Race and socioeconomic status can hinder and delay patient access migraine treatment and produce worse results, according to a to study published in the April issue of Headache. People of African descent and Latin ethnicity tend to go worse than other people of color and their white counterparts.
“It must be impactful for neurologists and other clinicians caring for migraine patients who few are able to successfully overcome barriers to achieving accurate diagnosis and appropriate, evidence-based, acute and preventive treatment,” Peter commented McAllister, MD, medical director at the New England Institute of Neurology and Headache and medical director of clinical research at Ki Clinical Research in Stamford, Conn. McAllister did not participate in this study.
Assess barriers to care
The researchers designed the study with the primary goal of estimating the number of migraine patients with unmet clinical needs and who suffered from four pre-identified care barriers. To assess their purpose, the researchers conducted an Internet – based longitudinal survey known as Study of the epidemiology and results of chronic migraine (CaMEO). They collected data over a year examining a cohort of patients who mimicked the diverse demographics of the American population. The researchers performed longitudinal assessments every 3 months for 15 months, incorporating cross-sectional analyzes that examined health use, family burden, and comorbidities or endophenotypes.
Eligible entrants were 18 years of age or older.
The researchers identified four barriers that hampered patient outcomes and served as the main results of the studies. They were:
Consultations from medical providers. The researchers used the study participants ’answers to the following question during their interactions with their healthcare providers to help assess the quality of their consulting experience:“ What type of doctor currently manages your headaches? ” The researchers included data from patients whose professionals fit the description of those they deemed most appropriate to meet the ongoing challenges of the headache. These medical professionals included general practitioners, family physicians, internal medicine physicians, nurses, nurses, neurologists, pain specialists, headache specialists, and obstetrics-gynecologists.
Diagnosis. Carefully assessing patients ’responses to a series of questions helped the researchers assess the accuracy of the diagnosis. Questions included: “Have you ever been diagnosed by a doctor or other health care professional with any of the following types of headaches?” Respondents were also given a list of options that provided additional context around their headaches and were encouraged to select all the appropriate answers. The list included a fictitious “citrus headache” response option to determine incorrect answers. For this study, the researchers considered it necessary to recognize a diagnosis of chronic migraine to ensure that patients received appropriate treatment.
Minimally appropriate pharmacological treatment. The researchers used the following question to determine whether chronic migraine and episodic migraine in patients were being managed with the minimum amount of drug treatment required. “Which of these medications (if any) are you currently using (or normally have on hand) to treat your headaches when you have them?” The researchers defined “minimally appropriate acute pharmacological treatment” as the use of any prescription non-steroidal anti-inflammatory drug (NSAID), triptan, ergotamine derivative, or isometheptor.
Avoid excessive use of medications. The study authors noted the sometimes nebulous process of characterizing the appropriate use of preventive medications in patients with episodic migraines as “not easy” for some patients, as not all patients require preventive treatment. Study participants were required to report having received any form of preventive therapy, defined as pharmacological therapies approved by guidelines and supported by data. These therapies include several unsportsmanlike conduct, antidepressants (e.g. doxepin, venlafaxine, duloxetine, amitriptyline, imipramine, nortriptyline, and desvenlafaxine), antihypertensives and toxin injections. Treatments such as behavioral and neuromodulatory therapies were excluded from the list.
According to the lead author Dawn C. Buse, PhD, from the Department of Neurology at Albert Einstein College of Medicine, New York, overuse of acute medications provides an important modifiable goal for intervention and recommends clinicians take the opportunity to optimize migraine care reducing patients ’dependence on acute therapies. Taking such initiatives to decrease overuse of medications is especially important in communities of color, which are more prone to overuse of medications for migraines.
Patients with higher income levels were more likely to overcome each barrier. People of African, African American, or multiracial descent were more prone to overuse of medications to control their migraines.
Of the 489,537 respondents invited to participate in the CaMEO study, 16,879 qualified for inclusion. Slightly more than half of the respondents (n = 9,184) [54.7%]) had a migraine-related disability score (MIDAS) equal to or greater than 6, a disability indicator of a less mild nature. The majority of patients with episodic migraines or chronic migraines (86.2%) had some form of health insurance coverage (n = 9,184; 84.1%; Pg = .048). Of the patients who were insured, 7,930 patients experienced episodic migraine (86.3%) and the rest had chronic migraine (n = 1,254; 13.7%). Patients with higher admissions were more likely to cross care barriers. While patients of African descent had higher consultation rates, they also had higher rates of drug overuse.
Patients with chronic migraine were more likely to be older than patients with episodic migraine (41.0 vs. 39.6 years; Pg = .0001) and female (83.0% vs. 79.0%; Pg = 0.001) and whites (84.5% vs. 79.1%; Pg <.001). Similarly, patients with chronic migraine were more likely to have a higher mean body mass index (29.8 kg / m2 vs. 28.9 kg / m2; Pg <.001) and lower full-time or part-time employment rates (56.8% vs. 67.1%; Pg <.001), and were less likely to have a 4-year degree (64.8 vs. 55.6; Pg <.001) and annual household incomes below $ 75,000 (72.6% vs. 64.6%; Pg <.001). Approximately three-quarters of patients with episodic migraine (75.7%; 1655/2187) and one-third of patients with chronic migraine (32.8%; 168/512) received accurate diagnoses.
The data found an association with excessive use of acute medications. Among current consultants who had received an accurate diagnosis and minimally appropriate treatment, rates of drug overuse were higher among those who reported two or more races (53%) and blacks and African Americans (45%). ) and the lowest among whites (33%) and those classified as “other” race (32%). Ethnic and cultural differences in headache literacy may contribute to differences in drug overuse.
Strategies to improve results
Both Buse and McAllister see the promotion of value and educational supply to help improve outcomes in marginalized communities and other groups adversely affected by various barriers.
“The incidence and spread of patients are key here, especially in those traditionally underrepresented in the migraine space, such as men, people of color, blue-collar workers, and so on,” McAllister noted.
Buse stressed the importance of education for patients and for health professionals. “A large percentage of people who meet the criteria for migraines in the United States do not seek care or even know they have migraines,” Buse said. “This finding underscores the importance of public health education on migraine, as well as providing support, education, and resources for migraine to front-line health professionals.”
Other strategies recommended by Buse to alleviate the impact of barriers include encouraging patient discussion, setting time for follow-up appointments and education, referring patients for neurological consultations, and other specialties when warranted, reviewing habits. essential for the control of migraine and create mutually agreed treatment plans.
Buse has received support and fees from AbbVie, Amgen, Avanir, Biohaven, Eli Lilly and Promius.
This article originally appeared on MDedge.com, which is part of the Medscape professional network.