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Title: Quality Indicators of Headache Evaluation and Treatment in U.S. Emergency Department Patients Authors: 1. John W. Hafner, MD FACEP*^+ 2. James R. Hubler, MD JD FACEP FAAEM*^+ 3. Jennifer Roberts, DO*^ 4. Daniel J. Sullivan, MD JD FACEP$+ Affiliations: *Department of Surgery, University of Illinois College of Medicine at Peoria ^OSF Saint Francis Medical Center, Peoria IL $ Department of Emergency Medicine, Cook County Hospital/Rush Medical College, Chicago, Illinois + The Sullivan Group, Inc., Risk Management Consulting Introduction: Patients with a chief complaint of non-traumatic headache (HA) represented 2.7% of emergency department (ED) visits in 2005 (3.1 million visits). Although the majority of these patients represent benign etiologies, some have serious and life-threatening conditions. Distinguishing patients that require urgent diagnostic studies and treatment requires the application of accepted evidence-based strategies and measurable indicators of quality care. These strategies and indicators are useful in understand patterns of care delivered and improving patient outcomes. This study describes specific quality identifiers of a 2 year national ED quality assessment for HA patients. Methods: An explicit review of the audit chart database from the Sullivan Group’s Emergency Medicine Risk Initiative (EMRI) was conducted for ED visits occurring between 1/1/2006 and 03/19/2008 representing 52 separate EDs nationwide. The EMRI is a national ED chart review and quality assessment product designed to review provider compliance with EM quality indicators in core chief complaint categories. ED charts are reviewed by trained individual hospital staff using a template web-based system and collated into a central national data repository. Records were analyzed if patient, provider and hospital abstracted information were complete for the ED visit. Quality scores were derived from the ratio of documented-to-total quality indicators (21 possible indicators). Pearson’s chi square and one-way ANOVA was used for bivariant analysis with p < 0.05 considered statistically significant. Binary logistic regression analysis was performed to determine the associations between visit characteristics and quality scores above and below the mean. Results: During the study period 2494 ED visits were included representing 52 individual EDs. HA patients were mostly female (75.7%) and eventually discharged from the ED (95.8%). Primary medical providers for the ED visits were medical physicians (MD) (80.4% of visits), osteopathic physicians (DO) (13.8%), nurse practitioners (NP) (1.6%) and physician assistants (PA) (4.3%). Patients rated their pain severity most often using a 10 point scale (87.9%), with most reporting initial scores of 8, 9, or 10 (60.8%). Most providers performed a detailed neurological exam (76.8%) and administered pain medication (83.9% overall; 67.6% parenteral medications). Forty-six percent of HA patients had a head computed tomography (CT) performed, with 7 SAH (0.3%) and 3 intracranial hemorrhage (0.1%) diagnoses reported. Of patients with negative head CT imaging, only 27% received a follow-up lumbar puncture (LP) or documented an informed refusal of the LP. Factors associated with a higher than mean overall quality score were non-university teaching hospitals, use of an ED discharge instructions program, a lack of resident physicians, physician providers (MD and DO), and trauma level 3 facilities. Conclusions: In a national sample of ED HA patients, the 21 quality indicators, such as LP following a negative CT and others, varied widely with provider type and facility characteristics. The majority of HA patients were discharged after receiving parenteral medication, but a minority had serious pathology.