1
|
Darcy S, Kelly E, Choong D, McCarthy A, O'Dowd S, Bogdanova-Mihaylova P, Murphy SM. The impact of headache disorders: a prospective analysis of headache referrals to outpatient and inpatient neurology and emergency services in an Irish University teaching hospital. Ir J Med Sci 2024; 193:397-405. [PMID: 37369930 PMCID: PMC10808417 DOI: 10.1007/s11845-023-03425-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2022] [Accepted: 06/07/2023] [Indexed: 06/29/2023]
Abstract
BACKGROUND Headache represents a significant proportion of disability globally in general practice, neurology outpatient settings, and emergency departments. There is scant literature regarding the impact of headache on healthcare services in Ireland. AIMS We aimed to investigate headache burden across the emergency department, inpatient stays, and neurology outpatient department referrals in an Irish University teaching hospital. METHODS We prospectively collected data regarding emergency department presentations, inpatient neurology consultations, and neurology outpatient referrals for patients with headache between 13th January and 8th March 2020. Data were analyzed using descriptive statistics. RESULTS There were 180 emergency department attendances, 50 inpatient consultations, and 76 outpatient referrals with headache. Neurological examinations were often incomplete; neuroimaging was commonly employed. Migraine was the most frequent headache diagnosis at discharge in the emergency department and among inpatients after neurology review. Diagnostic uncertainty was identified-33% of patients left the emergency department with no diagnosis, and "unknown/unspecified headache" was recorded on 49% of outpatient referrals and 30% of inpatient consult requests. Medication overuse headache coexisted with migraine in nine patients in the inpatient group. Prophylaxis had been trialed in 56% of patients with migraine referred to outpatients. CONCLUSIONS Primary headache disorders have a large impact on hospital services. Diagnostic uncertainty is common; neuroimaging is relied upon. Appropriate care pathways, education, and resource allocation should be prioritized.
Collapse
Affiliation(s)
- Sarah Darcy
- Department of Neurology, Tallaght University Hospital, Dublin 24, Tallaght, Ireland.
| | - Emmet Kelly
- Department of Neurology, Tallaght University Hospital, Dublin 24, Tallaght, Ireland
| | - Denise Choong
- Emergency Department, Tallaght University Hospital, Dublin 24, Tallaght, Ireland
| | - Allan McCarthy
- Department of Neurology, Tallaght University Hospital, Dublin 24, Tallaght, Ireland
| | - Sean O'Dowd
- Department of Neurology, Tallaght University Hospital, Dublin 24, Tallaght, Ireland
| | | | - Sinéad M Murphy
- Department of Neurology, Tallaght University Hospital, Dublin 24, Tallaght, Ireland
- Academic Unit of Neurology, Trinity College Dublin, Dublin, Ireland
| |
Collapse
|
2
|
Chu K, Kelly AM, Keijzers G, Kinnear F, Kuan WS, Graham C, Laribi S, Roberts T, Karamercan M, Cardozo-Ocampo A, Kamona S, Body R, Horner D, Klim S, Brown N, Wijeratne T. Computed tomography brain scan utilization in patients with headache presenting to emergency departments: a multinational study. Eur J Emerg Med 2023; 30:356-364. [PMID: 37310953 DOI: 10.1097/mej.0000000000001055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
BACKGROUND AND IMPORTANCE Recommended indications for emergency computed tomography (CT) brain scans are not only complex and evolving, but it is also unknown whether they are being followed in emergency departments (EDs). OBJECTIVE To determine the CT utilization and diagnostic yield in the ED in patients with headaches across broad geographical regions. DESIGN Secondary analysis of data from a multinational cross-sectional study of ED headache presentations over one month in 2019. SETTING AND PARTICIPANTS Hospitals from 10 participating countries were divided into five geographical regions [Australia and New Zealand (ANZ); Colombia; Europe: Belgium, France, UK, and Romania; Hong Kong and Singapore (HKS); and Turkey). Adult patients with nontraumatic headache as the primary presenting complaint were included. Patients were identified from ED management systems. OUTCOME MEASURES AND ANALYSIS The outcome measures were CT utilization and diagnostic yield. CT utilization was calculated using a multilevel binary logistic regression model to account for clustering of patients within hospitals and regions. Imaging data (CT requests and reports) were sourced from radiology management systems. MAIN RESULTS The study included 5281 participants. Median (interquartile range) age was 40 (29-55) years, 66% were women. Overall mean CT utilization was 38.5% [95% confidence interval (CI), 30.4-47.4%]. Regional utilization was highest in Europe (46.0%) and lowest in Turkey (28.9%), with HKS (38.0%), ANZ (40.0%), and Colombia (40.8%) in between. Its distribution across hospitals was approximately symmetrical. There was greater variation in CT utilization between hospitals within a region than between regions (hospital variance 0.422, region variance 0.100). Overall mean CT diagnostic yield was 9.9% (95% CI, 8.7-11.3%). Its distribution across hospitals was positively skewed. Regional yield was lower in Europe (5.4%) than in other regions: Colombia (9.1%), HKS (9.7%), Turkey (10.6%), and ANZ (11.2%). There was a weak negative correlation between utilization and diagnostic yield ( r = -0.248). CONCLUSION In this international study, there was a high variation (28.9-46.6%) in CT utilization and diagnostic yield (5.4-11.2%) across broad geographic regions. Europe had the highest utilization and the lowest yield. The study findings provide a foundation to address variation in neuroimaging in ED headache presentations.
Collapse
Affiliation(s)
- Kevin Chu
- Emergency and Trauma Centre, Royal Brisbane and Women's Hospital, Brisbane
- Faculty of Medicine, University of Queensland, Queensland
| | - Anne-Maree Kelly
- Joseph Epstein Centre for Emergency Medicine Research, Western Health, Melbourne
- Department of Medicine, Western Health, Melbourne Medical School, University of Melbourne, Melbourne, Victoria
| | - Gerben Keijzers
- Department of Emergency Medicine, Gold Coast University Hospital, Gold Coast
- School of Medicine, Bond University, Gold Coast
- School of Medicine, Griffith University, Gold Coast, Queensland, Australia
| | | | - Win Sen Kuan
- Emergency Medicine Department, National University Hospital, National University Health System, Singapore
| | - Colin Graham
- Accident and Emergency Medicine Academic Unit, Chinese University of Hong Kong, Hong Kong SAR, China
| | - Said Laribi
- Department of Emergency Medicine, Tours University Hospital, Tours, France
| | - Tom Roberts
- Faculty of Health and Life Sciences, University of the West of England, Bristol, UK
| | - Mehmet Karamercan
- Department of Emergency Medicine, Faculty of Medicine, Gazi University, Ankara, Turkey
| | | | - Sinan Kamona
- Adult Emergency Department, Auckland City Hospital
- Faculty of Health and Medical Sciences, University of Auckland, Auckland, New Zealand
| | - Richard Body
- Emergency Department, Manchester Royal Infirmary, Manchester University NHS Foundation Trust
- Division of Cardiovascular Science, University of Manchester, Manchester
| | - Daniel Horner
- Emergency Department, Northern Care Alliance NHS Foundation Trust, Salford
- Division of Infection, Immunity and Respiratory Medicine, University of Manchester, Manchester, UK
| | - Sharon Klim
- Joseph Epstein Centre for Emergency Medicine Research, Western Health, Melbourne
- Department of Medicine, Western Health, Melbourne Medical School, University of Melbourne, Melbourne, Victoria
| | - Nathan Brown
- Emergency and Trauma Centre, Royal Brisbane and Women's Hospital, Brisbane
- Faculty of Medicine, University of Queensland, Queensland
| | - Tissa Wijeratne
- Department of Medicine, Western Health, Melbourne Medical School, University of Melbourne, Melbourne, Victoria, Australia
| |
Collapse
|
3
|
Diagnostic yield of emergency MRI in non-traumatic headache. Neuroradiology 2023; 65:89-96. [PMID: 36029327 PMCID: PMC9816281 DOI: 10.1007/s00234-022-03044-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2022] [Accepted: 08/16/2022] [Indexed: 01/11/2023]
Abstract
PURPOSE Non-traumatic headache is one of the most common neurological complaints in emergency departments. A relatively low diagnostic yield of magnetic resonance imaging (MRI) among outpatients has been previously reported, but studies of emergency patients are lacking. We sought to determine the diagnostic yield of emergency MRI among outpatients presenting to the emergency department with non-traumatic headache. METHODS In this retrospective cohort study, we analyzed emergency MRI referrals in a tertiary hospital for non-traumatic headache over a five-year period. We recorded patient characteristics, relevant clinical information from the referrals, and imaging outcomes. RESULTS In total, 696 emergency patients with non-traumatic headache underwent MRI, most within 24 h of presentation. Significant findings related to headache were found in 136 (20%) patients, and incidental findings in 22% of patients. In a multivariate model, the predisposing factors of the significant findings were age, smoking, nausea, and signs/symptoms of infection. The protective factors were numbness and history of migraine. A predictive clinical score reached only moderate performance. CONCLUSION Although emergency MRI shows headache-related findings in one in five patients, accurate prediction modeling remains a challenge, even with statistically significant predictors and a large sample size.
Collapse
|
4
|
Contrast Medium Use in Computed Tomography for Patients Presenting with Headache: 4-year Retrospective Two-Center Study in Central and Western Regions of Ghana. Radiol Res Pract 2022; 2022:4736455. [PMID: 36248021 PMCID: PMC9553476 DOI: 10.1155/2022/4736455] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2022] [Revised: 08/04/2022] [Accepted: 09/14/2022] [Indexed: 11/17/2022] Open
Abstract
Background Contrast medium (CM) administration during computed tomography (CT) enhances the accuracy in the detection and interpretation of abnormalities. Evidence from literature also validate the essence of CM in imaging studies. CT, by virtue of its ubiquity, ease of use, speed, and lower financial footprint, is usually the first investigation in cases of headache. Through a multicenter retrospective analysis, we compared findings of contrast-enhanced CT (CECT) to noncontrast-enhanced CT (NCECT) head examinations among patients presenting with headache. Methods A multicenter retrospective analysis of four years' CT head examination data at two radiology centers located in Central and Western Regions of Ghana were reviewed. Records of patients who presented with headache as principal complaint between January 2017 and December 2020 were reviewed. A total of 477 records of patients with headache were identified, retrieved and evaluated. A Chi-square test and Fisher exact test were used to compare the CECT and NCECT groups. Binary logistic regression analysis was computed to assess association between CECT and each CT findings. Statistical significance was considered at p < 0.05 with a 95% confidence interval. Results A significant proportion of the patients was females (51.8% in CECT and 60% in NCECT). The NCECT group (40.06 ± 14.76 years) was relatively older than the CECT group (38.43 ± 17.64 years). There was a significant difference between the CECT and NCECT in terms of age (p=0.002) and facility CT was performed (p < 0.0001). The rate of abnormalities was higher in CECT (43.5%, 166/382) compared NCECT (37.9%, 36/95). There was no significant association between CT head findings and contrast enhancement. Conclusion CECT examination accounted for 5.6% increase in the detection of head abnormalities. Efforts required to establish local standard operation procedures (SOPs) for contrast medium use especially in CT head examinations. Further studies to improve the knowledge of agents, mechanism of action, and safety of contrast media used among practitioners in Ghana is recommended.
Collapse
|