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Toward better care: Rethinking practice patterns in neurology

 

Professional societies frequently issue clinical practice guidelines in an effort to reduce practice variability and improve care. Surveys, however, have found that generalists and specialist physicians alike prefer to rely on their own experience and the nuances presented by each patient.

“Guidelines try to establish national standards where there’s varying opinions, based on what everyone can agree,” says Scott L. Pomeroy, MD, PhD, neurologist in chief at Boston Children’s Hospital. “As a result, they tend not to be very specific in their recommendations. Once a parameter is promulgated by a society, people may or may not want to follow it.”

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As Pomeroy and colleagues wrote recently in the Journal of Child Neurology[C1] (online April 10), surprisingly few guidelines are supported by clinical trial evidence, and guidelines don’t always measurably improve patient outcomes (pain assessment and treatment of seizures in the emergency department being some notable exceptions).

Two recent developments promise to have much more impact on the quality of care. One is the family-centered medical home model. Neurology was among the first Boston Children’s departments to embrace active collaboration with their primary care colleagues. The other development is the launch of standardized clinical assessment and management plans, or SCAMPs. Recently featured in Health Affairs,[VCJ2] SCAMPs are quality improvement models in which care plans can be continually updated based on clinical experience.

Shared, integrated care

In 2009, a group of specialists from Boston Children's Hospital, including Pomeroy and Richard C. Antonelli, MD, MS, a primary care pediatrician and medical director of integrated care, met with primary care providers from Harvard Vanguard Medical Associates/Atrius Health to develop a collaborative care strategy for one of the most common of neurologic diagnoses: headache.

While the majority of pediatric headaches are benign and manageable in the primary care setting, PCPs often have felt the need to reassure families by referring children for imaging tests and specialist appointments that aren’t always needed. To help the collaborative care model succeed, family advisors were partners in designing the Headache Collaborative.

The pilot, involving Boston Children’s and six primary care practices, included educational sessions for PCPs covering headache epidemiology, evaluation and treatment, offered by Anna Minster, MD, of Boston Children’s Department of Neurology. Tools and workflows were jointly developed by families, PCPs and neurologists to support diagnosis and management of children with headaches. PCPs were given access to rapid advice from subspecialists at Boston Children’s—often within 30 minutes—and patients kept headache diaries with pain scales that could be viewed by the entire team.   

“Working jointly with PCPs, we took evidence-based guidelines and made them more robust for decision-making,” Antonelli explains. “The goal was to deliver actionable, timely information when and where it was needed—which permits patients to get high quality care in the highest-value setting and in a timely fashion.”

A survey was conducted after the pilot, and of the 22 PCPs who responded, 95 percent felt the program had increased their knowledge of managing headaches, and 85 percent felt it had improved care. Families reported feeling less anxious. Early results showed a shift of follow-up care from the Neurology clinic at Boston Children’s to the primary care medical home.

Reduced utilization

MRIIn another study, Boston Children’s neurologist David Urion, MD, demonstrates that co-located headache care can significantly reduce emergency department and MRI utilization with no adverse effects on outcome. He compared two urban community health center populations: one using co-located care, the other using traditional hospital-based consultations. Over the course of five years, the two groups had roughly the same number of headache cases: 173 in the co-located care group and 169 in the traditional-care group. ED visits differed dramatically, however: 17 in the co-located cohort, 306 in the traditional-care cohort. Only five MRI studies were ordered for the co-located group, all from ED visits, versus 102 in the traditional-care group: 89 generated by ED visits, 10 by neurology providers and 3 by primary care providers. No MRI study in either group had significant pathological findings.

Shared care models are spreading and increasing in scope. ThePediatric Physicians' Organization at Children's (PPOC) and the South Shore Physician Hospital Organization have joined the Headache Collaborative, and a second shared care program for attention-deficit hyperactivity disorder has been launched with the PPOC and the Northeast Physician Hospital Organization at Beverly Hospital.

Although the programs focus on specific diagnoses, the relationships they’ve created have led to collaborations across the spectrum of neurologic disorders. “I anticipate that as new finance models continue to evolve, collaborative care models will flourish,” says Antonelli.

Iterative improvement

The SCAMP program is a quality improvement platform that starts with current clinical guidelines, if they exist, but allows and even encourages clinicians to diverge from them as they manage individual patients. If they do, they must document their rationale, and the results of their decisions are tracked and used to update the guidelines as needed.

“The reasons that doctors choose not to follow a SCAMP are extremely important information and fuel improvement at a rapid clip,” says SCAMP co-developer James Lock, MD cardiologist in chief at Boston Children’s.

SCAMPs in Pediatric Neurology/Neurosurgery

Actively Enrolling

  • Agitation/aggression
  • Outpatient concussion management
  • Somatoform disorders

In development

  • Craniotomy
  • Ketogenic diet (epilepsy)
  • Syncope

Under consideration

  • ADHD
  • Autism

Although the SCAMP platform began in the Cardiovascular Program at Boston Children’s, it is now being implemented throughout and beyond the hospital, and several SCAMPs have been launched in pediatric neurology/neurosurgery (see table). Through the nonprofitInstitute for Relevant Clinical Data Analytics, participating hospitals and provider groups can pool pertinent clinical data to further fuel improvement.

Both the shared care and SCAMP initiatives have a huge potential to reduce costs and improve patient outcomes by bringing in multiple perspectives. “Collaborative work enables conversations around shared accountability and really facilitates the ability to design and implement transformational models of care,” Antonelli says.

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Sports Conference

Tenth Annual Sports-Related Conference on Concussion and Spine Injury

Friday, May 17, 2013

If you assess or care for athletes with concussion or spinal injuries, join us for this multidisciplinary conference. Hear the best practices of foremost experts in neurology, neurosurgery, sports medicine, athletic training, nursing, neuropsychology and more—plus remarks by former New England Patriots player Ted Johnson. Talks will be followed by in-depth breakout sessions. CME credits are available.

 

 

 

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Location:
Joseph B. Martin Conference Center at the Harvard Medical School
77 Avenue Louis Pasteur, Boston, MA 02115

Course directors:

  • Mark R. Proctor, MD, Director, Brain Injury Center, Boston Children’s Hospital
  • William Meehan, MD, Director, Sports Concussion Clinic, Boston Children’s Hospital
  • Alex Taylor, PsyD, Director, Neuropsychology, Brain Injury Center, Boston Children’s Hospital
  • Robert Cantu, MD, Chief, Neurosurgery, Emerson Hospital; Senior Advisor, Brain Injury Center, Boston Children’s Hospital

Click here to download the conference brochure and CME information.
Click here to register online.

Read below for highlights of last year’s conference:

The Ninth Annual Sports-Related Conference on Concussion and Spine Injury

Recovery has many factors, not just rest

According to Alex M. Taylor, PsyD, clinical neuropsychologist at Boston Children’s Hospital, proper rest after a concussion is essential, but it’s not the only factor affecting recovery; it’s also influenced by the athletes themselves. Past concussions, exertion post-concussion, learning disabilities, even psychological factors can make recovery time longer. The Centers for Disease Control and Prevention has an excellent guide on concussions for schools.

All neck muscles are not created equal

Taylor also noted that girls show more cognitive problems after concussion than boys, perhaps because their necks aren’t as strong. Robert C. Cantu, MD, from Emerson Hospital and Ann McKee, MD, from New England VA Medical Center recommend, “Strengthen your neck…hope you’ve got the right genetics.”

 

 

Headaches aren’t the only indicator of concussion

While headaches are the most common concussion symptom, they don’t always correlate with the severity of the concussion. Normal CT and MRI findings prompted Ellen Grant, MD, Director of Fetal and Neonatal Neuroimaging Research at Boston Children’s Hospital, to develop advanced imaging techniques to detect subtle concussion effects that may contribute to fatigue, inattention and memory problems.

 

 

Why young athletes shouldn’t just “tough it out” 

After a sports-related concussion, 20 to 30 percent of athletes report being symptom-free before their brain studies show that function is actually back to normal. NFL player Ted Johnson and NHL player Dan LaCouture spoke of how the culture of their respective sports increased the pressure to play after concussions.



Affecting emotion as well as memory

Once believed to just cause short-term memory problems, concussions are now linked to irritability, aggressiveness, paranoia, dementia, depression, even suicide. Many former contact-sport athletes have experienced these difficulties. Ann McKee, MD, showed slides of the atrophied brains of deceased former NFL players with a brain disorder called chronic traumatic encephalopathy (CTE.)

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Training

We offer several residency, internship and fellowship programs for practitioners seeking careers in the pediatric neuroscience community.

Neurosurgeon Benjamin Warf, MD (right), oversees a training program for pediatric neurosurgeons in Uganda. 

 

 

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Continuing Medical Education (CME)

Throughout the year, we offer several Continuing Medical Education courses. Upcoming events are listed below. To receive alerts about new courses, please send an email with "CME Notifications" in the subject line to neuroscience@childrens.harvard.edu.

The Michael J. Bresnan Course, run by course director David K. Urion, MD, will run from September 10 - 14.  The week long course offers updates on pediatric neurology to neurologists, pediatricians, nurses and nurse practitioners.

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For more information on the course please contact Stephanie Barros at stephanie.barros@childrens.harvard.edu.
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For up to the minute updates, debates and course information "Like" our Facebook page!

Updates in Pediatric Sleep Disorders is a 2 day course run by Directors Sanjeev Kothare, MD and Umakanth Khatwa, MD. The major objective of this course is to provide a comprehensive overview of the common pediatric sleep disorders. It is aimed towards pediatricians and other subspecialists treating children and young adults. It will also include a comprehensive review of basic sleep physiology and the circadian sleep-cycle. Specific areas of emphasis will include sleep apnea, nocturnal awakenings in childhood, difficulty with initiating and maintaining sleep and promoting good sleep hygiene in adolescents. It will review current standards of practice, and give cutting edge updates about recent developments in the diagnosis and treatment of pediatric sleep disorders. For more information please contact stephanie.barros@childrens.harvard.edu.

Additional courses and events are listed on the hospital’s main CME calendar.

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The future of pediatrics will be forged by thinking differently, breaking paradigms and joining together in a shared vision of tackling the toughest challenges before us.”
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