Pozo-Rosich et al. The Journal of Headache and Pain (2020) 21:74 https://doi.org/10.1186/s10194-020-01147-w The Journal of Headache and Pain RESEARCH ARTICLE Open Access Low-value care practice in headache: a Spanish mixed methods research study Patricia Pozo-Rosich1,2, Almudena Layos-Romero3, Jimmy Martin-Delgado4* , Julio Pascual5,6, Cristina Bailón5, Ana Tentor7, Alejandro Santiago8, Emilio Ignacio9, Antonio Torrés10 and José Joaquín Mira11,12 Abstract Background: Headache is one of the most prevalent diseases. The Global Burden of Disease Study ranks it as the seventh most common disease overall and the second largest neurological cause of disability in the world. The “Do Not Do” recommendations are a strategy for increasing the quality of care and reducing the cost of care for headache. This study aimed to identify specific low-value practices in headache care, determine their frequency, and estimate the cost overrun that they represent, in order to establish “Do not Do” recommendations specifically for headache by consensus and according to scientific evidence. Methods: This was a mixed methods research study that combined qualitative consensus-building techniques, involving a multidisciplinary panel of experts to define the “Do Not Do” recommendations in headache care, and a retrospective observational study with review of a randomized set of patient records from the past 6 months in four hospitals, to quantify the frequency of these “Do Not Do” practices. We calculated the sum of direct costs of medical consultations, medicines, and unnecessary diagnostic tests. Results: Seven “Do Not Do” recommendations were established for headache. In total, 3507 medical records were randomly reviewed. Low-value practices had a highly variable occurrence, depending on the hospital and type of headache. Overall, 34.1% of low-value practices were related to treatment, 21% were related to overuse of imaging in consultation, and 19% were related to emergency care. The estimated cost of low-value practices in the four hospitals was 203,520.47 euros per 1000 patients. Conclusions: This study identified low-value headache practices that need to be eradicated and provided data on their frequency and cost overruns. Keywords: Care, Cost, Do not Do recommendations, Headache, Patient safety, Mixed methods Introduction The Global Burden of Disease Survey [4] ranked head- Headache is one of the most prevalent diseases and one ache as the seventh most common disorder causing the of the main reasons for consultation in primary care and greatest decrease in quality of life in years. When consid- neurology services [1]. The prevalence of headache is ering only neurological diseases, migraine is the second around 51% and, in Spain, it has been estimated that most common disabling condition, after stroke. Accord- more than four million people suffer from migraine. Of ing to the World Health Organization (WHO), head- these, one million suffer from chronic migraine [2, 3]. aches are one of the most disabling health problems with the highest socioeconomic impact, since they are responsible for the inactivity of sufferers during the most * Correspondence: jimmy.martind@umh.es 4 ATENEA research group, Foundation for the Promotion of Health and productive years of their lives [5, 6]. Biomedical Research, Sant Joan d’Alacant, Spain Full list of author information is available at the end of the article © The Author(s). 2020 Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data. Pozo-Rosich et al. The Journal of Headache and Pain (2020) 21:74 Page 2 of 8 The Global Campaign against Headache, led by Lifting regarding the overuse of imaging tests or treatments that the Burden, together with the WHO, aims to reduce the should be avoided, there is still room to justify the im- gap in organizational, diagnostic, and therapeutic ap- portance of reaching agreements regarding other prac- proaches to headache worldwide, and particularly in tices that do not add value to specific headache care. Europe, and seeks to identify the quality dimensions of In this study, we aimed to identify specific low-value headache care that should be considered in order to pro- practices in headache care, determine their frequency, vide integrated quality care [7, 8]. The Eurolight study and estimate the cost overrun that they represent. “Do analyzed the organization and treatment of patients with not Do” recommendations specifically for headache were migraine in Europe and estimated that the annual cost established by consensus and according to scientific of care for headache patients is 173,000 million euros evidence. [9]. Migraine accounts for 64% of this total cost (110,000 million euros). Spain ranks second in Europe in terms of Methods the direct annual cost of headache [10]. The 2018 Atlas This was a mixed methods research study that combined of Migraine in Spain estimated that the annual total dir- qualitative consensus-seeking techniques, involving a ect cost per patient for healthcare services was 3847.29 multidisciplinary panel of experts, to define “Do not Do” euros for chronic migraine and 964.19 euros for episodic practices in headache, and a retrospective observational migraine. To these amounts must be added the cost as- study, with review of a random set of medical records sumed by the patient, which ranges from 1657.96 euros from four hospitals to quantify the frequency of these for chronic migraine and 878.04 euros for episodic mi- “Do not Do” practices. This study was conducted be- graine; and the indirect cost associated with the inability tween June and December 2019. to work for this reason, which has been estimated at 7464.83 euros for chronic migraine and 3199.15 euros Review of the literature for episodic migraine. The total cost per patient per year To prepare for the working session with the panel of ex- comes to 12,970.08 euros for chronic migraine and perts, a narrative review of the literature was carried out 5041.38 euros for episodic migraine [11]. after searching the following databases: PubMed, Scopus, Overuse is defined as “the provision of medical ser- and EMBASE. The following search terms were used: vices for which the potential for harm exceeds the po- “headache,” “migraine,” “neuroimaging,” “Global Cam- tential for benefit” [12]. Ultimately, overuse can be paign Against Headache,” “quality of care,” “do not do,” considered to occur along a continuum. At one end of “guidelines,” “treatment. Additionally, a manual search the continuum lie tests and treatments that are univer- was carried out on the websites of the following organi- sally beneficial when used for the appropriate patient. At zations: Sociedad Española de Neurología, Atlas de the other end of the continuum are services that are en- Migraña, Choosing Wisely USA, Choosing Wisely tirely ineffective, futile, or that possess such a high risk Canada, Choosing Wisely Australia, American Headache of harm to all patients that they should never be deliv- Society, International Headache Society, National Insti- ered. Most procedures and interventions lie between tute for Health and Care, and Scottish Intercollegiate these extremes, and consensus is needed to help eluci- Guidelines Network (SIGN). date whether these procedures and interventions should The titles and summary of the studies identified were be recommended, and to help decide which patient they reviewed by two authors to decide whether they were may benefit [13]. relevant to this study. The full text of the selected arti- The “Less is More,” “Right Care,” “Choosing Wisely,” cles or documents was revised to extract information on or “Do Not Do Recommendations” campaigns have “Do not Do” recommendations in headache. The infor- sought to establish consensus criteria to identify prac- mation was included based on its level of evidence, and tices that have low value in health care, in an effort to feasibility of execution. It was agreed that the SIGN clas- reduce them. Locally, the “Commitment for the Quality sification should be used as a guide to determine the of Care of the Scientific Societies in Spain,” of which 49 levels of evidence and degrees of recommendation. Prior scientific societies form part, have elaborated a list of to the working session of the group of experts, the infor- recommendations, each one in its specialty or specific mation was organized according to the stage of the care field, about what should not be done following the process, for example, diagnosis, evolution, treatment, or methodology of “Choosing Wisely.” In this case, there is control, and whether it was an emergency care situation only one recommendation for headache care in Spain or a neurological consultation. (Do not Do neuroimaging studies repeatedly in patients with primary headache (migraine and tension headache) Group working session without changes in their profile [14]). Although scientific The group of experts consisted of three specialists in societies internationally have established consensus neurology, and one specialist each in family medicine, Pozo-Rosich et al. The Journal of Headache and Pain (2020) 21:74 Page 3 of 8 hospital pharmacy, and neurological nursing. The se- Direct costs lection of these panelists took into account the in- Direct costs of ignoring this Do not Do recommenda- volvement of professionals throughout the care tions were estimated by summing the estimated costs of process, as well as their experience from the first medical consultations, diagnostic tests, and medicines level of care to monographic consultations for head- associated with low-value practices. This estimate was ache, as well as their specialized training. The work made considering the average costs of consultations and of the panel of experts included a group session and diagnostic tests in the health services of Madrid, Castile multiple telematic meetings until a sufficient degree and Leon, and Murcia (based on data from 2017) and of consensus was reached. Experts had gathered the reference prices for financing medicines by the Na- information during the literature review as well as tional Health System in Spain described in Order SCB/ additional evidence that they could provide. In the 1244/2018. The average cost of the first consultations face-to-face meeting of the panel of experts, the rec- was 82 euros, successive consultations were 71 euros, ommendations identified in the literature review were and emergency care was 175 euros. Brain functional analyzed one-by-one. In parallel, experts proposed studies with magnetic resonance imaging had an average and debated “Do not Do” recommendations associ- cost of 400 euros, and electroencephalogram 147 euros. ated with the headache care process in their areas of The overall direct cost of these low-value practices at expertise. JM and JJM produced a synthesis of the de- each center in the study period (6 months) was obtained bate and recorded recommendations through sum- by multiplying the direct cost, in euros, of consultations, mary sheets that were analyzed individually by tests, and medicines by the volume of patients with low- successive rounds of telematic meetings, and thereby value practices. Finally, considering a prevalence of 12– “Do not Do” recommendations were identified. The 13% for migraine, 2–3% for chronic migraine, and 51% consensus on which “Do not Do” recommendations for headache [11], we extrapolated the total direct cost should be proposed considered the quality of the evi- for the Spanish healthcare system for the agreed low- dence for each recommendation, the feasibility in value indications, by multiplying the cost per patient by identifying whether the undesirable practice was im- the number of patients that could be expected to have plemented in clinical practice, and the foreseeable ac- low-value indications according to our data. ceptance of the recommendation by the professional community. Summary cards included the code of the Results “Do not Do” recommendation, its definition, current The literature review identified nine relevant studies problem, number of instances of the undesirable prac- and three technical papers. Fourteen “Do not Do” tice occurring within a given number of consultations, recommendations and two proposals for discussion by sources of information, and evidence. the expert group were developed from this informa- tion. Overall, the expert panel suggested 17 “Do not Field study Do” recommendations at the group work session We measured the frequency by which these low-value (supplementary file is available with all the recom- or undesirable practices were implemented in an ob- mendations proposed by the expert panel). Finally, servational, retrospective, multicenter study. In this seven “Do not Do” recommendations were prioritized study, 3507 clinical records of patients who attended through telematic means based on the quality of the four university hospitals of the Spanish public health evidence for each recommendation, the feasibility in system over the past 6 months were randomly identifying whether the undesirable practice was im- reviewed. A minimum required sample size of 3068 plemented in clinical practice (data extraction from patients was calculated for a precision of 3%, p = q = the clinical information systems contributes to this 50% worst-case scenario, an expected proportion of identification), and the foreseeable acceptance of the losses due to incomplete information of 15%, and a recommendation by the professional community. Full confidence level (two-tailed) of 95%. The hospitals details of these seven “Do not Do” recommendations had between 367 and 1146 beds. The review of clin- are available in Table 1. ical records was carried out by applying algorithms The previous and only “Do not Do” recommendation for data extraction from clinical information systems stablished for headache in the local context, was kept that defined each of the “Do not Do” recommenda- and not only considered but it now approaches outpa- tions determined by consensus in the first part of the tients and emergency care. In this consensus other rec- study. The International Classification of Diseases ommendations from international organizations have (ICD-10) and the Anatomical Therapeutic Chemical been considered and rephrased for the Spanish context, Classification System (ATC) were used to select pa- for instance don’t use opioid or butalbital treatment for tients who had attended the hospital for headache. migraine except as a last resort and don’t perform Table 1 “Do Not Do” Recommendations in headache. Results of the consensus search panel Code Definition Evidence NHC- Do not recommend painkillers (NSAIDs, paracetamol, and others) more than 15 days per Diener et al. Pathophysiology, prevention, and treatment of medication overuse headache. 01 month in a primary headache that does not respond to treatment. Lancet Neurol. 2019;18(9):891–902. Numerator: Number of patients with primary headache (ICD-10-ES G44.2, G44.53, G44.83, Diener et al. Chronic headache due to overuse of analgesics and anti-migraine agents. Dtsch G44.84 and G44.85) who have continuous pharmacological treatment of more than 15 days Arztebl Int. 2018;115:365–370. with NSAIDs/acetaminophen. ATC GROUPS: ergotics: N02CA02, N02CA52; acetaminophen: Becker et al. Medication overuse headache in Canada. Cephalalgia. 2008;28(11):1218–20. N02BE01; AAS: N02BA01; NSAIDs: M01A Cheung et al. Medication overuse headache. Curr Neurol Neurosci Rep. 2015;15(1):509. Denominator: Total number of patients treated for primary headache. Headache Classification Committee of the International Headache Society (IHS). The International Classification of Headache Disorders, 3rd edition (beta version). Cephalalgia. 2013; 33(9):629–808. NHC- Do not withdraw preventive treatment in patients with primary headaches before 8 weeks if SIGN 155. Pharmacological management of migraine. A national clinical guideline. February 02 the efficacy and therapeutic dose is adequate. 2018 Numerator: Number of patients with preventive treatment ATC GROUPS Beta blockers: Hepp et al. Persistence and switching patterns of oral migraine prophylactic medications C07AA05, C07AA12, C07AB03, C07AB02; Antiepileptics: N03AX11, N03AG01; Renin-angiotensin among patients with chronic migraine: A retrospective claims analysis. Cephalalgia 2017,37(5): inhibiting drugs: C09AA03, C09CA06; N07CA03; Antidepressants: N06AA09, N06AX16; Botulinum 470–485. Toxin: M03AX01 not meeting criteria Pozo-Rosich et al. The Journal of Headache and Pain Denominator: Total patients being treated for primary migraine headache with (G43.1) and without aura (G43.0), chronic migraine (G43.3) and cluster headache (G44.0) NHC- Do not perform neurophysiological studies to establish the diagnosis of migraine or tension Guías diagnósticas y terapéuticas de la Sociedad Española de Neurología 2015;3. Guía oficial de 03 headache. práctica clínica en cefaleas. Editores: P Pozo Rosich, D Ezpeleta. Luzán5. Madrid 2015. ISBN: Numerator: Number of patients who have undergone neurophysiological studies (ICD-10-ES 978–84–15,198-99-4. 4A00) Gronseth GS, Greenberg MK. The utility of the electroencephalogram in the evaluation of Denominator: Total number of patients under treatment for primary migraine headache with patients presenting with headache: a review of the literature. Neurology 1995;45(7):1263–1267. (2020) 21:74 (G43.1) and without aura (G43.0), chronic migraine (G43.3), cluster headache (G44.0) and tension headache (G44.2). NHC- Do not perform neuroimaging studies on patients with tension headache, migraine without Becker et al. Guideline for primary care management of headache in adults. Can Fam Physician. 04 aura, and those with typical and episodic aura without alarm signs. 2015;61(8):670–679. Numerator: Number of neuroimages (CIE-10-ES BW28, BW38) performed in patients with the Ezpeleta D, Pozo-Rosich P, eds. Guía oficial de práctica clínica en cefaleas de la Sociedad Espa- diagnoses of Tension Headache (G44.2), Migraine without aura (G43.00), and Migraine with ñola de Neurología 2015; ediciones SEN. aura (G43.1) and Headache (R51) Guía práctica diagnóstico terapéutica de la cefalea del adulto y el niño en urgencias 2016. Denominator: Total number of neuroimages performed in the service per headache (CIE-10-ES Guías diagnóstico-terapéuticas de la Sociedad Española de Neurología. Editores: A Macaya, P R51) Pozo-Rosich. Luzán5. Madrid 2016. ISBN: 978–84–7989-867-0. NHC- Do not refer patients from primary care with a diagnosis of primary headache without having Guías diagnósticas y terapéuticas de la Sociedad Española de Neurología 2015. 3. Guía oficial 05 prescribed symptomatic treatment with triptans or standard preventive treatment. de práctica clínica en cefaleas. Editores: P Pozo Rosich, D Ezpeleta. Luzán5. Madrid 2015. ISBN: Numerator: Number of patients referred without preventive treatment guidelines Beta-blockers: 978–84–15,198-99-4. C07AA05, C07AA12, C07AB03, C07AB02; Antiepileptics: N03AX11, N03AG01; Renin-angiotensin Gago-Veiga et al. How and when to refer patients diagnosed with primary headache and inhibitor drugs: C09AA03, C09CA06; N07CA03; Antidepressants: N06AA09, N06AX16; Botulinum craniofacial neuralgia in the emergency department or primary care: recommendations of the toxin: M03AX01 not met. Spanish Society of Neurology’s Study Group. Neurologia 2017. pii: S0213–4853(17)30268–2. Denominator: Diagnosis of migraine without aura, migraine with aura, and others not specified (ICD-10-ES G43.00, G43.10, G43.70, G43.90). NHC- Do not perform complementary neuroimaging tests on an urgent basis on patients who do Expert panel on Neurologic Imaging. ACR Appropriateness Criteria: Headache, revised 2019. 06 not meet the established alarm criteria. Do et al. Red and orange flags for secondary headaches in clinical practice: SNNOOP10 list. Numerator: Number of neuroimages (ICD-10-ES BW28, BW38) performed on patients in the Neurology. 2019;92(3):134–144. emergency department who do not meet any alarm criteria Guía práctica diagnóstico terapéutica de la cefalea del adulto y el niño en urgencias 2016. Denominator: Total number of neuroimages performed on patients with primary headache: Guías diagnóstico-terapéuticas de la Sociedad Española de Neurología. Editores: A Macaya, P migraine with (G43.1) and without aura (G43.0), chronic migraine (G43.3) and cluster headache Pozo-Rosich. Luzán5. Madrid 2016. ISBN: 978–84–7989-867-0. (G44.0) in the emergency department. NHC- Do not use opiates as a symptomatic treatment for primary headache. Guías diagnósticas y terapéuticas de la Sociedad Española de Neurología 2015. Guía oficial de Page 4 of 8 Table 1 “Do Not Do” Recommendations in headache. Results of the consensus search panel (Continued) Code Definition Evidence 07 Numerator: Number of patients with opioid indication ATC GROUPS (N02AA) práctica clínica en cefaleas. Editores: P Pozo Rosich, D Ezpeleta. Luzán5. Madrid 2015. ISBN: Denominator: Total number of patients evaluated in the service for primary migraine headache 978–84–15,198-99-4. with (G43.1) and without aura (G43.0), chronic migraine (G43.3) and cluster headache (G44.0). Guía práctica diagnóstico terapéutica de la cefalea del adulto y el niño en urgencias 2016. Guías diagnóstico-terapéuticas de la Sociedad Española de Neurología. Editores: A Macaya, P Pozo-Rosich. Luzán5. Madrid 2016. ISBN: 978–84–7989-867-0. Becker WJ. Acute migraine treatment in adults. Headache. 2015;55(6):778–793. Evers S, Afra J, Frese A, Goadsby PJ, Linde M, May A, Sandor PS, European Federation of Neurological Societies. EFNS guideline on the drug treatment of migraine-revised report of an EFNS task force. Eur J Neurol. 2009;16(9):968–981. NHC: “Do not Do” in headache (translation from Spanish “No Hacer en Cefalea”) ATC Anatomical Therapeutic Chemical Classification System, ICD International Classification of Diseases Pozo-Rosich et al. The Journal of Headache and Pain (2020) 21:74 Page 5 of 8 Pozo-Rosich et al. The Journal of Headache and Pain (2020) 21:74 Page 6 of 8 electroencephalography (EEG) for headaches [15]. Fi- Table 3 Estimated costs of ignoring “Do not Do” recommendations nally, three “Do not Do” recommendations were priori- Code Average Procedure/ Total direct Occurrence Estimated tized different from other previously stablished. These consultation Drug cost per 1000 cost cost (B) (C = A + B) patients (D) (C × D) recommendations were related with preventive treat- (A) per 1000 ment drugs and its duration, and proper referral from patients primary care to specialized care. NHC-01 82,00 € 6,15 € 88,15 € 16 1.410,40 € Review of the medical records revealed that consensus NHC-02 71,00 € 71,57 € 142,57 € 341 48.616,37 € “Do-not-Do” practices were implemented clinically in most NHC-03 82,00 € 347,00 € 429,00 € 7 3.003,00 € of the hospitals participating in this study, although with varying frequency (Table 2). Practice NHC-02, involving NHC-04 82,00 € 240,08 € 322,80 € 210 67.788,00 € withdrawal of preventive treatment before 15 days, was the NHC-05 82,00 € - 82,00 € 40 3.280,00 € most common, at 34.1% of the records reviewed. NHC-05, NHC-06 175,0 0€ 240,08 € 415,80 € 190 79.002,00 € related to correct referral from the first level to neurology, NHC-07 82,00 € 2,14 € 84,14 € 5 420,70 € had an occurrence of 4% and varied greatly between cen- A: Average consultation cost obtained from available information ters. Indicator data showed adequate use of diagnostic aids B: Average cost of each diagnostic procedure or therapeutic guideline used C: Total direct cost of low-value practices along with correct use of opiates, NSAIDs, and acetamino- D: Occurrence of “Do not Do” in 1000 patients phen. Even thought that it is important to point out the high variability among hospitals in most of the “Do not do” recommendations predominantly in NHC-02, 04 and 05. gradually spread throughout health systems worldwide. Recommendations related to diagnostic tests or proce- The results of this study indicate that there is significant dures accumulated most of the avoidable expenses for the variability between centers in terms of the prescription healthcare system, even though there is widely agreement and use of diagnostic tests that do not provide value or on its low value in specific cases. Costs associated of ignor- that may even be harmful to patients and emphasize the ing this “Do not Do” vary from 88,15€ to 429,00€ each need for intervention to avoid these low-value practices. time it happens, depending on the average cost of the pro- The “Do not Do” recommendations for headache care cedure or drug. NHC-02 which has been specially tailored developed by consensus in this study are supported by sci- and prioritized for Spanish hospitals has an individual dir- entific evidence and experience in daily clinical practice. ect cost per patient of 142,57 €. If we extrapolated this They address the entire care process, from correct referral value to an estimated annual cost per 1000 patients of from the first level to neurology consultation [16], to the these seven low-value or undesirable practices, we could overuse of neuroimaging without alarm criteria, defined in reach the amount of 203,520.47 euros (Table 3). If further the consultation or emergency department [17], the in- action is performed to prevent NHC-02 and NHC-04 up appropriate use of neurophysiological studies [18], the to 75% of this expense could be saved. abuse of analgesic treatment [19, 20], the use of opioids for primary headaches [21], and the withdrawal of pre- Discussion ventive medication [22]. Although these “Do not Do” rec- The concept of doing what is really needed rather than ommendations are similar to some previously published focusing on what is dispensable (Right Care) has by the American Headache Society [23] they have been elaborated in the context of the Spanish public health sys- Table 2 Frequency with which the consensus “Do not Do” tem, and are probably applicable to other national health practices were implemented systems. Three recommendations related with preventive Code Numerator (N) Denominator (N) Indicator (%) Range treatment and a proper referral to specialized care could NHC-01 53 3314 1.6 0–39.6 be added to low-value care literature. Our results highlight that implementing these “Do NHC-02 1136 3329 34.1 2.2–62.9 not Do” practices not only jeopardize patient safety, but NHC-03 23 3329 0.7 0–8.3 also endanger the integrity and maintenance of the Na- NHC-04 694 3311 21.0 16.1–62.5 tional Health System. The main avoidable cost was re- NHC-05 133 3326 4,0 0–58.2 lated to non-recommended diagnostic tests, which may NHC-06 635 3337 19,0 11–19.6 also be attributed to the practice of defensive medicine NHC-07 18 3361 0,5 0–8.8 by practitioners, or to pressure from patients [24]. If we extrapolate these results to the whole of the health sys- Numerator: Number of patients with a certain diagnosis or condition who have received a treatment or procedure that they should not have received; tem in Spain, in terms of direct costs, this amounts to cases of overuse defined by consensus of the expert group within a an annual figure of approximately 615 million euros, given time period. Denominator: The number of patients with a given diagnosis or condition who have been treated in the unit within a given based on the last reported prevalence of 3,026,072 time period people diagnosed with migraine in 2015 [18]. Pozo-Rosich et al. The Journal of Headache and Pain (2020) 21:74 Page 7 of 8 The reduction of these practices with low diagnostic workers, for example watchful waiting [34]. A proper or therapeutic value or of practices that are harmful to and trustful communication, between provider and patients has been achieved in some of the centers par- patients have demonstrated in previous studies to im- ticipating in this study (for example, the use of opiates prove outcomes and lowering the incidence of low value for the treatment of primary headaches and the abuse of practice [25]. analgesics) by incorporating criteria for carrying out ex- This study had some limitations. First, the quality of aminations or for prescribing medication. It is important the information recorded in the clinical records may to notice the high variability among the participating have led to under-identification of cases of overuse. Al- hospitals. This is due that some services, hospitals, or though an algorithm was defined with specification of health areas in Spain can independently generate its own diagnostic and therapeutic codes (numerators and de- measures to reduce low value care. This can be for one nominators) to record the same data in all centers, pos- instance the inability of prescribing opioids for headache sible variability in coding between centers cannot be or the active blocking of CT scans for headaches without ruled out. For ethical reasons, professionals could only alarm signs. This approach in implementation science review the clinical history of patients from their own has been described as PRECEDE, in which there are center, and thus cross-validation of the overuse coding multiple factors, including knowledge, attitudes and be- was not possible. liefs (as predisposing factors), enabling factors, such as active decision support and work flow innovations in Conclusion point-of-care tools as the electronic medical record and In conclusion, the consensus “Do not Do” recommenda- finally reinforcing factors (motivation to sustain behavior tions developed in this study are relevant to daily clinical change) [24]. practice. We found that the incidence of low-value prac- The literature reflects the outcome of interventions tices varied depending on the hospital and the type of based on communication of the benefit of following headache: there was greater variability in drug prescrip- these recommendations, acting on professional attitudes, tion, and more similar results in the overuse of neuroim- knowledge, and behavior, or on changes in patient de- aging. This study provided data on low-value practices mands [25, 26]. For example, the results of the Choosing in headache care, and also illustrated that a reduction of Wisely campaign are inconsistent; while significant re- these low-value practices is both possible and desirable. ductions in some “Do not Do” practices have been achieved, there has been no change in the implementa- tions of others by professionals [27, 28]. These and other Supplementary information Supplementary information accompanies this paper at https://doi.org/10. findings on the level of awareness of these recommenda- 1186/s10194-020-01147-w. tions among professionals [29–31] suggest that more effort is needed to make these “Do not Do” recommen- Additional file 1: Supplemental file 1. Do not Do recommendations dations known (also including campaigns directed at pa- proposed by the expert panel. tients). They also emphasize that it is necessary not only to identify and measure low-value practices, but also to Abbreviations establish how to convey these results to the professionals SIGN: Scottish Intercollegiate Guidelines Network; ICD: International Classification of Diseases; ATC: Anatomical Therapeutic Chemical and specialists involved in headache. These first two Classification System; NSAIDs: Nonsteroidal anti-inflammatory drugs steps are essential for improving the quality of care pro- vided and thereby reduce the cost of delivering such Acknowledgments care. Clinical staff from the participating hospitals collaborated selflessly in the There are also other possible factors that modify the hospital services, making the second phase of this study possible. compliment with “Do not Do” recommendations. Our Authors’ contributions study doesn’t approached other causes related to sociode- Design and conception of the study made by JJM. EI, AT, JJM and JM mographic and personal characteristics of patient and pro- contributed with qualitative expertise methods research. PPZ, ALR, JP, CB, AT, vider as they have been discussed in other studies [32]. and AS contributed as experts and EMR databases for the second phase of the study. JJM and JM contributed with data analysis. All authors equally These recommendations pursue the objective of im- contributed to the writing of the draft. All authors revised and approved the proving quality of healthcare and patient safety, and sim- final draft for its publication. ultaneously lowering low value care. But “Do not Do” recommendations can’t effectively fulfill this aim by its Funding This study has been funded by non-restrictive funding from Allergan Spain. own. It must be accompanied by other policies related to patient safety and quality of care [33]. These measures Availability of data and materials will backup physicians and allow them to provide better The datasets used and/or analyzed during the current study are not available health care. Also, other techniques can help healthcare to ensure data privacy according the Spanish laws. Pozo-Rosich et al. The Journal of Headache and Pain (2020) 21:74 Page 8 of 8 Ethics approval and consent to participate 15. Langer-Gould AM, Anderson WE, Armstrong MJ, Cohen AB, Eccher MA, No patient consent was required since access to medical records was made Iverson DJ, Potrebic SB, Becker A, Larson R, Gedan A, Getchius TS (2013) The by the physicians responsible for their treatment (exemption under the American Academy of Neurology's top five choosing wisely Spanish Science Act). recommendations. Neurology. 81(11):1004–1011 16. Gago-Veiga AB, García-Azorín D, Mas-Sala N, Ordás CM, Ruiz-Piñero M, Torres-Ferrús M et al (2017) Cómo y cuándo derivar un paciente con cefalea Consent for participation primaria y neuralgia craneofacial desde Urgencias y Atención Primaria: Not applicable. recomendaciones del Grupo de Estudio de Cefalea de la Sociedad Española de Neurología. Neurología. https://doi.org/10.1016/j.nrl.2017.08.001 Competing interests 17. Do TP, Remmers A, Schytz HW, Schankin C, Nelson SE, Obermann M et al No Allergan Spain staff participated in the design, execution, data capture, (2019) Red and orange flags for secondary headaches in clinical practice. interpretation of results, and elaboration of conclusions of this study. Neurology 92(3):134–144 Responsibility for the study rested entirely with the authors. 18. Ezpeleta D, Pozo-Rosich P, editores. Guías diagnóstica y terapéuticas de la Sociedad Española de Neurología 2015. Guía oficial de práctica clínica en Author details cefaleas. Madrid: Sociedad Española de Neurología; 2015 1 19. Diener H-C, Holle D, Dresler T, Gaul C (2018) Chronic headache due to Headache Unit, Neurology Department, Vall d’Hebron Hospital, Barcelona, Spain. 2Headache and Neurological Pain Research Group, VHIR, Universitat overuse of analgesics and anti-migraine agents. Dtsch Aerzteblatt Online. Autonoma of Barcelona, Barcelona, Spain. 3Albacete General University https://doi.org/10.3238/arztebl.2018.0365 Hospital, Albacete, Spain. 4ATENEA research group, Foundation for the 20. Cheung V, Amoozegar F, Dilli E (2015) Medication Overuse Headache. Curr Promotion of Health and Biomedical Research, Sant Joan d’Alacant, Spain. Neurol Neurosci Rep 15(1):509 5 University Hospital Marqués de Valdecilla, Santander, Spain. 6University of 21. Becker WJ (2015) Acute Migraine Treatment in Adults. Headache J Head Cantabria and IDIVAL, Santander, Spain. 7Barrio del Pilar Health Center, Face Pain 55(6):778–793 Madrid, Spain. 8University Hospital Infanta Leonor, Madrid, Spain. 9Cádiz 22. 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