Headache service quality evaluation: implementation of quality indicators in primary care in Europe

DOI: https://doi.org/10.1186/s10194- 021- 01236- 4

Abstract-Summary Lifting The Burden (LTB) and European Headache Federation (EHF) have devel- oped a set of headache service quality indicators, successfully tested in specialist headache centres.

We assess their implementation in primary care. We included 28 primary-care clinics in Germany (4), Turkey (4), Latvia (5) and

Portugal (15).

Enquiries were in nine domains: diagnosis, individualized management, referral pathways, patient education and reassurance, convenience and comfort, patient sat- isfaction, equity and efficiency of headache care, outcome assessment and safety.

The principal finding was that Implementation proved feasible and practical in

primary care.

Headache-related disability and quality of life were not part of routine clinical

enquiry.

Most patients (> 85%) expressed satisfaction with their care. Almost all the participating clinics provided equitable and easy access to treat-

ment, and follow-up for most headache patients, without unnecessary barriers.

The study demonstrated that headache service quality indicators can be used in

primary care, proving both practical and fit for purpose.

These findings signal the need for additional training in headache diagnosis and management in primary care, where most headache patients are necessarily treated. They underline the importance of headache service quality evaluation in primary

care, not only to identify-quality failings but also to guide improvements.

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This study also demonstrated that patients’ satisfaction is not, on its own, a good

indicator of service quality.

Background In primary care management of headache, education does indeed improve prac- tice [274].

There is need to take a much more expansive view: the concept of service quality

must take centre-stage in headache care, wherever it is delivered [178].

In a series of evaluations, these indicators were first implemented in a pilot study in two highly specialized headache centres (at the University Hospital Essen, Germany, and the Hospital de Luz in Lisbon, Portugal) using the questionnaires developed for doctors, other health-care providers (HCPs), service managers, secre- taries or administrators and patients [272].

Both studies found the quality indicators to be practical in specialist care and fit

for purpose at this level: treatment deficits were identified and eliminated [507].

Its secondary purpose is to assess the quality of headache management currently in primary care in Europe, identifying deficits and providing guidance for improvement.

Methods Approvals were obtained in each country in accordance with local regulations (some did not require ethics approval for studies with the primary purpose of service quality improvement).

During 2019, a total of 53 primary-care practices from four European countries were invited to participate (10 from Germany, five from Turkey, five from Latvia and 33 from Portugal), identified through personal contacts and selected to repre- sent, as far as possible, the geographic distinctions of the four countries.

The data were collected prospectively under the supervision of the local princi- pal investigator using the prescribed SQE questionnaires for each group of inter- viewees and for extraction of data from patients’ records.

Data were entered locally and anonymously into spreadsheets provided, and in this form transferred to the data collection centre (Clinic for Neurology, Geriatric Medicine and Neurorehabilitation in the Evangelical Hospital Unna), where they were merged and analyzed descriptively.

Results Diagnostic diaries were available in a minority (0% in Germany to 30% in Latvia), with many HCPs unaware of them and others believing they were too time-consuming.

One third of practices in Latvia, but fewer elsewhere, used an instrument for dis-

ability assessment at the time of diagnosis.

In Germany and Portugal, two thirds of practices had an access route to psycho-

logical therapies, but in Turkey and Latvia only one-third.

Almost all practices were able to offer their patients follow-up, when considered necessary, although few used standardized follow-up diaries or outcome assessment instruments to monitor progress.

Most practices (83%, but only 67% in Turkey) offered equal access to their

(headache) service for all patients.

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The most marked differences could be identified in domain A (Accurate diagno- sis) and domain H (Outcome assessment), but there were notable deficits in primary care relative to specialist care in other individual quality indicators (for example in the availability of information leaflets [D1a]).

Discussion Basic but structured education of GPs has been shown to improve their practice, significantly increasing proportions of patients given specific diagnoses and treat- ments, both indicators of headache care quality [274, 508].

Pertaining to this, an important particular finding was that a substantial propor- tion of patients of these primary-care practices received non-specific ICD codes such as R51 (“headache”) rather than specific headache diagnoses.

While the study fulfilled its primary goal of demonstrating that the SQE method- ology is applicable and practical in primary care, understandable to HCPs and patients without being unduly time consuming, we note a limitation and caveat in regard to this: only 53% of invited primary-care clinics agreed to participate.

Despite that it was not the study’s primary purpose, it uncovered opportunities

for improvement in the management of headache patients in primary care.

Conclusion This study, the first evaluating headache service quality indicators in primary care in Europe, confirmed the indicators to be practical and fit for purpose, able to iden- tify areas for improvement in pursuit of care quality.

While quality criteria must be deployed at all levels within health-care-systems (and this study has confirmed that they can be), primary care is the setting of great- est importance since it is where management of the majority of headache-patients can and should be based [178, 509, 510].

This study, in the context of the collaborative LTB/EHF SQE project of which it

is part, is a step towards bringing headache service quality centre-stage.

Acknowledgement A machine generated summary based on the work of Lenz, B.; Katsarava, Z.; Gil- Gouveia, R.; Karelis, G.; Kaynarkaya, B.; Meksa, L.; Oliveira, E.; Palavra, F.; Rosendo, I.; Sahin, M.; Silva, B.; Uludüz, D.; Ural, Y.  Z.; Varsberga-Apsite, I.; Zengin, S. T.; Zvaune, L.; Steiner, T. J.; 2021 in The Journal of Headache and Pain.

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