By Deborah Brauser
Medscape
April 15, 2010 — Uninsured patients with moderate to severe migraine are twice as likely to not receive standard care, defined as abortive and prophylactic therapy, than those with private health insurance, according to results from a national survey study by researchers from Harvard Medical School.
“Adding site of care to [our] regression model suggested that 1 mechanism for this discrepancy was the reliance of the uninsured on EDs [emergency departments], a site where standard migraine care is often omitted,” write the study authors.
In addition, they found that migraine patients with Medicaid were 50% more likely to receive substandard treatment than those with private insurance, suggesting that “access to some forms of insurance is not the same as access to adequate care.”
“The tragedy is that we know how to treat this disabling condition, but because they are uninsured or inadequately insured, millions of Americans suffer needlessly,” said senior study author Rachel Nardin, MD, assistant professor of neurology at Harvard Medical School and chief of neurology at the Cambridge Health Alliance in Massachusetts, in a release.
“Neurologists as well as all doctors need to advocate for healthcare reforms that provide clear access and appropriate care for everyone with migraine,” Dr. Nardin added to Medscape Neurology. “There is still a lot of work to be done to make our health system better for this group of patients.”
This study is published in the April 13 issue of Neurology.
Migraines Cost Employers Billions
Migraine headaches affect 18% of women and 6% of men in the United States, cause a loss of 4 to 6 workdays each year, and cost employers as much as $17 billion annually, according to the study. They add that approximately 15% of Americans are currently uninsured.
The standard of care guidelines for moderate to severe migraine from the American Academy of Neurology (AAN) recommend “a triptan or dihydroergotamine (DHE) as first line therapy, based on their superiority to nonsteroidal anti-inflammatory drugs (NSAIDS) and older migraine-specific medications such as ergotamine/caffeine,” report the study authors.
The AAN also recommends prophylactic therapy for these patients, especially if their migraines are frequent, do not respond completely to the abortive therapy, or are disabling.
For this study, the investigators sought to evaluate whether insurance status was associated with prescription of the AAN’s recommended standard migraine therapy, defined as a triptan or DHE plus 1 of the prophylactic medications listed in the AAN’s latest practice guidelines, if needed. NSAIDs were excluded as prophylactic therapy in this study.
Data from the National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey were assessed for 6814 patients and their 68.6 million visits from 1997-2007 due to migraine. These surveys, conducted by the National Center for Health Statistics, report patient visits to physicians’ offices, hospital outpatient departments, and EDs.
Less Medication Prescribed for Uninsured
Results showed that “after controlling for age, gender, race/ethnicity, geographic location, and year, [migraineurs] with no insurance or Medicaid were significantly less likely than the privately insured to receive abortive…and prophylactic therapy,” report the study authors.
Table. Migraine Therapy by Insurance Status
Insurance Status OR (95% CI)
Abortive therapy
No Insurance 2.0 (1.3 – 3.0)
Medicaid 1.6 (1.1 – 2.3)
Prophylactic therapy
No insurance 2.0 (1.3 – 2.9)
Medicaid 1.5 (1.0 – 2.1)
CI = confidence interval; OR = odds ratio for failure to receive medication
A total of 7.9% of the 68.6 million migraine visits were by those without insurance, and 34.1% of these patients received all of their migraine care at EDs compared with 13.2% of those with private insurance.
Controlling for site of care showed that the odds ratio (OR) for not receiving standard care was significantly greater for ED visits vs visits to physicians’ offices (OR, 4.8 vs 1.0 for abortive therapy; OR, 8.7 vs 1.0 for prophylactic therapy). There was also a significant trend for substandard care in EDs for the uninsured.
Finally, patients older than 65 years were associated with failure to receive abortive therapies (OR, 3.8), “perhaps because contraindications to triptans are common in the elderly,” the study authors note, whereas Hispanics (OR, 2.1) and those in the Midwest (OR, 1.5) were less likely to receive prophylactic therapy.
Study limitations include that the treating clinician made migraine diagnoses without independent verification, no data existed on migration durations, and the definition of prophylactic medication was broad and may have been used for indications other than migraine.
Our study strongly suggests that absent or inadequate insurance and site of care are the major drivers for substandard migraine care.
“Overall, our study strongly suggests that absent or inadequate insurance and site of care are the major drivers for substandard migraine care,” said Dr. Nardin.
“While the results for the noninsured weren’t unexpected, what was a little more surprising was what we found if you had Medicaid, which is one of the main ways that Americans are going to get insurance in the new health bill,” she noted. “Many, many private doctors don’t take Medicaid insurance because it’s used poorly. So we’re basically forcing these patients to go to emergency rooms, which is just not good for them and not good for our health system overall.
“A study like ours is a good reminder to doctors that when we want to take care of patients with migraine, it’s just as important to think about the larger health system as it is to understand what the best drugs are,” concluded Dr. Nardin. “If these patients can’t get in to see us, we can’t treat this neurologic condition that causes a lot of personal pain and suffering as well as a huge cost to society.”
All Patients With Migraine Deserve to Be Treated
“These findings were not surprising, and I could have predicted the results,” said Stephen Silberstein, MD, professor of neurology and director of the headache clinic at Thomas Jefferson University in Philadelphia, Pennsylvania, past president of the American Headache Society, and head of the Headache Research Group for the World Federation of Neurology, during an interview with Medscape Neurology.
“If you have no insurance or bad insurance and don’t see a doctor [for this disorder], you get second-rate care. [The investigators] proved what we all believe,” said Dr. Silberstein, who was not associated with this study.
“Migraine is one of the most major, disabling disorders out there, and we currently have a standard of care,” he added. “Maybe Medicaid carriers should be forced to follow the same standard of care or be punished. In fact, we’re working on that now. We’re trying to work on standards of care for migraines for insurance companies.”
When asked if EDs should be forced to follow the same standard of care guidelines, Dr. Silberstein said that that’s a different scenario. “It’s very different when someone comes into the [ED] with a severe headache. Basically, they see these patients 1 time, and it’s not safe to start an acute and preventative program without follow-up.”
“I think the fundamental issue is not that the [ED] is doing something wrong, it’s that the patients have to go there for acute care. That’s not the place to have headache treated.”
“I think it’s important for neurologists to realize that migraine is underdiagnosed and undertreated,” summarized Dr. Silberstein. “If a patient has a disabling headache, we should th
ink migraine and treat it with the best medicines available. Overall, I just think we need to demand that all patients with disabling pain disorders get respect and get appropriately treated.”
Dr. Nardin reports having received honoraria for lectures not funded by industry, serves on the editorial board of Muscle & Nerve, and has received royalties from publications in UpToDate. Disclosures for the coauthors are listed in the article. Dr. Silberstein has disclosed no relevant financial relationships.
Neurology. 2010;74:1178-1183.
http://www.medscape.com/viewarticle/720295