Abstract and Introduction
Objective: The objective of this study was to understand current practice, clinician understanding, attitudes, barriers, and facilitators to optimal headache neuroimaging practices.
Background: Headaches are common in adults, and neuroimaging for these patients is common, costly, and increasing. Although guidelines recommend against routine headache neuroimaging in low-risk scenarios, guideline-discordant neuroimaging is still frequently performed.
Methods: We administered a 60-item survey to headache clinicians at the Veterans Affairs health system to assess clinician understanding and attitudes on headache neuroimaging and to determine neuroimaging practice patterns for three scenarios describing hypothetical patients with headaches. Descriptive statistics were used to summarize responses, stratified by clinician type (physicians or advanced practice clinicians [APCs]) and specialty (neurology or primary care).
Results: The survey was successfully completed by 431 of 1426 clinicians (30.2% response rate). Overall, 317 of 429 (73.9%) believed neuroimaging was overused for patients with headaches. However, clinicians would utilize neuroimaging a mean (SD) 30.9% (31.7) of the time in a low-risk scenario without red flags, and a mean 67.1% (31.9) of the time in the presence of minor red flags. Clinicians had stronger beliefs in the potential benefits (268/429, 62.5%) of neuroimaging compared to harms (181/429, 42.2%) and more clinicians were bothered by harms stemming from the omission of neuroimaging (377/426, 88.5%) compared to commission (329/424, 77.6%). Additionally, APCs utilized neuroimaging more frequently than physicians and were more receptive to potential interventions to improve neuroimaging utilization.
Conclusions: Although a majority of clinicians believed neuroimaging was overused for patients with headaches, many would utilize neuroimaging in low-risk scenarios with a small probability of changing management. Future studies are needed to define the role of currently used red flags given their importance in neuroimaging decisions. Importantly, APCs may be an ideal target for future optimization efforts.
Headaches are common in adults, with a 93% lifetime prevalence, including 15% having severe headaches or migraine.[1,2] Neuroimaging for these patients is common, costly, and increasing: occurring in 5.1% of headache visits in 1995, increasing to 14.7% in 2010, and costing almost $1 billion per year. Given that the prevalence of abnormalities in patients with chronic headaches is comparable to that in a healthy population,[4–7] guidelines recommend against routine headache neuroimaging in low-risk scenarios.[8,9] Additionally, a systematic review performed by the American Headache Society resulted in recommendations against performing neuroimaging in patients with a normal neurologic examination and without "red flags." Despite this evidence, guideline-discordant neuroimaging is still frequently performed for patients with headaches, likely resulting in downstream harms.
Many factors may contribute to the risk of guideline discordant neuroimaging. For example, the guidelines themselves are limited. Whereas guidelines recommend against headache neuroimaging except in patients with various red flags, different guidelines identify different red flags and many red flags have limited evidence to support their use. Additionally, clinical guidelines without multifaceted implementation strategies are often ineffective. Beyond the guidelines themselves, other clinician characteristics, such as experience level, belief in harm vs. benefit tradeoff, knowledge of guidelines, financial incentives, consideration of patient preferences, and limited time or personnel resources, may result in guideline-discordant utilization.[14–16] Although clinical decision support systems (CDSS) generally lead to modest increases in appropriateness and reduced overall use of diagnostic imaging in a variety of clinical contexts, a number of additional strategies (including shared decision-making, electronic specialty referrals, restrictions of magnetic resonance imaging (MRI) ordering, less time pressure, and other guideline implementation strategies) may effectively optimize neuroimaging decisions and/or be preferred by clinicians.
The goal of this study was to inform future implementation efforts that optimize headache neuroimaging. Therefore, we aimed to better understand current practice, clinician understanding and attitudes, and barriers and facilitators to optimal headache neuroimaging practices through a clinician survey of primary care physicians, neurologists, and advanced practice clinicians (APCs). We hypothesized that current practice, clinician understanding and attitudes, and barriers and facilitators to optimal headache neuroimaging practices would differ between primary care physicians and neurologists, and between physicians and APCs. We administered the survey at the Veterans Affairs (VA) health system, where headache neuroimaging is common, and implementation interventions may be easier to enact. Currently, the specific factors that drive headache neuroimaging decisions for clinicians are largely unknown. Additionally, more evidence is needed to determine which implementation strategies are most likely to be effective and acceptable to headache neuroimaging clinicians.
Headache. 2022;62(1):36-56. © 2022 Blackwell Publishing