eastern practices dermatology and dermatologic surgery in Belleville, N.J. He is the author of numerous articles and textbook chapters, and is a longtime monthly columnist for Dermatology News. Write to him at dermnews@mdedge.com.

Many of the personnel questions I receive concern the dreaded “marginal employee” – a person who has never done anything truly heinous to merit firing, but neither anything special to merit continued employment. I advise getting rid of such people and then changing the hiring criteria that bring you marginal employees in the first place.

katleho Seisa/Getty Images

Most bad hires come about because employers do not have a clear vision of the kind of employee they want. Many office manuals do not contain detailed job descriptions. If you don’t know exactly what you are looking for, your entire selection process will be inadequate from initial screening of applicants through assessments of their skills and personalities. Many physicians compound the problem with poor interview techniques and inadequate verification.

So now is the time, before a job vacancy occurs, to reevaluate your entire hiring process.. Take a hard look at your job descriptions, and update them if necessary. A good job description lists the major responsibilities of the position, with the relative importance of each duty and the critical knowledge, skills, and education levels necessary for each function. In other words, it describes, accurately and in detail, exactly what you expect from the employee you will hire to perform that job.

Once you have a clear job description in mind (and in print), take all the time you need to find the best possible match for it. This is not a place to cut corners. Screen your candidates carefully and avoid lowering your expectations. This is the point at which it might be tempting to settle for a marginal candidate, just to get the process over with.

It also is tempting to hire the candidate that you have the “best feeling” about, even though he or she is a poor match for the job, and then try to mold the job to that person. Every doctor knows that hunches are no substitute for hard data.


Be alert for red flags in résumés: significant time gaps between jobs; positions at companies that are no longer in business, or are otherwise impossible to verify; job titles that don’t make sense, given the applicant’s qualifications.

Background checks are a dicey subject, but publicly available information can be found, cheaply or free, on multiple websites created for that purpose. Be sure to tell applicants that you will be verifying facts in their résumés; it’s usually wise to get their written consent to do so.

Many employers skip the essential step of verification; many applicants know that. (I once actually overheard a new hire say, “I won’t be here long if they check my references.” And by golly, she was right!) If a reference is reluctant to tell you anything substantive, ask, “Would you hire this person again?” You can interpret a lot from the answer – or lack of one.

Interviews often get short shrift as well. Many doctors tend to do all the talking. The purpose of an interview is to allow you to size up the prospective employee, not to deliver a lecture on the sterling attributes of your office. Important interview topics include educational background, skills, experience, and unrelated job history.

By law, you cannot ask an applicant’s age, date of birth, sex, creed, color, religion, or national origin. Other forbidden subjects include disabilities, marital status, military record, number of children (or who cares for them), addiction history, citizenship, criminal record, psychiatric history, absenteeism, or workers’ compensation.

There are acceptable alternatives to some of those questions, however: You can ask if applicants have ever gone by another name (for your background check), for example. You can ask if they are legally authorized to work in this country, and whether they will be physically able to perform the duties specified in the job description. While past addictions are off limits, you do have a right to know about current addictions to illegal substances.

Once you have hired people whose skills and personalities best fit your needs, train them well, and then give them the opportunity to succeed. “The best executive,” wrote Theodore Roosevelt, “is the one who has sense enough to pick good [people] to do what he [or she] wants done, and self-restraint enough to keep from meddling with them while they do it.”
 

Dr. Eastern practices dermatology and dermatologic surgery in Belleville, N.J. He is the author of numerous articles and textbook chapters, and is a longtime monthly columnist for Dermatology News. Write to him at dermnews@mdedge.com.

PHILADELPHIA – The level of exposure to white light is associated with acute risk of headache onset in patients with episodic migraine, according to research presented at the annual meeting of the American Headache Society. The data raise the question of whether modifying light exposure could reduce headache frequency in this population, said Suzanne M. Bertisch, MD, MPH, a physician and clinical investigator in the division of sleep and circadian disorders at Brigham and Women’s Hospital in Boston.

About 40% of patients with migraine identify light as a trigger. Most studies that have examined the association between light and migraine onset have been retrospective and have relied on subjective measures of light exposure.

From March 2016 to August 2017, Dr. Bertisch and colleagues enrolled 101 adults with episodic migraine into a prospective cohort study. For 79 of these participants, light exposure was measured continuously for 6 weeks by actigraph. In the morning and evening, participants recorded data such as headache onset, duration, and intensity in electronic headache diaries. They also recorded data about covariates such as caffeine intake, alcohol intake, sleep, and stress.

Dr. Bertisch and colleagues divided the day into four 6-hour periods and calculated mean light exposure within each period. After researchers adjusted for covariates, they found that higher mean photopic illuminance was associated with a 12% higher risk of headache during the same period. Mean photopic illuminance was not associated with headache onset in the next period, however.

Dr. Bertisch had no disclosures relevant to this study.

egreb@mdedge.com

PHILADELPHIA – The level of exposure to white light is associated with acute risk of headache onset in patients with episodic migraine, according to research presented at the annual meeting of the American Headache Society. The data raise the question of whether modifying light exposure could reduce headache frequency in this population, said Suzanne M. Bertisch, MD, MPH, a physician and clinical investigator in the division of sleep and circadian disorders at Brigham and Women’s Hospital in Boston.

About 40% of patients with migraine identify light as a trigger. Most studies that have examined the association between light and migraine onset have been retrospective and have relied on subjective measures of light exposure.

From March 2016 to August 2017, Dr. Bertisch and colleagues enrolled 101 adults with episodic migraine into a prospective cohort study. For 79 of these participants, light exposure was measured continuously for 6 weeks by actigraph. In the morning and evening, participants recorded data such as headache onset, duration, and intensity in electronic headache diaries. They also recorded data about covariates such as caffeine intake, alcohol intake, sleep, and stress.

Dr. Bertisch and colleagues divided the day into four 6-hour periods and calculated mean light exposure within each period. After researchers adjusted for covariates, they found that higher mean photopic illuminance was associated with a 12% higher risk of headache during the same period. Mean photopic illuminance was not associated with headache onset in the next period, however.

Dr. Bertisch had no disclosures relevant to this study.

egreb@mdedge.com

PHILADELPHIA – The level of exposure to white light is associated with acute risk of headache onset in patients with episodic migraine, according to research presented at the annual meeting of the American Headache Society. The data raise the question of whether modifying light exposure could reduce headache frequency in this population, said Suzanne M. Bertisch, MD, MPH, a physician and clinical investigator in the division of sleep and circadian disorders at Brigham and Women’s Hospital in Boston.

About 40% of patients with migraine identify light as a trigger. Most studies that have examined the association between light and migraine onset have been retrospective and have relied on subjective measures of light exposure.

From March 2016 to August 2017, Dr. Bertisch and colleagues enrolled 101 adults with episodic migraine into a prospective cohort study. For 79 of these participants, light exposure was measured continuously for 6 weeks by actigraph. In the morning and evening, participants recorded data such as headache onset, duration, and intensity in electronic headache diaries. They also recorded data about covariates such as caffeine intake, alcohol intake, sleep, and stress.

Dr. Bertisch and colleagues divided the day into four 6-hour periods and calculated mean light exposure within each period. After researchers adjusted for covariates, they found that higher mean photopic illuminance was associated with a 12% higher risk of headache during the same period. Mean photopic illuminance was not associated with headache onset in the next period, however.

Dr. Bertisch had no disclosures relevant to this study.

egreb@mdedge.com

Obese children and adolescents with multiple sclerosis (MS) had twice as many relapses on first-line treatment as compared with their non-obese counterparts, results of a recent large, single-center study show. The rate of switching to second-line disease-modifying therapy was consequently about 50% higher among the obese children in the study, which included a total of 453 pediatric patients.

The link between obesity and treatment response suggests that the management of these younger patients with MS could be improved through weight loss or body mass index (BMI)-adjusted dosing, according to Peter Huppke, MD, of Georg August University in Göttingen, Germany, and co-investigators.

“The findings do not indicate that obesity promotes greater disease activity, but pharmacokinetic factors are more likely associated with treatment response,” Dr. Huppke and co-authors said in a report on their study, which was published online ahead of print July 15 in JAMA Neurology.

This is believed to be the first-ever study to find an association between BMI and treatment response in pediatric patients with MS, according to the authors, who said they also confirmed a link between obesity and MS.

Specifically, obesity increased MS susceptibility by two-fold as compared with healthy controls, a finding that they said adds to a small but growing body of evidence that high BMI is associated with increased risk of the disease in these younger individuals.

This retrospective study included 453 pediatric patients with MS treated at the Center for MS in Childhood and Adolescence in Göttingen, Germany between 1990 and 2016. About two-thirds were female and the mean age at MS diagnosis was about 14 years.

Of those patients, 126 (27.8%) were classified as obese based on a BMI greater than the 90^th percentile, according to the report.

Dr. Huppke and co-investigators found that high BMI was linked to a significantly increased odds of pediatric MS, with odds ratios of 2.19 (95% CI, 1.5-3.1; P < 0.001) in girls and 2.14 (95% CI, 1.3-3.5; P = 0.003) in boys.

A total of 277 of these pediatric patients received a first-line disease-modifying therapy for 6 months or longer, including 249 treated with interferon beta and 51 treated with glatiramer.

Relapses were more common in obese patients, according to the report. with an annualized relapse rate of 1.29, compared to just 0.72 for those who were not overweight (P < 0.001).

Consequently, likelihood of receiving a second-line treatment was about 1.5 times higher in the obese or extremely obese patients, investigators said.

“A healthy weight may potentially optimize treatment outcomes and reduce disease-related burden and health care costs,” they concluded in the report, adding that BMI-adjusted dosing may “increase the value” of first-line disease-modifying therapies.

Dr. Huppke reported disclosures related to Bayer Health Care, Merck Serono, and Novartis not associated with the current study.

SOURCE: Huppke B, et al. JAMA Neurol. 2019 Jul 15. doi: 10.1001/jamaneurol.2019.1997

Obese children and adolescents with multiple sclerosis (MS) had twice as many relapses on first-line treatment as compared with their non-obese counterparts, results of a recent large, single-center study show. The rate of switching to second-line disease-modifying therapy was consequently about 50% higher among the obese children in the study, which included a total of 453 pediatric patients.

The link between obesity and treatment response suggests that the management of these younger patients with MS could be improved through weight loss or body mass index (BMI)-adjusted dosing, according to Peter Huppke, MD, of Georg August University in Göttingen, Germany, and co-investigators.

“The findings do not indicate that obesity promotes greater disease activity, but pharmacokinetic factors are more likely associated with treatment response,” Dr. Huppke and co-authors said in a report on their study, which was published online ahead of print July 15 in JAMA Neurology.

This is believed to be the first-ever study to find an association between BMI and treatment response in pediatric patients with MS, according to the authors, who said they also confirmed a link between obesity and MS.

Specifically, obesity increased MS susceptibility by two-fold as compared with healthy controls, a finding that they said adds to a small but growing body of evidence that high BMI is associated with increased risk of the disease in these younger individuals.

This retrospective study included 453 pediatric patients with MS treated at the Center for MS in Childhood and Adolescence in Göttingen, Germany between 1990 and 2016. About two-thirds were female and the mean age at MS diagnosis was about 14 years.

Of those patients, 126 (27.8%) were classified as obese based on a BMI greater than the 90^th percentile, according to the report.

Dr. Huppke and co-investigators found that high BMI was linked to a significantly increased odds of pediatric MS, with odds ratios of 2.19 (95% CI, 1.5-3.1; P < 0.001) in girls and 2.14 (95% CI, 1.3-3.5; P = 0.003) in boys.

A total of 277 of these pediatric patients received a first-line disease-modifying therapy for 6 months or longer, including 249 treated with interferon beta and 51 treated with glatiramer.

Relapses were more common in obese patients, according to the report. with an annualized relapse rate of 1.29, compared to just 0.72 for those who were not overweight (P < 0.001).

Consequently, likelihood of receiving a second-line treatment was about 1.5 times higher in the obese or extremely obese patients, investigators said.

“A healthy weight may potentially optimize treatment outcomes and reduce disease-related burden and health care costs,” they concluded in the report, adding that BMI-adjusted dosing may “increase the value” of first-line disease-modifying therapies.

Dr. Huppke reported disclosures related to Bayer Health Care, Merck Serono, and Novartis not associated with the current study.

SOURCE: Huppke B, et al. JAMA Neurol. 2019 Jul 15. doi: 10.1001/jamaneurol.2019.1997

Obese children and adolescents with multiple sclerosis (MS) had twice as many relapses on first-line treatment as compared with their non-obese counterparts, results of a recent large, single-center study show. The rate of switching to second-line disease-modifying therapy was consequently about 50% higher among the obese children in the study, which included a total of 453 pediatric patients.

The link between obesity and treatment response suggests that the management of these younger patients with MS could be improved through weight loss or body mass index (BMI)-adjusted dosing, according to Peter Huppke, MD, of Georg August University in Göttingen, Germany, and co-investigators.

“The findings do not indicate that obesity promotes greater disease activity, but pharmacokinetic factors are more likely associated with treatment response,” Dr. Huppke and co-authors said in a report on their study, which was published online ahead of print July 15 in JAMA Neurology.

This is believed to be the first-ever study to find an association between BMI and treatment response in pediatric patients with MS, according to the authors, who said they also confirmed a link between obesity and MS.

Specifically, obesity increased MS susceptibility by two-fold as compared with healthy controls, a finding that they said adds to a small but growing body of evidence that high BMI is associated with increased risk of the disease in these younger individuals.

This retrospective study included 453 pediatric patients with MS treated at the Center for MS in Childhood and Adolescence in Göttingen, Germany between 1990 and 2016. About two-thirds were female and the mean age at MS diagnosis was about 14 years.

Of those patients, 126 (27.8%) were classified as obese based on a BMI greater than the 90^th percentile, according to the report.

Dr. Huppke and co-investigators found that high BMI was linked to a significantly increased odds of pediatric MS, with odds ratios of 2.19 (95% CI, 1.5-3.1; P < 0.001) in girls and 2.14 (95% CI, 1.3-3.5; P = 0.003) in boys.

A total of 277 of these pediatric patients received a first-line disease-modifying therapy for 6 months or longer, including 249 treated with interferon beta and 51 treated with glatiramer.

Relapses were more common in obese patients, according to the report. with an annualized relapse rate of 1.29, compared to just 0.72 for those who were not overweight (P < 0.001).

Consequently, likelihood of receiving a second-line treatment was about 1.5 times higher in the obese or extremely obese patients, investigators said.

“A healthy weight may potentially optimize treatment outcomes and reduce disease-related burden and health care costs,” they concluded in the report, adding that BMI-adjusted dosing may “increase the value” of first-line disease-modifying therapies.

Dr. Huppke reported disclosures related to Bayer Health Care, Merck Serono, and Novartis not associated with the current study.

SOURCE: Huppke B, et al. JAMA Neurol. 2019 Jul 15. doi: 10.1001/jamaneurol.2019.1997

PHILADELPHIA – A surprisingly large number of patients with migraine who first seek care for migraine in a primary care setting receive an initial migraine diagnosis from a neurologist, said Alice R. Pressman, PhD at the annual meeting of the American Headache Society.

Dr. Pressman, executive director of research, development, and dissemination for Sutter Health, and her research colleagues analyzed data from primary care patients who sought care for migraine in the Sutter Health healthcare network in Northern California. They found that women were 10% more likely than men to consult a neurologist and that Asian patients had a longer time to a first neurology encounter for migraine, compared with Caucasian patients.

“Those who sought care from neurology had more severe migraine symptomology, disability, and comorbidities,” the researchers reported. Furthermore, patients with migraine seen by neurologists were more likely to receive prescriptions for acute and preventive migraine medications, compared with patients only seen by primary care physicians.

The study, known as the Migraine Signature Study, used electronic health records (EHR) and patient-reported questionnaire data to examine the clinical experiences and care of patients with migraine.

The primary care population consisted of 1.4 million adults with at least one office visit to primary care in 2013-2017. Using the validated Migraine Probability Algorithm, the researchers identified approximately 94,000 patients who sought care for migraine.

The investigators also invited 38,536 patients to complete an online survey about migraine criteria, symptomology, health resource utilization, and patient-reported outcomes such as disability, acute treatment optimization, cutaneous allodynia, depression, anxiety, and posttraumatic stress disorder (PTSD).

Of the patients who sought care for migraine, 72,624 patients did not receive migraine care from neurology, and 21,525 did.

Patients with migraine care from a neurologist were more likely to have at least one acute migraine medication order (89.4% vs. 80.6%), at least one preventive migraine medication order (78.6% vs. 49.1%), and any migraine medication order (95.3% vs. 85.9%). In addition, those with at least one medication order in the primary care setting had fewer orders per person per year, compared with those with at least one medication order in the neurology setting (1.1 vs. 1.6).

About one-third of the patients who sought care for migraine had no migraine encounters in the first 12 months of the study. Of the more than 33,000 patients with first migraine consults, approximately two-thirds did not receive a neurology consultation during the study and received their migraine diagnosis in the primary care setting.

Of the 31% of patients with first migraine consults in primary care who later had a neurology consult, two-thirds received a migraine diagnosis from neurology. “The high rate of initial migraine diagnosis within neurology was surprising among this sample with primary care encounters first,” the researchers said.

The investigators also examined patient-reported outcomes from 391 respondents who received migraine care from neurology and 399 respondents who received migraine care from primary care. “Patients who consulted a neurologist were likely to report moderate-to-severe disability, poor acute treatment optimization, and major depression,” they said. “Allodynia, anxiety, and PTSD did not differ by type of provider.”

Confounding may have influenced the results, and the researchers plan to assess factors such as headache frequency and severity using patient-reported survey data in future analyses.

The Migraine Signature Study was supported by Amgen, Inc.

jremaly@mdedge.com

PHILADELPHIA – A surprisingly large number of patients with migraine who first seek care for migraine in a primary care setting receive an initial migraine diagnosis from a neurologist, said Alice R. Pressman, PhD at the annual meeting of the American Headache Society.

Dr. Pressman, executive director of research, development, and dissemination for Sutter Health, and her research colleagues analyzed data from primary care patients who sought care for migraine in the Sutter Health healthcare network in Northern California. They found that women were 10% more likely than men to consult a neurologist and that Asian patients had a longer time to a first neurology encounter for migraine, compared with Caucasian patients.

“Those who sought care from neurology had more severe migraine symptomology, disability, and comorbidities,” the researchers reported. Furthermore, patients with migraine seen by neurologists were more likely to receive prescriptions for acute and preventive migraine medications, compared with patients only seen by primary care physicians.

The study, known as the Migraine Signature Study, used electronic health records (EHR) and patient-reported questionnaire data to examine the clinical experiences and care of patients with migraine.

The primary care population consisted of 1.4 million adults with at least one office visit to primary care in 2013-2017. Using the validated Migraine Probability Algorithm, the researchers identified approximately 94,000 patients who sought care for migraine.

The investigators also invited 38,536 patients to complete an online survey about migraine criteria, symptomology, health resource utilization, and patient-reported outcomes such as disability, acute treatment optimization, cutaneous allodynia, depression, anxiety, and posttraumatic stress disorder (PTSD).

Of the patients who sought care for migraine, 72,624 patients did not receive migraine care from neurology, and 21,525 did.

Patients with migraine care from a neurologist were more likely to have at least one acute migraine medication order (89.4% vs. 80.6%), at least one preventive migraine medication order (78.6% vs. 49.1%), and any migraine medication order (95.3% vs. 85.9%). In addition, those with at least one medication order in the primary care setting had fewer orders per person per year, compared with those with at least one medication order in the neurology setting (1.1 vs. 1.6).

About one-third of the patients who sought care for migraine had no migraine encounters in the first 12 months of the study. Of the more than 33,000 patients with first migraine consults, approximately two-thirds did not receive a neurology consultation during the study and received their migraine diagnosis in the primary care setting.

Of the 31% of patients with first migraine consults in primary care who later had a neurology consult, two-thirds received a migraine diagnosis from neurology. “The high rate of initial migraine diagnosis within neurology was surprising among this sample with primary care encounters first,” the researchers said.

The investigators also examined patient-reported outcomes from 391 respondents who received migraine care from neurology and 399 respondents who received migraine care from primary care. “Patients who consulted a neurologist were likely to report moderate-to-severe disability, poor acute treatment optimization, and major depression,” they said. “Allodynia, anxiety, and PTSD did not differ by type of provider.”

Confounding may have influenced the results, and the researchers plan to assess factors such as headache frequency and severity using patient-reported survey data in future analyses.

The Migraine Signature Study was supported by Amgen, Inc.

jremaly@mdedge.com

PHILADELPHIA – A surprisingly large number of patients with migraine who first seek care for migraine in a primary care setting receive an initial migraine diagnosis from a neurologist, said Alice R. Pressman, PhD at the annual meeting of the American Headache Society.

Dr. Pressman, executive director of research, development, and dissemination for Sutter Health, and her research colleagues analyzed data from primary care patients who sought care for migraine in the Sutter Health healthcare network in Northern California. They found that women were 10% more likely than men to consult a neurologist and that Asian patients had a longer time to a first neurology encounter for migraine, compared with Caucasian patients.

“Those who sought care from neurology had more severe migraine symptomology, disability, and comorbidities,” the researchers reported. Furthermore, patients with migraine seen by neurologists were more likely to receive prescriptions for acute and preventive migraine medications, compared with patients only seen by primary care physicians.

The study, known as the Migraine Signature Study, used electronic health records (EHR) and patient-reported questionnaire data to examine the clinical experiences and care of patients with migraine.

The primary care population consisted of 1.4 million adults with at least one office visit to primary care in 2013-2017. Using the validated Migraine Probability Algorithm, the researchers identified approximately 94,000 patients who sought care for migraine.

The investigators also invited 38,536 patients to complete an online survey about migraine criteria, symptomology, health resource utilization, and patient-reported outcomes such as disability, acute treatment optimization, cutaneous allodynia, depression, anxiety, and posttraumatic stress disorder (PTSD).

Of the patients who sought care for migraine, 72,624 patients did not receive migraine care from neurology, and 21,525 did.

Patients with migraine care from a neurologist were more likely to have at least one acute migraine medication order (89.4% vs. 80.6%), at least one preventive migraine medication order (78.6% vs. 49.1%), and any migraine medication order (95.3% vs. 85.9%). In addition, those with at least one medication order in the primary care setting had fewer orders per person per year, compared with those with at least one medication order in the neurology setting (1.1 vs. 1.6).

About one-third of the patients who sought care for migraine had no migraine encounters in the first 12 months of the study. Of the more than 33,000 patients with first migraine consults, approximately two-thirds did not receive a neurology consultation during the study and received their migraine diagnosis in the primary care setting.

Of the 31% of patients with first migraine consults in primary care who later had a neurology consult, two-thirds received a migraine diagnosis from neurology. “The high rate of initial migraine diagnosis within neurology was surprising among this sample with primary care encounters first,” the researchers said.

The investigators also examined patient-reported outcomes from 391 respondents who received migraine care from neurology and 399 respondents who received migraine care from primary care. “Patients who consulted a neurologist were likely to report moderate-to-severe disability, poor acute treatment optimization, and major depression,” they said. “Allodynia, anxiety, and PTSD did not differ by type of provider.”

Confounding may have influenced the results, and the researchers plan to assess factors such as headache frequency and severity using patient-reported survey data in future analyses.

The Migraine Signature Study was supported by Amgen, Inc.

jremaly@mdedge.com

PHILADELPHIA – Mindfulness-based cognitive therapy tailored for migraine may reduce migraine-related disability, even as the number of headache days and pain intensity remain unchanged, according to randomized clinical trial results.

“The fact that people can improve how they live their daily life even with the same amount of headache days and the same pain intensity is remarkable,” said study investigator Elizabeth K. Seng, PhD, associate professor of psychology at Yeshiva University and research associate professor of neurology at Albert Einstein College of Medicine, both in New York. “I think this gives us a little bit of a clue about when to use these kinds of treatments.”

Dr. Seng presented findings from the phase 2b pilot trial at the annual meeting of the American Headache Society.

To study the efficacy of mindfulness-based cognitive therapy for migraine, Dr. Seng and her research colleagues recruited participants with migraine in the New York City area between 2015 and 2018. In all, 60 patients were randomized to receive 8 weekly individual 75-minute mindfulness-based cognitive therapy for migraine sessions or 8 weeks on a wait list with treatment as usual.

Primary outcomes were Month 0 to Month 4 changes in perceived disability, measured using the Henry Ford Disability Inventory (HDI) and functional disability measured using the Migraine Disability Assessment Scale (MIDAS). Secondary outcomes included changes in headache days per 30 days and headache pain intensity.

Participants had a mean age of about 40 years, about 92% were women, and approximately half of the patients had chronic migraine. Participants had an average baseline HDI of 51.4, and 83.3% had MIDAS scores indicating severe disability. Patients averaged 10.4 headache attack days per month, and mean headache attack severity on a 0-10 scale was 6.2. Attrition did not significantly differ between the mindfulness-based cognitive therapy and control groups.

Patients who received mindfulness-based cognitive therapy for migraine experienced an approximately 15-point reduction on the HDI scale at 4 months, whereas wait-listed patients did not experience much of a change, Dr. Seng said. The difference between groups was statistically significant.

At 4 months, a smaller proportion of patients in the mindfulness-based cognitive therapy group had a MIDAS score of 21 or greater, but the difference between groups was not statistically significant. The data indicate a large effect that the study was underpowered to detect, Dr. Seng said.

A planned subgroup analysis found that mindfulness-based cognitive therapy produced changes in disability that were greater in patients with episodic migraine, compared with patients with chronic migraine. A reduction in MIDAS scores was statistically significant among patients with episodic migraine.

During the trial, one patient experienced increased headache frequency and intensity and changed their preventive treatment regimen, which investigators considered unrelated to mindfulness-based cognitive therapy. In addition, one patient experienced flooding – a vivid recollection of a traumatic event – which is an expected effect of meditation and relaxation therapy, Dr. Seng said. The patient completed the study and was satisfied with the mindfulness-based cognitive therapy training, she said.

“Preliminary evidence suggests that mindfulness-based cognitive therapy could be recommended to reduce headache-related disability in people with episodic migraine or people who have some kind of effective prevention on board, but they are still experiencing high levels of disability,” Dr. Seng said.

Although flooding may occur in patients with a trauma history who use meditation and relaxation, the techniques still may be useful, Dr. Seng said. “In the VA setting, we use meditation and relaxation all the time. But it helps to forewarn patients that they might experience distressful flooding and [to provide] techniques that they can use to reduce the impact of that.”

jremaly@mdedge.com

PHILADELPHIA – Mindfulness-based cognitive therapy tailored for migraine may reduce migraine-related disability, even as the number of headache days and pain intensity remain unchanged, according to randomized clinical trial results.

“The fact that people can improve how they live their daily life even with the same amount of headache days and the same pain intensity is remarkable,” said study investigator Elizabeth K. Seng, PhD, associate professor of psychology at Yeshiva University and research associate professor of neurology at Albert Einstein College of Medicine, both in New York. “I think this gives us a little bit of a clue about when to use these kinds of treatments.”

Dr. Seng presented findings from the phase 2b pilot trial at the annual meeting of the American Headache Society.

To study the efficacy of mindfulness-based cognitive therapy for migraine, Dr. Seng and her research colleagues recruited participants with migraine in the New York City area between 2015 and 2018. In all, 60 patients were randomized to receive 8 weekly individual 75-minute mindfulness-based cognitive therapy for migraine sessions or 8 weeks on a wait list with treatment as usual.

Primary outcomes were Month 0 to Month 4 changes in perceived disability, measured using the Henry Ford Disability Inventory (HDI) and functional disability measured using the Migraine Disability Assessment Scale (MIDAS). Secondary outcomes included changes in headache days per 30 days and headache pain intensity.

Participants had a mean age of about 40 years, about 92% were women, and approximately half of the patients had chronic migraine. Participants had an average baseline HDI of 51.4, and 83.3% had MIDAS scores indicating severe disability. Patients averaged 10.4 headache attack days per month, and mean headache attack severity on a 0-10 scale was 6.2. Attrition did not significantly differ between the mindfulness-based cognitive therapy and control groups.

Patients who received mindfulness-based cognitive therapy for migraine experienced an approximately 15-point reduction on the HDI scale at 4 months, whereas wait-listed patients did not experience much of a change, Dr. Seng said. The difference between groups was statistically significant.

At 4 months, a smaller proportion of patients in the mindfulness-based cognitive therapy group had a MIDAS score of 21 or greater, but the difference between groups was not statistically significant. The data indicate a large effect that the study was underpowered to detect, Dr. Seng said.

A planned subgroup analysis found that mindfulness-based cognitive therapy produced changes in disability that were greater in patients with episodic migraine, compared with patients with chronic migraine. A reduction in MIDAS scores was statistically significant among patients with episodic migraine.

During the trial, one patient experienced increased headache frequency and intensity and changed their preventive treatment regimen, which investigators considered unrelated to mindfulness-based cognitive therapy. In addition, one patient experienced flooding – a vivid recollection of a traumatic event – which is an expected effect of meditation and relaxation therapy, Dr. Seng said. The patient completed the study and was satisfied with the mindfulness-based cognitive therapy training, she said.

“Preliminary evidence suggests that mindfulness-based cognitive therapy could be recommended to reduce headache-related disability in people with episodic migraine or people who have some kind of effective prevention on board, but they are still experiencing high levels of disability,” Dr. Seng said.

Although flooding may occur in patients with a trauma history who use meditation and relaxation, the techniques still may be useful, Dr. Seng said. “In the VA setting, we use meditation and relaxation all the time. But it helps to forewarn patients that they might experience distressful flooding and [to provide] techniques that they can use to reduce the impact of that.”

jremaly@mdedge.com

PHILADELPHIA – Mindfulness-based cognitive therapy tailored for migraine may reduce migraine-related disability, even as the number of headache days and pain intensity remain unchanged, according to randomized clinical trial results.

“The fact that people can improve how they live their daily life even with the same amount of headache days and the same pain intensity is remarkable,” said study investigator Elizabeth K. Seng, PhD, associate professor of psychology at Yeshiva University and research associate professor of neurology at Albert Einstein College of Medicine, both in New York. “I think this gives us a little bit of a clue about when to use these kinds of treatments.”

Dr. Seng presented findings from the phase 2b pilot trial at the annual meeting of the American Headache Society.

To study the efficacy of mindfulness-based cognitive therapy for migraine, Dr. Seng and her research colleagues recruited participants with migraine in the New York City area between 2015 and 2018. In all, 60 patients were randomized to receive 8 weekly individual 75-minute mindfulness-based cognitive therapy for migraine sessions or 8 weeks on a wait list with treatment as usual.

Primary outcomes were Month 0 to Month 4 changes in perceived disability, measured using the Henry Ford Disability Inventory (HDI) and functional disability measured using the Migraine Disability Assessment Scale (MIDAS). Secondary outcomes included changes in headache days per 30 days and headache pain intensity.

Participants had a mean age of about 40 years, about 92% were women, and approximately half of the patients had chronic migraine. Participants had an average baseline HDI of 51.4, and 83.3% had MIDAS scores indicating severe disability. Patients averaged 10.4 headache attack days per month, and mean headache attack severity on a 0-10 scale was 6.2. Attrition did not significantly differ between the mindfulness-based cognitive therapy and control groups.

Patients who received mindfulness-based cognitive therapy for migraine experienced an approximately 15-point reduction on the HDI scale at 4 months, whereas wait-listed patients did not experience much of a change, Dr. Seng said. The difference between groups was statistically significant.

At 4 months, a smaller proportion of patients in the mindfulness-based cognitive therapy group had a MIDAS score of 21 or greater, but the difference between groups was not statistically significant. The data indicate a large effect that the study was underpowered to detect, Dr. Seng said.

A planned subgroup analysis found that mindfulness-based cognitive therapy produced changes in disability that were greater in patients with episodic migraine, compared with patients with chronic migraine. A reduction in MIDAS scores was statistically significant among patients with episodic migraine.

During the trial, one patient experienced increased headache frequency and intensity and changed their preventive treatment regimen, which investigators considered unrelated to mindfulness-based cognitive therapy. In addition, one patient experienced flooding – a vivid recollection of a traumatic event – which is an expected effect of meditation and relaxation therapy, Dr. Seng said. The patient completed the study and was satisfied with the mindfulness-based cognitive therapy training, she said.

“Preliminary evidence suggests that mindfulness-based cognitive therapy could be recommended to reduce headache-related disability in people with episodic migraine or people who have some kind of effective prevention on board, but they are still experiencing high levels of disability,” Dr. Seng said.

Although flooding may occur in patients with a trauma history who use meditation and relaxation, the techniques still may be useful, Dr. Seng said. “In the VA setting, we use meditation and relaxation all the time. But it helps to forewarn patients that they might experience distressful flooding and [to provide] techniques that they can use to reduce the impact of that.”

jremaly@mdedge.com

PHILADELPHIA – Patients with a history of migraine who underwent any type of surgery and then received a perioperative prescription for a headache abortive agent such as a triptan had 37% fewer readmissions for pain during the 30 days following surgery compared with patients who did not receive a migraine abortive prescription, according to an observational review of nearly 22,000 migraine patients from the Boston area.

Mitchel L. Zoler/MDedge News

While this statistically significant observational association must be viewed with caution, it provides compelling evidence for clinicians to prescribe a migraine abortive agent to migraineurs soon after surgery so that patients have these drugs handy if a migraine strikes, a possibility made likely by the stress and disruption of surgery, Katharina Platzbecker, MD, said at the annual meeting of the American Headache Society.

Postoperative migraine patients who received an abortive prescription specifically for a triptan or ergotamine showed an even stronger protective association, with an adjusted, statistically-significant 67% reduced rate of 30-day readmission for pain compared with the 50% of migraine patients who did not receive an abortive agent prescription after their surgery, said Dr. Platzbecker, a research fellow in the department of anesthesia, critical care, and pain medicine at Beth Israel Deaconess Medical Center in Boston. Only 8% of patients in the study received a triptan or ergotamine, with the vast majority of these patients getting a triptan.

The other types of abortive drugs prescribed perioperatively to migraine patients were NSAIDs or acetaminophen, received by 47% of the patients studied. The adjusted analysis showed that patients who received a prescription for one of these drugs had a statistically significant 35% reduced rate of 30-day readmission for pain. Patients who did not receive a prescription for a migraine abortive drug often got an opioid prescription, which went to 87% of the entire study population. Some patients received perioperative prescriptions for more than one drug. The analysis also showed that periopertive opioid prescriptions had no significant association with the 30-day rate of pain readmissions. In addition, prescription of any pain-reducing medication immediately prior to surgery as prophylaxis, which occurred in 17% of patients, had no significant association with the rate of 30-day postoperative pain readmission.


Despite the lack of clear causal evidence, clinicians should “definitely” be more aggressive in prescribing abortive treatments, especially triptans, to patients with a history of migraine who undergo surgery, Dr. Platzbecker said in an interview. These patients “are likely at risk for migraine [episodes] after surgery,”

Her study used data collected from nearly 25,000 patients with a history of a migraine billing diagnosis who underwent surgery and was a patient in either the Beth Israel or Partners (Massachusetts General Hospital and Brigham and Women’s Hospital) health systems during 2005-2017. Complete data that fulfilled the requirements of the study were available for 21,932 of these patients, of whom 11,011 (50%) received a perioperative prescription for an abortive drug and 10,921 (50%) did not. The prescribing occurred totally at the discretion of each patient’s physicians and surgeons. The researchers defined perioperative prescription as a billing entry for a drug anytime after surgery and within 30 days of hospital discharge or until readmission. The entire group studied averaged about 50 years old, more than 80% were women, and those who received an abortive treatment prescription generally had longer surgeries, more inpatient surgeries, and higher rates of various comorbidities. The adjusted statistical analysis took into account baseline differences like these.

Additional sensitivity analyses showed that perioperative prescriptions for abortive treatments also linked with significant reductions in all 30-day hospital readmissions, and with 30-day pain readmissions in patients who received surgery as inpatients as well as in those who were outpatients, and the association was specific to migraine patients. When Dr. Platzbecker expanded the group of patients she examined to more than 62,000 with any headache diagnosis the association between receiving a prescription for an abortive treatment and reduced 30-day pain readmissions became statistically insignificant.

Dr. Platzbecker and her associates previously reported results from an adjusted analysis showing that patients from the same database with a history of migraine who underwent surgery had an overall 42% increased rate of 30-day readmissions for pain compared with surgery patients who had no migraine history (Cephalagia. 2019 Feb;39[2]:286-95).

Dr. Platzbecker had no commercial disclosures.

mzoler@mdedge.com

On Twitter @mitchelzoler

This article was updated 7/16/19.

PHILADELPHIA – Patients with a history of migraine who underwent any type of surgery and then received a perioperative prescription for a headache abortive agent such as a triptan had 37% fewer readmissions for pain during the 30 days following surgery compared with patients who did not receive a migraine abortive prescription, according to an observational review of nearly 22,000 migraine patients from the Boston area.

Mitchel L. Zoler/MDedge News

While this statistically significant observational association must be viewed with caution, it provides compelling evidence for clinicians to prescribe a migraine abortive agent to migraineurs soon after surgery so that patients have these drugs handy if a migraine strikes, a possibility made likely by the stress and disruption of surgery, Katharina Platzbecker, MD, said at the annual meeting of the American Headache Society.

Postoperative migraine patients who received an abortive prescription specifically for a triptan or ergotamine showed an even stronger protective association, with an adjusted, statistically-significant 67% reduced rate of 30-day readmission for pain compared with the 50% of migraine patients who did not receive an abortive agent prescription after their surgery, said Dr. Platzbecker, a research fellow in the department of anesthesia, critical care, and pain medicine at Beth Israel Deaconess Medical Center in Boston. Only 8% of patients in the study received a triptan or ergotamine, with the vast majority of these patients getting a triptan.

The other types of abortive drugs prescribed perioperatively to migraine patients were NSAIDs or acetaminophen, received by 47% of the patients studied. The adjusted analysis showed that patients who received a prescription for one of these drugs had a statistically significant 35% reduced rate of 30-day readmission for pain. Patients who did not receive a prescription for a migraine abortive drug often got an opioid prescription, which went to 87% of the entire study population. Some patients received perioperative prescriptions for more than one drug. The analysis also showed that periopertive opioid prescriptions had no significant association with the 30-day rate of pain readmissions. In addition, prescription of any pain-reducing medication immediately prior to surgery as prophylaxis, which occurred in 17% of patients, had no significant association with the rate of 30-day postoperative pain readmission.


Despite the lack of clear causal evidence, clinicians should “definitely” be more aggressive in prescribing abortive treatments, especially triptans, to patients with a history of migraine who undergo surgery, Dr. Platzbecker said in an interview. These patients “are likely at risk for migraine [episodes] after surgery,”

Her study used data collected from nearly 25,000 patients with a history of a migraine billing diagnosis who underwent surgery and was a patient in either the Beth Israel or Partners (Massachusetts General Hospital and Brigham and Women’s Hospital) health systems during 2005-2017. Complete data that fulfilled the requirements of the study were available for 21,932 of these patients, of whom 11,011 (50%) received a perioperative prescription for an abortive drug and 10,921 (50%) did not. The prescribing occurred totally at the discretion of each patient’s physicians and surgeons. The researchers defined perioperative prescription as a billing entry for a drug anytime after surgery and within 30 days of hospital discharge or until readmission. The entire group studied averaged about 50 years old, more than 80% were women, and those who received an abortive treatment prescription generally had longer surgeries, more inpatient surgeries, and higher rates of various comorbidities. The adjusted statistical analysis took into account baseline differences like these.

Additional sensitivity analyses showed that perioperative prescriptions for abortive treatments also linked with significant reductions in all 30-day hospital readmissions, and with 30-day pain readmissions in patients who received surgery as inpatients as well as in those who were outpatients, and the association was specific to migraine patients. When Dr. Platzbecker expanded the group of patients she examined to more than 62,000 with any headache diagnosis the association between receiving a prescription for an abortive treatment and reduced 30-day pain readmissions became statistically insignificant.

Dr. Platzbecker and her associates previously reported results from an adjusted analysis showing that patients from the same database with a history of migraine who underwent surgery had an overall 42% increased rate of 30-day readmissions for pain compared with surgery patients who had no migraine history (Cephalagia. 2019 Feb;39[2]:286-95).

Dr. Platzbecker had no commercial disclosures.

mzoler@mdedge.com

On Twitter @mitchelzoler

This article was updated 7/16/19.

PHILADELPHIA – Patients with a history of migraine who underwent any type of surgery and then received a perioperative prescription for a headache abortive agent such as a triptan had 37% fewer readmissions for pain during the 30 days following surgery compared with patients who did not receive a migraine abortive prescription, according to an observational review of nearly 22,000 migraine patients from the Boston area.

Mitchel L. Zoler/MDedge News

While this statistically significant observational association must be viewed with caution, it provides compelling evidence for clinicians to prescribe a migraine abortive agent to migraineurs soon after surgery so that patients have these drugs handy if a migraine strikes, a possibility made likely by the stress and disruption of surgery, Katharina Platzbecker, MD, said at the annual meeting of the American Headache Society.

Postoperative migraine patients who received an abortive prescription specifically for a triptan or ergotamine showed an even stronger protective association, with an adjusted, statistically-significant 67% reduced rate of 30-day readmission for pain compared with the 50% of migraine patients who did not receive an abortive agent prescription after their surgery, said Dr. Platzbecker, a research fellow in the department of anesthesia, critical care, and pain medicine at Beth Israel Deaconess Medical Center in Boston. Only 8% of patients in the study received a triptan or ergotamine, with the vast majority of these patients getting a triptan.

The other types of abortive drugs prescribed perioperatively to migraine patients were NSAIDs or acetaminophen, received by 47% of the patients studied. The adjusted analysis showed that patients who received a prescription for one of these drugs had a statistically significant 35% reduced rate of 30-day readmission for pain. Patients who did not receive a prescription for a migraine abortive drug often got an opioid prescription, which went to 87% of the entire study population. Some patients received perioperative prescriptions for more than one drug. The analysis also showed that periopertive opioid prescriptions had no significant association with the 30-day rate of pain readmissions. In addition, prescription of any pain-reducing medication immediately prior to surgery as prophylaxis, which occurred in 17% of patients, had no significant association with the rate of 30-day postoperative pain readmission.


Despite the lack of clear causal evidence, clinicians should “definitely” be more aggressive in prescribing abortive treatments, especially triptans, to patients with a history of migraine who undergo surgery, Dr. Platzbecker said in an interview. These patients “are likely at risk for migraine [episodes] after surgery,”

Her study used data collected from nearly 25,000 patients with a history of a migraine billing diagnosis who underwent surgery and was a patient in either the Beth Israel or Partners (Massachusetts General Hospital and Brigham and Women’s Hospital) health systems during 2005-2017. Complete data that fulfilled the requirements of the study were available for 21,932 of these patients, of whom 11,011 (50%) received a perioperative prescription for an abortive drug and 10,921 (50%) did not. The prescribing occurred totally at the discretion of each patient’s physicians and surgeons. The researchers defined perioperative prescription as a billing entry for a drug anytime after surgery and within 30 days of hospital discharge or until readmission. The entire group studied averaged about 50 years old, more than 80% were women, and those who received an abortive treatment prescription generally had longer surgeries, more inpatient surgeries, and higher rates of various comorbidities. The adjusted statistical analysis took into account baseline differences like these.

Additional sensitivity analyses showed that perioperative prescriptions for abortive treatments also linked with significant reductions in all 30-day hospital readmissions, and with 30-day pain readmissions in patients who received surgery as inpatients as well as in those who were outpatients, and the association was specific to migraine patients. When Dr. Platzbecker expanded the group of patients she examined to more than 62,000 with any headache diagnosis the association between receiving a prescription for an abortive treatment and reduced 30-day pain readmissions became statistically insignificant.

Dr. Platzbecker and her associates previously reported results from an adjusted analysis showing that patients from the same database with a history of migraine who underwent surgery had an overall 42% increased rate of 30-day readmissions for pain compared with surgery patients who had no migraine history (Cephalagia. 2019 Feb;39[2]:286-95).

Dr. Platzbecker had no commercial disclosures.

mzoler@mdedge.com

On Twitter @mitchelzoler

This article was updated 7/16/19.

PHILADELPHIA – Migraine patients fared as well when managed for a year by telemedicine as when managed by a 12-month series of routine office visits in a single-center, randomized trial with 40 patients, the first reported randomized study of the impact of true telemedicine on mid-term migraine management.

“Telemedicine was viable and produced similar outcomes at 1 year in a highly disabled cohort,” Deborah I. Friedman, MD, said at the annual meeting of the American Headache Society. Many patients expressed high satisfaction with the approach. In addition to resulting in predictably shorter travel times for patients, it also linked with a cut in the consultation length by about a quarter, reported Dr. Friedman, a professor of neurology and chief of the division of headache medicine at UT Southwestern Medical Center in Dallas.

“There is a lot of opportunity for telemedicine, particularly in headache medicine because usually after the first visit we mostly just talk with patients with no further examinations, so it lends itself to telemedicine. It extends your reach.” Dr. Friedman said in a video interview. It is particularly attractive to patients who live a substantial distance from the clinic or find it hard to fit an office visit into their schedule, but some participants said they preferred the direct interaction of an office visit, she noted.

In addition to showing the efficacy of telemedicine in this setting, Dr. Friedman said that she hoped the findings may help pave the way for easier insurance payment for telemedicine consultations with migraineurs.

“One of the main reasons I did this study was to provide evidence to use for compensation for telemedicine visits. It will be good to have evidence in the medical literature that the outcomes are similar and that nothing is lost in patient care with telemedicine,” she said.

The study randomized 40 patients scheduled to see Dr. Friedman for the first time for a migraine consultation and to start treatment. After all patients had their initial office visit and examination, 22 of the patients entered the telemedicine arm and had follow-up consultations after 4-6 weeks, and after 3, 6, 9, and 12 months. The remaining 18 patients were randomized to receive these consultations in the office. Eighteen of the telemedicine patients and 12 of the in-office patients returned for a 12-month assessment. Patients averaged about 40 years old, they had actual or potential travel distances for in-office visits that in some cases exceeded 300 miles one way, and their Migraine Disability Assessment score averaged just above 40.

The telmedicine patients completed 93% of their visits compared with 88% of the in-office patients, a difference that was not statistically different. Migraine Disability Assessment scores improved by an average of 24 points in the telemedicine patients and by an average 19 points among the in-office controls, a difference that was not significant. The two groups also showed similar levels of treatment response for reductions in number of headache days and headache severity improvement. Average session length was 25 minutes with telemedicine and 34 minutes in office, a statistically significant difference that Dr. Friedman attributed to the interest by patients who have traveled long distances to see her to “get their money’s worth” from their visit.


Dr. Friedman highlighted the importance of having the visual aspect of a telemedicine consultation in addition to the conversation. For the trial the audio-visual link was via a standard laptop connection. Some patients assigned to telemedicine voiced regret over not being able to be examined, immediately start a new treatment, or receive drug samples. Dr. Friedman said that she couldn’t think of any migraine patients to whom she wouldn’t offer the option of telemedicine visits following an initial, in-person visit. But her use of telemedicine in routine practice is on hold right now as her institution, UT Southwestern, is still working out its consent and billing system, she said.

The study received partial funding from Merck. Dr. Friedman had no relevant disclosures.

mzoler@mdedge.com

On Twitter @mitchelzoler

SOURCE: Friedman DI. Headache. 2019 June;59[S1]:1-208, LBOR01.

PHILADELPHIA – Migraine patients fared as well when managed for a year by telemedicine as when managed by a 12-month series of routine office visits in a single-center, randomized trial with 40 patients, the first reported randomized study of the impact of true telemedicine on mid-term migraine management.

“Telemedicine was viable and produced similar outcomes at 1 year in a highly disabled cohort,” Deborah I. Friedman, MD, said at the annual meeting of the American Headache Society. Many patients expressed high satisfaction with the approach. In addition to resulting in predictably shorter travel times for patients, it also linked with a cut in the consultation length by about a quarter, reported Dr. Friedman, a professor of neurology and chief of the division of headache medicine at UT Southwestern Medical Center in Dallas.

“There is a lot of opportunity for telemedicine, particularly in headache medicine because usually after the first visit we mostly just talk with patients with no further examinations, so it lends itself to telemedicine. It extends your reach.” Dr. Friedman said in a video interview. It is particularly attractive to patients who live a substantial distance from the clinic or find it hard to fit an office visit into their schedule, but some participants said they preferred the direct interaction of an office visit, she noted.

In addition to showing the efficacy of telemedicine in this setting, Dr. Friedman said that she hoped the findings may help pave the way for easier insurance payment for telemedicine consultations with migraineurs.

“One of the main reasons I did this study was to provide evidence to use for compensation for telemedicine visits. It will be good to have evidence in the medical literature that the outcomes are similar and that nothing is lost in patient care with telemedicine,” she said.

The study randomized 40 patients scheduled to see Dr. Friedman for the first time for a migraine consultation and to start treatment. After all patients had their initial office visit and examination, 22 of the patients entered the telemedicine arm and had follow-up consultations after 4-6 weeks, and after 3, 6, 9, and 12 months. The remaining 18 patients were randomized to receive these consultations in the office. Eighteen of the telemedicine patients and 12 of the in-office patients returned for a 12-month assessment. Patients averaged about 40 years old, they had actual or potential travel distances for in-office visits that in some cases exceeded 300 miles one way, and their Migraine Disability Assessment score averaged just above 40.

The telmedicine patients completed 93% of their visits compared with 88% of the in-office patients, a difference that was not statistically different. Migraine Disability Assessment scores improved by an average of 24 points in the telemedicine patients and by an average 19 points among the in-office controls, a difference that was not significant. The two groups also showed similar levels of treatment response for reductions in number of headache days and headache severity improvement. Average session length was 25 minutes with telemedicine and 34 minutes in office, a statistically significant difference that Dr. Friedman attributed to the interest by patients who have traveled long distances to see her to “get their money’s worth” from their visit.


Dr. Friedman highlighted the importance of having the visual aspect of a telemedicine consultation in addition to the conversation. For the trial the audio-visual link was via a standard laptop connection. Some patients assigned to telemedicine voiced regret over not being able to be examined, immediately start a new treatment, or receive drug samples. Dr. Friedman said that she couldn’t think of any migraine patients to whom she wouldn’t offer the option of telemedicine visits following an initial, in-person visit. But her use of telemedicine in routine practice is on hold right now as her institution, UT Southwestern, is still working out its consent and billing system, she said.

The study received partial funding from Merck. Dr. Friedman had no relevant disclosures.

mzoler@mdedge.com

On Twitter @mitchelzoler

SOURCE: Friedman DI. Headache. 2019 June;59[S1]:1-208, LBOR01.

PHILADELPHIA – Migraine patients fared as well when managed for a year by telemedicine as when managed by a 12-month series of routine office visits in a single-center, randomized trial with 40 patients, the first reported randomized study of the impact of true telemedicine on mid-term migraine management.

“Telemedicine was viable and produced similar outcomes at 1 year in a highly disabled cohort,” Deborah I. Friedman, MD, said at the annual meeting of the American Headache Society. Many patients expressed high satisfaction with the approach. In addition to resulting in predictably shorter travel times for patients, it also linked with a cut in the consultation length by about a quarter, reported Dr. Friedman, a professor of neurology and chief of the division of headache medicine at UT Southwestern Medical Center in Dallas.

“There is a lot of opportunity for telemedicine, particularly in headache medicine because usually after the first visit we mostly just talk with patients with no further examinations, so it lends itself to telemedicine. It extends your reach.” Dr. Friedman said in a video interview. It is particularly attractive to patients who live a substantial distance from the clinic or find it hard to fit an office visit into their schedule, but some participants said they preferred the direct interaction of an office visit, she noted.

In addition to showing the efficacy of telemedicine in this setting, Dr. Friedman said that she hoped the findings may help pave the way for easier insurance payment for telemedicine consultations with migraineurs.

“One of the main reasons I did this study was to provide evidence to use for compensation for telemedicine visits. It will be good to have evidence in the medical literature that the outcomes are similar and that nothing is lost in patient care with telemedicine,” she said.

The study randomized 40 patients scheduled to see Dr. Friedman for the first time for a migraine consultation and to start treatment. After all patients had their initial office visit and examination, 22 of the patients entered the telemedicine arm and had follow-up consultations after 4-6 weeks, and after 3, 6, 9, and 12 months. The remaining 18 patients were randomized to receive these consultations in the office. Eighteen of the telemedicine patients and 12 of the in-office patients returned for a 12-month assessment. Patients averaged about 40 years old, they had actual or potential travel distances for in-office visits that in some cases exceeded 300 miles one way, and their Migraine Disability Assessment score averaged just above 40.

The telmedicine patients completed 93% of their visits compared with 88% of the in-office patients, a difference that was not statistically different. Migraine Disability Assessment scores improved by an average of 24 points in the telemedicine patients and by an average 19 points among the in-office controls, a difference that was not significant. The two groups also showed similar levels of treatment response for reductions in number of headache days and headache severity improvement. Average session length was 25 minutes with telemedicine and 34 minutes in office, a statistically significant difference that Dr. Friedman attributed to the interest by patients who have traveled long distances to see her to “get their money’s worth” from their visit.


Dr. Friedman highlighted the importance of having the visual aspect of a telemedicine consultation in addition to the conversation. For the trial the audio-visual link was via a standard laptop connection. Some patients assigned to telemedicine voiced regret over not being able to be examined, immediately start a new treatment, or receive drug samples. Dr. Friedman said that she couldn’t think of any migraine patients to whom she wouldn’t offer the option of telemedicine visits following an initial, in-person visit. But her use of telemedicine in routine practice is on hold right now as her institution, UT Southwestern, is still working out its consent and billing system, she said.

The study received partial funding from Merck. Dr. Friedman had no relevant disclosures.

mzoler@mdedge.com

On Twitter @mitchelzoler

SOURCE: Friedman DI. Headache. 2019 June;59[S1]:1-208, LBOR01.

PHILADELPHIA – The headache field is not free of the gender bias that affects medicine in general, said Elizabeth W. Loder, MD, chief of the Division of Headache and Pain at Brigham and Women’s Hospital in Boston, at the annual meeting of the American Headache Society. Women accrue credentials and are accorded respect as headache experts more slowly than men, she said. They are underrepresented among the speakers at headache conferences and are less likely than men to be invited to write editorials for peer-reviewed publications. Furthermore, a significant proportion of female headache specialists experiences sexual harassment in their professional environments.

Bias also affects interactions between patients and headache specialists, said Dr. Loder. Regardless of their gender, patients expect female care providers to be sympathetic and understanding. If they perceive that a female physician does not sufficiently display these attributes, they often write critical reviews of them on the Internet. In contrast, male physicians are not expected to be particularly caring, and patients praise them highly when they are.

Recognition of these biases is increasing, however. Representation of women in professional societies and on conference programs will improve, and emerging codes of conduct will reduce sexual harassment, said Dr. Loder. Headache specialists can take various steps, such as offering recognition and encouragement, to make the field more welcoming to women and to other disadvantaged groups.

egreb@mdedge.com

PHILADELPHIA – The headache field is not free of the gender bias that affects medicine in general, said Elizabeth W. Loder, MD, chief of the Division of Headache and Pain at Brigham and Women’s Hospital in Boston, at the annual meeting of the American Headache Society. Women accrue credentials and are accorded respect as headache experts more slowly than men, she said. They are underrepresented among the speakers at headache conferences and are less likely than men to be invited to write editorials for peer-reviewed publications. Furthermore, a significant proportion of female headache specialists experiences sexual harassment in their professional environments.

Bias also affects interactions between patients and headache specialists, said Dr. Loder. Regardless of their gender, patients expect female care providers to be sympathetic and understanding. If they perceive that a female physician does not sufficiently display these attributes, they often write critical reviews of them on the Internet. In contrast, male physicians are not expected to be particularly caring, and patients praise them highly when they are.

Recognition of these biases is increasing, however. Representation of women in professional societies and on conference programs will improve, and emerging codes of conduct will reduce sexual harassment, said Dr. Loder. Headache specialists can take various steps, such as offering recognition and encouragement, to make the field more welcoming to women and to other disadvantaged groups.

egreb@mdedge.com

PHILADELPHIA – The headache field is not free of the gender bias that affects medicine in general, said Elizabeth W. Loder, MD, chief of the Division of Headache and Pain at Brigham and Women’s Hospital in Boston, at the annual meeting of the American Headache Society. Women accrue credentials and are accorded respect as headache experts more slowly than men, she said. They are underrepresented among the speakers at headache conferences and are less likely than men to be invited to write editorials for peer-reviewed publications. Furthermore, a significant proportion of female headache specialists experiences sexual harassment in their professional environments.

Bias also affects interactions between patients and headache specialists, said Dr. Loder. Regardless of their gender, patients expect female care providers to be sympathetic and understanding. If they perceive that a female physician does not sufficiently display these attributes, they often write critical reviews of them on the Internet. In contrast, male physicians are not expected to be particularly caring, and patients praise them highly when they are.

Recognition of these biases is increasing, however. Representation of women in professional societies and on conference programs will improve, and emerging codes of conduct will reduce sexual harassment, said Dr. Loder. Headache specialists can take various steps, such as offering recognition and encouragement, to make the field more welcoming to women and to other disadvantaged groups.

egreb@mdedge.com

PHILADELPHIA – More than one-third of patients with migraine who take prescription medications use opioids, although guidelines recommend against it, according to a study presented at the annual meeting of the American Headache Society. Opioid use among migraineurs is associated with indicators of poor health, such as high body mass index (BMI), high pain scores, and cardiovascular comorbidities. Some variables associated with opioid use are modifiable.

Mitchel L. Zoler/MDedge News

Medical associations do not recommend opioid use for migraine because it may increase the risks of dependence, suboptimal outcomes, and new-onset chronic migraine. Richard B. Lipton, MD, Edwin S. Lowe Chair in neurology at Albert Einstein College of Medicine in Bronx, New York, and colleagues analyzed data from the Chronic Migraine Epidemiology and Outcomes (CaMEO) study to identify variables associated with opioid use among patients who treat their headaches with acute prescription medications.

Using a web panel that was demographically similar to the U.S. population, CaMEO identified people with migraine, based on the criteria of the International Classification of Headache Disorders, 3rd Edition. Dr. Lipton and colleagues examined participants who reported currently using or having on hand acute prescription pain medication to treat headaches. The researchers compared the features (e.g., demographics, attack frequency, treatment choices, headache-related disability, and comorbidity) of self-reported opioid users with those of nonusers. They created nested, multivariable, binary logistic regression models to evaluate opioid use or nonuse as the outcome. Dr. Lipton and colleagues entered covariates in blocks (i.e., sociodemographics, headache and respondent characteristics, psychiatric comorbidities, emergency facility use for headache in the preceding 6 months, and one or more cardiovascular [CV] comorbidity) and removed nonsignificant sociodemographic variables from the model.

The researchers identified 2,388 respondents with migraine who currently used acute prescription medications for headache. Of this group, 867 (36.3%) used opioids. Compared with opioid nonusers, opioid users had significant increases in monthly headache days; frequency of emergency care use for headache within the past 6 months; medication overuse frequency; presence of allodynia, depression, anxiety, and CV comorbidity; Total Pain Index (TPI) scores; and diabetes diagnoses.

Factors significantly associated with opioid use included male sex (odds ratio [OR], 1.74); increasing body mass index BMI (OR, 1.02); allodynia (OR, 1.39); increasing monthly headache day frequency; increasing TPI scores excluding the head, face, and neck (1.32); anxiety (OR, 1.37); depression (OR, 1.50); one or more CV comorbidity (OR, 1.56); and emergency facility use for headache in the past 6 months (OR, 1.73). The OR of opioid use was 1.37 in patients with a monthly headache frequency of 10-14 days and 1.62 in patients with a frequency of 15 or more days, compared with patients with a monthly headache frequency of 0-4 days.

Receiving a diagnosis of migraine or chronic migraine was associated with a significantly lower likelihood of opioid use (OR, 0.38).

Allergan funded the CaMEO study and paid Dr. Lipton for consulting services.

egreb@mdedge.com

SOURCE: Lipton R et al. AHS 2019. Abstract 629332.

PHILADELPHIA – More than one-third of patients with migraine who take prescription medications use opioids, although guidelines recommend against it, according to a study presented at the annual meeting of the American Headache Society. Opioid use among migraineurs is associated with indicators of poor health, such as high body mass index (BMI), high pain scores, and cardiovascular comorbidities. Some variables associated with opioid use are modifiable.

Mitchel L. Zoler/MDedge News

Medical associations do not recommend opioid use for migraine because it may increase the risks of dependence, suboptimal outcomes, and new-onset chronic migraine. Richard B. Lipton, MD, Edwin S. Lowe Chair in neurology at Albert Einstein College of Medicine in Bronx, New York, and colleagues analyzed data from the Chronic Migraine Epidemiology and Outcomes (CaMEO) study to identify variables associated with opioid use among patients who treat their headaches with acute prescription medications.

Using a web panel that was demographically similar to the U.S. population, CaMEO identified people with migraine, based on the criteria of the International Classification of Headache Disorders, 3rd Edition. Dr. Lipton and colleagues examined participants who reported currently using or having on hand acute prescription pain medication to treat headaches. The researchers compared the features (e.g., demographics, attack frequency, treatment choices, headache-related disability, and comorbidity) of self-reported opioid users with those of nonusers. They created nested, multivariable, binary logistic regression models to evaluate opioid use or nonuse as the outcome. Dr. Lipton and colleagues entered covariates in blocks (i.e., sociodemographics, headache and respondent characteristics, psychiatric comorbidities, emergency facility use for headache in the preceding 6 months, and one or more cardiovascular [CV] comorbidity) and removed nonsignificant sociodemographic variables from the model.

The researchers identified 2,388 respondents with migraine who currently used acute prescription medications for headache. Of this group, 867 (36.3%) used opioids. Compared with opioid nonusers, opioid users had significant increases in monthly headache days; frequency of emergency care use for headache within the past 6 months; medication overuse frequency; presence of allodynia, depression, anxiety, and CV comorbidity; Total Pain Index (TPI) scores; and diabetes diagnoses.

Factors significantly associated with opioid use included male sex (odds ratio [OR], 1.74); increasing body mass index BMI (OR, 1.02); allodynia (OR, 1.39); increasing monthly headache day frequency; increasing TPI scores excluding the head, face, and neck (1.32); anxiety (OR, 1.37); depression (OR, 1.50); one or more CV comorbidity (OR, 1.56); and emergency facility use for headache in the past 6 months (OR, 1.73). The OR of opioid use was 1.37 in patients with a monthly headache frequency of 10-14 days and 1.62 in patients with a frequency of 15 or more days, compared with patients with a monthly headache frequency of 0-4 days.

Receiving a diagnosis of migraine or chronic migraine was associated with a significantly lower likelihood of opioid use (OR, 0.38).

Allergan funded the CaMEO study and paid Dr. Lipton for consulting services.

egreb@mdedge.com

SOURCE: Lipton R et al. AHS 2019. Abstract 629332.

PHILADELPHIA – More than one-third of patients with migraine who take prescription medications use opioids, although guidelines recommend against it, according to a study presented at the annual meeting of the American Headache Society. Opioid use among migraineurs is associated with indicators of poor health, such as high body mass index (BMI), high pain scores, and cardiovascular comorbidities. Some variables associated with opioid use are modifiable.

Mitchel L. Zoler/MDedge News

Medical associations do not recommend opioid use for migraine because it may increase the risks of dependence, suboptimal outcomes, and new-onset chronic migraine. Richard B. Lipton, MD, Edwin S. Lowe Chair in neurology at Albert Einstein College of Medicine in Bronx, New York, and colleagues analyzed data from the Chronic Migraine Epidemiology and Outcomes (CaMEO) study to identify variables associated with opioid use among patients who treat their headaches with acute prescription medications.

Using a web panel that was demographically similar to the U.S. population, CaMEO identified people with migraine, based on the criteria of the International Classification of Headache Disorders, 3rd Edition. Dr. Lipton and colleagues examined participants who reported currently using or having on hand acute prescription pain medication to treat headaches. The researchers compared the features (e.g., demographics, attack frequency, treatment choices, headache-related disability, and comorbidity) of self-reported opioid users with those of nonusers. They created nested, multivariable, binary logistic regression models to evaluate opioid use or nonuse as the outcome. Dr. Lipton and colleagues entered covariates in blocks (i.e., sociodemographics, headache and respondent characteristics, psychiatric comorbidities, emergency facility use for headache in the preceding 6 months, and one or more cardiovascular [CV] comorbidity) and removed nonsignificant sociodemographic variables from the model.

The researchers identified 2,388 respondents with migraine who currently used acute prescription medications for headache. Of this group, 867 (36.3%) used opioids. Compared with opioid nonusers, opioid users had significant increases in monthly headache days; frequency of emergency care use for headache within the past 6 months; medication overuse frequency; presence of allodynia, depression, anxiety, and CV comorbidity; Total Pain Index (TPI) scores; and diabetes diagnoses.

Factors significantly associated with opioid use included male sex (odds ratio [OR], 1.74); increasing body mass index BMI (OR, 1.02); allodynia (OR, 1.39); increasing monthly headache day frequency; increasing TPI scores excluding the head, face, and neck (1.32); anxiety (OR, 1.37); depression (OR, 1.50); one or more CV comorbidity (OR, 1.56); and emergency facility use for headache in the past 6 months (OR, 1.73). The OR of opioid use was 1.37 in patients with a monthly headache frequency of 10-14 days and 1.62 in patients with a frequency of 15 or more days, compared with patients with a monthly headache frequency of 0-4 days.

Receiving a diagnosis of migraine or chronic migraine was associated with a significantly lower likelihood of opioid use (OR, 0.38).

Allergan funded the CaMEO study and paid Dr. Lipton for consulting services.

egreb@mdedge.com

SOURCE: Lipton R et al. AHS 2019. Abstract 629332.