Saturday, October 6 th Handouts Afternoon Concurrent Sessions. Strategies for Headache Management

Transcription

1 Second Annual CME Meeting Southern Headache Society Challenges In Headache Medicine Saturday, October 6 th Handouts Afternoon Concurrent Sessions Strategies for Headache Management 2:15 PM Case Studies from Carolina Headache Institute; Alan Finkel, MD Alan Finkel, MD 3:30 PM Creating an Office Rescue Center Brian Loftus, MD

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7 October 6, 2012 Creating An Office Rescue Center Brian D. Loftus, MD Bellaire Neurology BetterQOL, Inc Disclosures - Relevant for this subject BetterQOL, Inc - co-owner owner and developer of iheadache. Examples of electronic diaries use iheadache Allergan - speaker/consultant - OnabotulinumtoxinA for Chronic migraine Off label discussions Why Office Rescue Center? The only FDA approved treatment for chronic migraine is onabotulinumtoxina. All other therapies (acute and preventative) for this indication are off label. There is no FDA approved treatment for migraine status. There is no FDA approved treatment for NDPH. Improve patient quality of life Improve physician quality of life Improve practice economics Patient Quality of Life Patient alternatives to rescue room: ER Urgent Care Suffering Physician Quality of Life Unique service - premium practice Immediate improvement in patients Improved practice economics 1

8 October 6, 2012 Physician QOL other ideas Walk to work Therapy dog Physician QOL other ideas Self scoring headache diaries Repeated no-show fines Firing patients 84 year old white male first seen 4/ for daily headaches since age 12 or so. Headaches Tension Type No treatment needed until headaches worsened in mid 30s. Treated for the 60s to mid-70s with valium, narcotics during which time he was CFO of Fortune 100 company Told psych by multiple neurologist in 1960s Periactin helped 13 years ( ) 1989) headaches returned - daily - tx by multiple MDs including years with Dr. Ninan Mathew (1990s) Failed amitriptylene, celexa, topiramate, propranolol SamE helpful until 2003 Severe headaches returned - 5 months of relief with duloxetine Current Meds include (neuro active meds only) Diazepam Cymbalta Namenda (Alzh) Dalmane Hydrocodone (3-4 days weekly) Demerol (less than weekly) CoQ10 Medical illnesses (partial list) CAD with hx CABG Prostate CA - hx radical prostatectomy High Cholesterol Exam Frail appearing, elderly mail, otherwise normal neuro exam some ataxia 2

9 October 6, 2012 DX NDPH or Chronic Tension Type Headache Possible Medication Overuse Headache 1st thought - age 84 - don t kill him Multiple Prior workups No FDA approved treatments Cause of NDPH - Maybe TNF alpha (Rozen T, Swidan SZ. Headache, 2007 Jul-Aug;47(7): ) Haloperidol Lowers TNF alpha at least in serum in RA patients Safe if normal QTc - check EKG Gave 5 mg in 500 cc NS over 30 minutes (typical reported migraine status dosing) H/A free for 2 plus months Repeats as needed 3/3/2010 7/5/ /2/2010 8/31/2011 9/20/ /3/2011 3/27/12 Migraine Status Chronic Migraine Most common use of headache rescue room Goal is to control acute headaches and help gain control while waiting for prevention to work Most commonly used cocktail Metoclopramide 10 mg IVP Dihydroergotamine 1 mg IVP over 2 or more minutes IV Magnesium 1 gram in 50 cc IVP over 5-6 minutes Migraine Status Chronic Migraine Ketorolac for those that do not respond Ondansetron when metoclopramide unavailable Haloperidol for those that do not respond Repeated IV magnesium as prevention for short term relief or after multiple preventative failures IV fluids for dehydrated patients Rescue Room Use for HA Use of Rescue Room Over Time IV Push IV infuse st 1/2 3

10 October 6, 2012 Rescue Room 2011 for HA 847 individual patient IV push treatments for migraine About 1/2 of these are IV magnesium alone for CDH 86 IV infusions including IV fluids for severe headaches with nausea/vomiting Need one extra MA for IV treatments in 2011 (3 in practice) Income from injections covers cost of 2 MAs Rescue Room What You Need Chair Personnel who can give IV medication Proper Billing Proper Collection Billing for Rescue Room Billing for Rescue Room IV Push medication IV Push add on IV infusion medication (takes 15 min or longer) IV Hydration (0-90 minutes) IV Hydration (additional 60 minutes) Appropriate J codes (medications, IV fluids, but not flush) Add -25 modifier to office visit Know what to collect at time of service Get IV injection codes in office both with and without office visit - may patients have deductibles and copays for this service Outpatient Financials If you do things right, your outpatient financials can look like this... Patient AR total is <4% of insurance AR. Insurance AR > 30 days - about 5% Days in AR Bad debt < 1% Questions? 4