Transcript Patient 228KB PPT - Migraine in Primary Care Advisors

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MIGRAINE IN PRIMARY CARE ADVISORS
Migraine Action Association
Northampton, 13 June 2003
10.30-3.30 pm
Guidelines for the development of the
specialist headache patient
Programme
• Dr Andrew Dowson: Current status of the
MIPCA / MAA patient project
• Ms Ann Turner: Finalisation of the MIPCA /
MAA patient checklist
• Dr Bill Laughey: Finalisation of the MIPCA /
MAA headache diary
Discussion session:
• Roles of the specialist headache patient
• Setting up specialist headache patient
services
• Dr Andrew Dowson: Conclusions
Objectives
• Review and finalise the MIPCA / MAA
patient checklist
• Review and finalise the MIPCA / MAA
headache diary
• Discuss the role of the specialist
headache patient
• Discuss the accreditation process
• Next steps
– Nationwide meetings
Outputs
• Academic article
• MIPCA newsletter for GP
• Slide set for educational use
Current status of the MIPCA / MAA
patient project
Dr Andrew Dowson
Where we stand at present
New MIPCA guidelines for migraine
management in primary care
• MIPCA diagnostic algorithm for
headache
• Management tailored to each patient’s
needs
• MIPCA algorithm for migraine
• ‘10 Commandments’ of headache
• Primary care headache team
Careful diagnosis
• MIPCA has developed a simple but
comprehensive scheme for the
differential diagnosis of headache
subtypes
• Diagnosis can then be confirmed with
additional questions
Exclude sinister
Headache (<0.1%)
Patient presenting
with headache
Q1. What is the impact of the headache
on the sufferer’s daily life?
low
ETTH (50%)
High
Q2. How many days of headache
does the patient have every month?
Migraine/CDH
 15
> 15
Consider short-lasting
Headaches (<0.1%)
CDH (2-4%)
Q3. For patients with chronic daily
headache, on how may days per week
does the patient take analgesic medications?
<2
No medication
overuse
Migraine (15%)
Q4. For patients with migraine, does the
patient experience reversible sensory
symptoms associated with their attacks?
2
Medication
overuse
Yes
With aura
No
Without aura
Dowson AJ et al. Curr Med Res Opin 2002;18:414-39
Management individualised for each
patient
• Behavioural therapy recommended for all
• Acute therapy recommended for all
• Prophylactic therapy recommended for
certain patients
• Complementary therapies may be useful as
adjunctive therapy
Follow-up procedures
• Instigate proactive long-term follow-up
procedures
• Monitor the outcome of therapy
– Headache diaries
– Impact questionnaires (MIDAS/HIT)
• Make appropriate treatment decisions
Detailed history, patient education and buy-in
Diagnostic screening and differential diagnosis
Assess illness severity
Attack frequency and duration
Pain severity
Impact (MIDAS or HIT questionnaires)
Non-headache symptoms
Patient history and preferences
Intermittent
mild-to-moderate migraine
(+/- aura)
Intermittent
moderate-to severe migraine
(+/- aura)
Behavioural/complementary therapies
Aspirin/NSAID (large dose)
Aspirin/paracetamol plus anti-emetic
Initial consultation
Rescue
Initial treatment
Oral triptan
Rescue
Nasal spray/subcutaneous
triptan
Copyright MIPCA 2002, all rights reserved
Initial
treatment
Initial
treatment
Aspirin/NSAID (large dose)
Aspirin/paracetamol plus anti-emetic
Paracetamol plus isometheptane
Oral triptan
If unsuccessful
Oral triptan
Rescue
Follow-up treatment
Alternative oral triptan
Nasal spray/subcutaneous
triptan
If unsuccessful
Frequent headache
(i.e. 4 attacks per month)
Migraine
Consider prophylaxis +
acute treatment for
breakthrough migraine
attacks
If unsuccessful
Chronic daily
Headache (CDH)?
If
management
unsuccessful
Copyright MIPCA 2002, all rights reserved
Consider referral
Implementation of guidelines
• Primary care headache team
– GP, practice nurse, ancillary staff and sometimes
pharmacist (core team)
– Pharmacist
– Community nurses
Associate team
– Optician
members
– Dentist
– Complementary practitioners
– Specialist physician (additional resource)
Primary care
Community nurse
Optician
Pharmacist
Practice
nurse
Specialist
care
Ancillary
staff
Primary care
physician
Physician with expertise
in headache:
GP; PCT; specialist
Dentist
Complementary
practitioner
Patient
Associate team
Core team
Copyright MIPCA
2002, all rights
reserved
Patient checklist
Use of patient checklist
Pre-consultation
• Identification of headache as an issue by the
patient / doctor / nurse / pharmacist
• Making a special appointment to see the
doctor about your headache
• Completion of the patient checklist by the
patient
• Bring completed checklist to consultation
• Use by the headache team to initiate
management
Content of patient checklist
• Headache features
– Aid to diagnosis
• Headache symptoms
– Description and severity
• Medication use
– Effectiveness and tolerability
– OTC
– Prescription
Issues with patient checklist
• Is it too long?
– Briefer version needed?
• Need for validation
– Road test with a group of patients?
– Publishing of data will help endorse use
Headache diary
Headache diary
•
•
•
•
Suitable for use in primary care
Patient-held long-term diary
Comprehensive and definitive
When to use:
– Baseline assessments
– Treatment choice
– Follow-up
Headache diary - content
• Patient details and appointment record
• Daily diary:
–
–
–
–
Headache and other symptoms
Burden
Medications used
Other relevant information
• Monthly analysis
• Yearly calendar
• Self-rating of headache management
Patient guidelines
Pre-consultation
• First medical contact for headache
– Opportunistic or specific
– GP, nurse, pharmacist
– Other healthcare professional
• e.g. dentist, optician, gynaecologist
• Patient support group
– Migraine Action Association
Pre-consultation
Patients’ actions
Contacts
Nurse
Doctor
Pre-consultation
Patient checklist /
diary
Pharmacist
Other healthcare
professional
Migraine Action
Association
Make appointment to
see doctor/nurse
The first consultation
• Meet with the practice nurse to evaluate checklist /
diary
– Complete headache history questionnaire
• Agree terms of mutual respect and working in
partnership with the doctor
• Talk to the doctor about:
– Headache features
– Medications used and their effects
– Your expectations of treatment
• Ask for information
• Commit to, and take charge of your own
management
• Agree targets and procedures
• Talk to the practice specialist headache patient
Diagnostic procedures
• Provide full and accurate information
• Agree to complete a headache diary
and/or an impact questionnaire if asked
to do so
• Patient needs to be motivated and
accept a joint effort is required
Initial management
• Provide full and accurate information
• Agree to complete a headache diary
and/or an impact questionnaire if asked
to do so
• Agree targets and keep expectations
realistic
Initial treatments
• Take your medications as prescribed
• Keep a record of treatment efficacy and any
side effects
– Headache diary
• Consider lifestyle alterations if suggested
• Also use complementary therapies if you
wish but keep your doctor informed and tell
your therapist about any medication you are
taking
The first consultation
Patients’ actions
Contacts
Patient checklist /
diary
Nurse
Doctor
First headache
consultation
Headache history
(Screening, diagnosis,
management)
Impact questionnaire
Headache diary
Specialist patient
Make appointment for follow-up
Roles of the healthcare
professionals at the 1st consultation
• Nurse
– Screening (checklist, history, impact)
– Provision of advice (lifestyle and nonprescription therapies)
• GP
– Diagnosis
– Management
Follow-up
• Make and attend follow-up appointments
• Ask questions if unsure of anything
• Complete headache diaries and impact
questionnaires as requested
• Be aware that the headache may change over
time
• Be honest about treatment effects and your
preferences
• Do not overuse medications
• Review with the specialist patient
Follow-up
Patients’ actions
Contacts
Headache diary
Impact questionnaire
Nurse
Follow-up
Doctor
Specialist patient
Headache diary
Impact questionnaire
Make further follow-up
appointments
Patient / professional responsibilities:
Pre-consultation
Patient
• Identification of headache as
an issue by the patient /
doctor / nurse / pharmacist
• Make a special appointment
to see the doctor about your
headache
• Complete the patient
checklist that the practice
nurse gives you
• Take time to prepare what
you want to say
Doctor / nurse
• Hold special headache
consultations
• Hold, explain and give out
patient checklist form
• Arrange for a specialist
patient to be available
Patient / professional responsibilities:
The first consultation
Patient
• Meet with the practice nurse to
evaluate checklist
–
•
•
Agree terms of mutual respect and
working in partnership with the
doctor
Talk to the doctor about:
–
–
–
•
•
•
•
Complete headache history
questionnaire
Headache features
Medications used and their effects
Your expectations of treatment
Ask for information
Commit to, and take charge of your
own management
Agree targets and procedures
Talk to the practice specialist
headache patient
Doctor / nurse
• Review patient checklist and
complete headache history
questionnaire
• Give out headache diary and impact
questionnaire
• Provide information, education and
guidance
• Agree terms of mutual respect and
working in partnership
• Allow sufficient time for
consultation
• Communicate effectively with the
patient
• Set targets and procedures
• Diagnosis
• Management strategy
• Prescribe treatments
• Refer to a specialist patient
Patient / professional responsibilities:
Diagnostic procedures
Patient
• Provide full and
accurate information
• Agree to complete a
headache diary and/or
an impact questionnaire
if asked to do so
Doctor
• Conduct diagnostic
screening
• Confirm diagnosis
• Listen to what the
patient tells you
Patient / professional responsibilities:
Initial management
Patient
• Provide full and accurate
information
• Agree to complete a
headache diary and/or
an impact questionnaire
if asked to do so
• Agree targets and keep
expectations realistic
Doctor
• Assess illness severity
accurately
• Provide therapy
appropriate to the
patient’s individual
needs and preferences
• Set targets and discuss
expected outcomes
• Provide sufficient
treatment for at least 1
month
Patient / professional responsibilities:
Treatments
Patient
• Take your medications as
prescribed
• Keep a record of treatment
efficacy and any side effects
• Consider lifestyle alterations
if suggested
• Also use complementary
therapies if you wish but
keep your doctor informed
and tell your therapist about
any medications you are
taking
Doctor
• Prescribe acute medication
and behavioural therapies to
all patients
• Prescribe additional
prophylaxis if warranted
• Take account of the patient’s
lifestyle needs
• Advise of expected side
effects
• Allow patients to use
complementary therapies
Patient / professional responsibilities:
Follow-up
Patient
• Make and attend follow-up
appointments
• Ask questions if unsure of
anything
• Complete headache diaries
and impact questionnaires
as requested
• Be aware that the headache
may change over time
• Be honest about treatment
effects and your
preferences
• Do not overuse medications
• Review with the specialist
patient
Doctor / nurse
• Organise regular follow-up
consultations
• Review and give out followup assessment tools
– Headache diaries
– Impact questionnaires
• Adapt management to
changes in the illness or the
patient’s circumstances
• Monitor therapy regularly
and switch if necessary
• Beware of CDH developing
Finalisation of the MIPCA / MAA
headache diary
Dr Bill Laughey
The MIPCA diary project
• Aim: to produce one or more diaries
suitable for use in primary care for all
patients with headache
• Project started in 2002
• Project leaders
– Dr Bill Laughey
– Dr Sue Lipscombe
– Ms Ann Turner
Who are the diaries for?
• The patient
• The doctor / health professional
• Both
What is the diary for?
• Recording data
– Triggers, patterns, results of medication,
frequency of medication taken
• To make the patient feel the healthcare
professional is interested
• To help the healthcare professional make
lifestyle and medication suggestions
• To be a patient-held record of their personal
headache history
When should a diary be used?
• Initial evaluation of the patient
– Baseline assessments
– Helping the choice of initial medications
• In follow-up
– To record the progression of the headache
– To monitor the response to therapy
– To help in the choice of appropriate
medications
Headache diary
• Beneficial for the prospective management
of migraine
• Type of diary which can be used
– Patient-held long-term diary for continual use,
containing basic information on patterns of
headache
– Can also be used over a specific timescale for
intense monitoring
• Data from the diary can be used to
individualise follow-up treatment decisions
MIPCA diary
•
•
•
•
•
•
Basic information
Appointment record
Day-by-day diary
Monthly analysis
Yearly calendar for month-by-month analysis
Informative leaflet on headaches (use MAA
document in their 2003 diary)
• Produced as a plastic-covered booklet that
individual pages can be inserted into
Basic information
Name: . . . . . . . . . . . . . .
Date of birth . . . . . .
Month: . . . . . . . . . . . . . . Year: . . . . . . . . . . . . .
Regular medication (headache): . . . . . . . . . . . . . . . . . .
(prescription/ non-prescription)
Dose: . . . . . . . . Date of last prescription: . . . . . . . . . . .
Regular medication (non-headache): . . . . . . . . . . . . . . . .
Appointment record
Patient: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Doctor/Nurse . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Practice Tel no: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Your next appointment is:
Date: . . . . . . . . . . . . . . . . . . . . . . . . . .
Date: . . . . . . . . . . . . . . . . . . . . . . . . . .
Date: . . . . . . . . . . . . . . . . . . . . . . . . . .
Date: . . . . . . . . . . . . . . . . . . . . . . . . . .
Date: . . . . . . . . . . . . . . . . . . . . . . . . . .
Time: . . . . . . . . . . . . . . . . . . .
Time: . . . . . . . . . . . . . . . . . . .
Time: . . . . . . . . . . . . . . . . . . .
Time: . . . . . . . . . . . . . . . . . . .
Time: . . . . . . . . . . . . . . . . . . .
Please tell us in good time if you cannot attend.
Thank you
(monitor for drop outs from care)
Daily diary: Core questions
Day
Headache present (Y/N)
Start time (am / pm)
Headache duration (h)
Peak severity (mild / mod /
mod-sev / sev / excruciating)
Medications taken for
headache (list and dose)
Effectiveness of medications
(excellent / good / reasonable
/ poor / nil)
1
2
3
4
5,
etc
Monthly analysis
Daily diary: Generic headache questions
Day
Presence of non-headache
symptoms (list)
Presence of factors that
trigger the headache (list)
Time lost from normal
activities (h)
Side effects of medications
(list)
Menstrual period present
(Y/N)
Other illnesses (list)
Other relevant information
(list)
1
2
3
4
5, etc Monthly
analysis
Yearly calendar
Factor
Total number of headaches
Days with headache
Ave duration of headache
Ave severity of headache
Days with impaired function
Days of medication
Total dose
Total number of tablets
Best medication
Headache-free days
Normal function days
Jan
Feb
Mar
Apr
May
Self-rating of headache management
Rate your relief medication
Question
Yes
1. Does your medication allow you to function normally within 2
hours of dosing?
2. Does your medication give some degree of relief in at least 2
headaches out of 3?
3. Are you satisfied with your relief medication?
4. Do you have no bothersome side effects?
If you answered No to any of these questions, please see your doctor
No
Rate your preventative medication
Question
Yes
1. Has your preventative medication at least halved the number of
headaches you have per month?
2. Are you satisfied with your preventative medication?
If you answered No to any of these questions, please see your doctor
No
Rate the impact of your headache
Question
Yes
No
1. Does your headache significantly interfere with your work
and/or your leisure time?
2. Does your headache significantly interfere with your sense of
emotional well-being?
3. Do you have any other concerns which you think you should
mention to your doctor?
If you answered Yes to any of these questions, please see your doctor
Next steps
• Production of finalised diary
• Testing of the diary in the clinic
– Reliability / validity / clinical utility
• Publication of results
• Production of finalised diary
– Sponsorship?
• Distribution and PR
– Medical and general media
Aspirations for diary
• Sustainable – year or more
• Comprehensive – daily, monthly, yearly
• Adaptable – e.g. photocopy more
sheets
• Provide Information – more than a
record
Information content of diary
•
•
•
•
•
•
About this diary
About MAA
About MIPCA
Migraine and headache information
How to get the most from your GP
Useful resources
Daily record suggestion
•
•
•
•
•
•
•
•
•
•
Headache yes/no
Migraine yes/no
Severity
Nausea/Vomiting
Dislike Light, Noise, Smell
Aura: yes/no
Medication name and amount
Medication effective: yes/no
Period: yes/no
Notes: e.g. Triggers
Issues relating to the diary
• Too complicated for the average patient?
• To complicated to complete during a
headache?
• Monthly and annual analyses will need to
completed by a GP / nurse
• Problems with self-rating
– Treatments may differ with different situations
Discussion session:
Roles of the specialist headache patient
Setting up specialist headache patient
services
Defining the roles of the specialist
headache patient - 1
• Mentor for newly diagnosed headache
patients
– Practical support
• Encourage diary keeping
• Exchange ideas for treatment (acute and preventative)
• Role in the clinic service
– Triage agency
Defining the roles of the specialist
headache patient - 2
• Developing networks of care
– Holding patient information sheets
• Development of local strategies
– Management
– Research
– Audit
Implementation of a specialist
headache patient service
• Accreditation
• Development of patient groups / meetings
– How best to conduct patient meetings
– Small meetings in surgeries?
• Development of a course / syllabus
– Via MIPCA / MAA?
• Dissemination
– Media
– Training
Expert Patient Programme
Expert Patient Programme
• Department of Health led initiative – not
disease specific
• Pilot phase 2002-2004
• Mainstreamed NHS 2007
• 2 senior trainers UK wide (Stanford
University-trained assessors/quality
management of courses)
• 2 trainers per PCT (DOH aim)
• Volunteer tutors (delivering in community)
Expert Patient Programme
• Recruit volunteer tutors
(must have long term condition)
• 4-day residential training course
• Must deliver 2 community based courses
• Must be assessed by lead trainers
• Courses consist of 6 x two and half hour
sessions
• Generic courses
• 7th session condition specific
Expert Patient Programme
• Currently 500 volunteers UK wide
(although mainly England)
• Includes Arthritis Care, Endometriosis
Society, MS Society, Parkinson’s Disease
Society
• 2 tutors attached to each PCT
• Each course delivered by 2 tutors
Expert Patient Programme
Training delivered:
• Overview of selfmanagement
• Chronic health conditions
• Relaxation/cognitive
symptom management
• Feedback/problem solving
• Anger/fear/frustration
• Fitness/exercise
• Better breathing
• Fatigue
• Nutrition
• Living wills/power of
attorney
•
•
•
•
•
•
Community resources
Communication
Medication
Making treatment decisions
Depression
Informing the health and
social care team
• Working with your health
and social care
professionals
• Future plans
Expert Patient Programme
Key benefits of training:
• Reduced severity of symptoms such as levels of
pain
• Reduced levels of depression, fatigue and anxiety
• Better medication compliance and reduction in
medication intake such as use of painkillers
• Reduced visits to GPs, A&E and Outpatients
• Reduction in length of stay in hospital
• Better communication with professionals
• Improvement in lifestyle
• Enhanced quality of professional-patient
relationships and of consultations
Expert Patient Programme
Key benefits of training
• Improvement in lifestyle and behaviours
e.g. relaxation, exercise, diet
• Improved life control and activity
• Improved resourcefulness and life
satisfaction
• Greater self-efficacy, independence and
mobility
• Participants may find employment or
become more active in the community
Expert Patient Programme
Five-core self management issues:
•
•
•
•
Problem-solving
Decision-making
Resource utilisation
Developing effective partnerships with care
professionals
• Taking action
Expert Patient Programme
Costs
Generic self-management programme
• EPP recommend using established deliverers e.g.
Arthritis Care for training
• £2500 per group of 10-18 on 4-day residential
course to train as tutors
• Must then deliver 2 courses in community for
sufferers of long term conditions
• LMCA approximate total cost of training and
delivering courses 2 Tutors x 2 courses = £7000
Expert Patient Programme
“You can break the pain cycle”
• One day course of approximately four and
half hours.Group size as before 10-18
• Aims to teach self-management of pain
only
• Often used as taster for full course; or for
participants who cannot attend the full
course
Cost = £1000
Expert Patient Programme
Empowering the migraine and headache
patient
• Is the Department of Health programme
appropriate for migraine/headache patients?
• Do we need to develop an alternative programme
that is disease-specific and may encompass the
relevant elements of the EPP programme?
Expert Patient Programme
The way forward-suggestions
• Develop and deliver a pilot scheme of 7 one day courses at
locations throughout the country that are a combination of
education on headache management, elements of the generic
self-management programme and awareness raising of the
Expert Patient Programme
• The courses will aim to give each participant information on
managing their headache/migraine more effectively but may
also encourage them to enrol in a generic Expert Patient
course and possibly to become an Expert Patient tutor.
Cost of 7 one day courses would be approximately £30K
Expert Patient Programme
The way forward - suggestions
• Buy into the EPP or courses delivered by e.g.
Arthritis Care to develop our ‘own’ tutors who in
turn would deliver courses in their community
• Encourage members to access courses already
being delivered through EPP and PCTs and which
are freely available (MAA could do this via website
and newsletter)
• Develop and deliver our own disease-specific
courses