Family Practice Vol. 18, No. 5, 524-527
© Oxford University Press 2001
The consultation |
Are headache patients who initiate their referral to a neurologist satisfied with the consultation? A population study of 927 patients—the North Norway Headache Study (NNHS)
Department of Neurology, Tromsø University Hospital and
a Department of Neurology, Nordland Central Hospital, Bodø, University of Tromsø, Norway.
Svein Ivar Bekkelund, Department of Neurology, Tromsø University Hospital, N-9038 Tromsø, Norway.
Bekkelund SI and Salvesen R. Are headache patients who initiate their referral to a neurologist satisfied with the consultation? A population study of 927 patients—the North Norway Headache Study (NNHS). Family Practice 2001; 18: 524–527.
Received 8 December 2000; Revised 30 March 2001; Accepted 4 May 2001.
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Abstract |
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Background. Headache is a common problem in primary care. Although most patients are treated by GPs, many are referred to specialist consultation. Knowledge of how the referrals can be improved is therefore an important issue.
Objectives. The aim of this study was to determine the relationship between self-initiating referral to a neurologist and the patient's satisfaction with the specialist consultation.
Methods. All patients who had been examined by a neurologist for headache within a 2-year period from three neurological centres in North Norway completed a questionnaire.
Results. A total of 1052 patients from a population of 1403 headache patients (75%) returned the questionnaire while 927 patients answered questions about initiating the referral to the specialist. Two hundred and twenty patients (24%) initiated the referral to the neurologist themselves; 52% of those who self-initiated the referral were dissatisfied with the specialist consultation compared with 42% of those referred by the doctor, P = 0.002. Chronic headache, tension-type headache (TTH) and daily use of analgesic drugs were associated with dissatisfaction.
Conclusions. Patients with headache who initiated the referral to a neurologist themselves were less satisfied with the specialist consultation. Selecting referrals containing proper medical information may improve satisfaction in severe headache patients treated in a neurological practice.
Keywords. Headache, neurologist, satisfaction, self-referral.
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Introduction |
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Headache is a common complaint in the general population. Epidemiological studies have shown an annual prevalence of migraine in 6% of men and 15–17% in women.1,2 The 1-year prevalence of tension-type headache (TTH) ranges from 28 to 63% in men and from 34 to 86% in women.1,3 Lost working days and reduced efficiency at work are reported as a common consequence of migraine and TTH.4–6 In a Danish population, one-half of patients with migraine and one-sixth of those with TTH had seen a GP for their headache complaints.7 Another study reports that only a minority of migraine patients see a doctor each year.8 These data indicate that the burden of headache in the general population could be relieved by medical intervention, especially for migraineurs.
Headache is the most common problem in patients referred to neurological care from GPs.9,10 In a previous study in our department, headache represented one-third of all out-patients referred to a neurological consultation.11 Little is known about the patient's influence on the decision to refer to a neurological specialist examination. In the present study, we aimed to determine the relationship between patients' satisfaction with the specialist consultation and whether the patients themselves initiated the referral.
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Method |
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Subjects
The present study is based on data from the North Norway Headache Study (NNHS). Northern Norway comprises the three counties north of the Arctic circle; Nordland, Troms and Finnmark. Two neurological departments (Tromsø and Bodø) serve a total of 460 000 inhabitants living in this area. In addition, at a third hospital (Vefsn) in the southern part of the region, out-patients referred from GPs are seen by a consulting neurologist visiting the hospital regularly. We included all patients referred by GPs to these centres within this region during a 2-year period. Approximately 450 GPs and 15 neurologists working at hospitals are provided in North Norway. Additionally, 12 doctors are trained to become neurologists. No neurologists worked in private centres in the survey period. In Norway, all patients seen by specialists working in public hospitals need to be referred by a GP or other specialists. In order to evaluate the motivation for initiating the referral, we therefore asked the patients to complete a questionnaire. Most private clinics welcome self-referring patients. The lack of private neurological clinics in northern Norway therefore provide a representative population of patients for this study.
From hospital databases, we registered 1403 consecutive patients with a major diagnosis of headache from 1 July 1996 to 30 June 1998 (2 years). The survey was undertaken shortly after this period. We mailed a questionnaire to all these patients, asking inter alia for characteristics of their headaches including the presence of accompanying symptoms of migraine and TTH as previously described by the International Headache Society (IHS).12 Drug-associated headache was diagnosed when analgesics were used on a daily basis, and the best headache relief was obtained from a strong analgesic. Patients with mixed migraine and TTH had at least two main symptoms from each group according to the IHS criteria.12
A total of 1052 persons (75%) returned the questionnaire after one reminder. Altogether, 927 answered the questions concerning referral initiation to a neurologist and the degree of satisfaction with the neurologist. The patients answered the following questions: (i) "Who suggested that you should see a neurologist?" Answer options included ‘yourself', ‘the GP', ‘the family' and ‘other health personnel'. (ii) "Are you satisfied with the way the neurologist treated your headache?" The patients answered ‘yes' or ‘no'. We also asked for age, sex, duration of headache and education level (number of years at school). The number of years at school was defined as a marker of socioeconomic status in the study.
Analysis
Results are calculated using Stat View Graphics (Macintosh) and presented as the mean ± 2 standard deviations (SDs). We used student's t-test to compare continuous variables, and chi-square test for categorical data between subgroups of patients. Due to the possibility of reporting false-positive results (type 1 error) by performing multiple analysis in the study, we adjusted the P-value by using Bonferroni's correction. We therefore regarded P < 0.008 as the level of statistical significance in this study.
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Results |
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Social and clinical characteristics are listed in Table 1
. From a total of 927 referrals to a neurological specialist centre, 221 patients (24%), 74 men (25%) and 147 women (23%), initiated the referral themselves. A majority of the patients (n = 665) reported that the GP initiated the referral. The other referrals were initiated by ‘other members of the family' (n = 18) and ‘other health personnel' (n = 23). The self-initiating patients had a longer duration of headache compared with the subgroup of patients where the decision for referral was made solely by the doctor (Table 2). A significantly higher proportion of those with TTH were self-initiators, whereas migraine, and mixed TTH and migraine were equally distributed in both groups (Table 3). A similar proportion of patients with unclassified headache could be registered in the two groups (Table 3). Of the self-initiators, 110/210 (52%) were dissatisfied with the specialist consultation compared with 300/665 (42%) of those who had a doctor-initiated referral.
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In the self-initiating group, 84 (40%) reported presence of headache more often than 3 days per week (defined as chronic headache) compared with 211 (32%) in the other group, P = 0.01. Additionally, those who reported daily use of strong analgesic drugs more often initiated the referral to the neurological consultation, but this was not significant (43/221 patients versus 86/665 patients), P = 0.01.
Among those who reported the presence of other disorders, 27 had heart disease, 25 had suffered a stroke and one had multiple sclerosis. No other well-defined chronic disorders were reported. No statistical change in the outcome could be detected after controlling for the presence of concomitant disorders.
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Discussion |
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The high prevalence of headache in the general population is reflected, although only partly, in the large number of headache patients seen in both general and neurological practice.1,2,13,14 Accordingly, in the University Hospital of Tromsø, which is one of the two northernmost hospitals with a department of neurology, we previously have reported that headache-related problems were the cause of referral in about a third of all out-patients referred to the department.11 Headache patients therefore form a substantial part of the workload of the neurologist. Appropriate service for these patients is therefore important not only for the individual patient, but also to provide the optimal priority for different groups of patients referred from general practice. The main purpose of the present work was to analyse how the process of referring out-patients to neurologists determines patient satisfaction. We set out to test the hypothesis that patients who self-initiated the referral to a specialist were more satisfied with the specialist consultation than other headache patients. The finding that a significantly higher proportion of those who self-initiated the referral were dissatisfied with the neurological consultations opposes this hypothesis.
In a recent study in migraine patients, the patients reported satisfaction with the secondary neurological care and that the treatment prescribed by the neurologist decreased the frequency and duration of headaches.15 When neurologists were asked about their experience with headache, the majority of them answered that they justified their experience by examining a large number of headache patients in the practice according to a previous study.13 To our knowledge, no previous study trying to evaluate the consequence of the patient's own decision to initiate referral to a neurological consultation has been reported. Our results show that an improved service to headache patients might be achieved by better co-operation between GPs and neurologists. According to a previous study, the relationship between a patient's satisfaction with the neurologist and time spent on the consultation as reported in migraineurs argues for the need for better education about headache syndromes among GPs.15 In a study analysing the problem of non-attendance at an out-patient clinic, the authors concluded that patients who did not get the opportunity to discuss their health problem thoroughly with the GP attended a planned specialist consultation less frequently than others.16 Whether time spent on the patient is too short, or GPs have too little knowledge of or interest in headache syndromes remain to be answered. Many factors may influence the decision to refer patients to secondary care, however. In a recent Finish study, the authors concluded that referrals did not occur randomly as expected since referrals for headaches showed a peak on Tuesdays.17 In this retrospective study, we are not able to identify causes of dissatisfaction. Also, we were unable to evaluate dissatisfaction over time. This may represent a confounder in the study.
The problem of selecting patients for secondary health care is complicated by the fact that only a minority of headache patients with migraine and TTH actually see a doctor.8 Especially in migraine, impaired health-related quality of life and co-morbid depression as well as other concomitant disorders have been reported recently by several authors.18,19 These findings indicate a potential for improved medical care in migraine patients. In our study, a higher proportion of both migraine and TTH patients reported that they were dissatisfied with the specialist consultation. These findings indicate that other features of headache rather than specific syndromes such as migraine and TTH may contribute to dissatisfaction.
In an earlier study, women with a long history of migraine and associated psychiatric morbidity, and who themselves initiated the referral, reported less satisfaction with the specialist consultation at the neurological clinic.20 The presence of concomitant chronic disease as reported by the questionnaire did not affect the main outcome in our study. However, we did not perform validated investigation of co-morbid conditions such as depression or musculoskeletal complaints. A further analysis of variables associated with headache problems should be carried out.
This report demonstrates less satisfaction with specialist consultations in headache patients who initiated the referral themselves. Selecting patients to be referred to secondary neurological care should therefore be based mainly on medical grounds.
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References |
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