In an accompanying editorial, the journal's editor John F. Rothrock, MD, commented, "The very magnitude of the public health burden imposed by chronic headache would seem to demand identification and adoption of just such models."
"Any chronic disease relies on patient self-management for successful outcomes. Patient education is the most important element needed to improve the self-efficacy of patients managing their own disorder," said Morris Maizels, MD, of the Kaiser Permanente Woodland Hills Medical Center Department of Family Practice. "While group medical care may sound unusual, it is already widely accepted for diabetes, pregnancy education, and many psychiatric disorders."
The Kaiser Permanente Woodland Hills Headache Clinic serves a patient population of 160,000 members and is staffed by a family physician/headache specialist, two registered nurse practitioner (RNP) health specialists, and a clinic coordinator. Groups of 10 to 15 patients experiencing migraine, chronic migraine or tension-type headache, attend education sessions led by registered nurse practitioners. After participating in the group program, they are offered an individual consultation.
In contrast to a conventional medical model based on interaction between one patient and a physician, disease management uses multidisciplinary teams to treat groups of patients. Disease management programs have been widely used for costly, life-threatening illnesses such as coronary artery disease, congestive heart failure and diabetes. However, this paper shows that conditions such as migraine can also be successfully treated with this approach.
In addition to Dr. Maizels, the paper's other authors are Valerie Saenz, RNP, of the Kaiser Permanente Woodland Hills Medical Center Department of Family Practice; and Jonathon Wirjo, project analyst, SCPMG Strategic Business Initiative.
Two hundred and sixty-four patients participated in the study between April 1999 and April 2000 and reported relief of their headache pain. The greatest improvement was seen in the most severely affected patients.
Patients with primary headache disorders, migraine, chronic migraine or tension-type headache, initially participate in an education program. Those patients whose referrals suggest cluster headache, recent onset of headache or otherwise unexplained headaches are seen directly without participating in the educational program.
The education session is led by the RNP. Patients complete a detailed questionnaire and discuss their headache pain as well as talk about migraine, diagnosis, triggers, and treatment options.
After the session, patients schedule consultations with a registered nurse practitioner or a physician. Patients with more complicated diagnoses including use of narcotics or history of repeated treatment failures, were seen by a physician.
The project utilized triptans, a class of medications approved by the FDA that were discovered by researchers seeking a molecule that functions the same way as the neurotransmitter serotonin which is thought to play a role in inflammation.
"We think that acknowledging that headache is a chronic disease is a very important development," said Dr. Maizels. "Government agencies and third-party payers are insisting on good care for conditions like heart disease and diabetes, but they have not mandated care for the treatment of the very disabling disorder of migraine. Doctors at Kaiser Permanente have sought innovative means of providing care without straining health resources which usually target the 'life-threatening' disorders."
At the same time the Woodland Hills clinic was established, the care given to headache patients in the Kaiser Permanente Woodland Hills Emergency Department was evaluated. Findings included that some patients complaining of headache pain were often not adequately diagnosed or treated. In response, patients who had come to the ER for headache treatment were contacted by letter and offered the opportunity to self-refer to the clinic. The number of headache-related clinic visits was determined by reviewing computer appointment histories and clinic charts. Headache class appointments and initial consultations were not counted as visits.
Kaiser Permanente is a prepaid, group practice health maintenance organization (HMO), founded in 1945. The Kaiser Permanente Southern California Region has more than 3.1 million members. It includes 3,600 physicians in the Southern California Permanente Medical Group (SCPMG) and 46,000 Kaiser Foundation Health Plan and Hospitals employees. The Region is served by 11 major medical centers.