A Nursing Intervention to Enhance Wellness and Patient Adherence to Therapy for Headache - NEWPATH Study
Submitted by Kimberly Brigden BScN RN
Objective: To ascertain whether the implementation of a nurse-initiated phone call between initial and follow-up Headache appointments has the potential to enhance wellness and treatment plan adherence by reducing common barriers experienced by patients with chronic Headache.
Methods: Between October-December 2017, a follow-up phone call was placed by the Registered Nurse to all new patients, at the approximate midpoint between the patientâ€™s initial appointment and their first scheduled follow up appointment. The Registered Nurse reviewed each patientâ€™s individual treatment plan with the patient and addressed any concerns expressed.
Results: A total of 111 phone calls were placed, 48% of which successfully reached the patient. The patients ranged in age from 6 â€“ 80, with a mean age of 35. Approximately 76% of the sample was females and 24% males. Of the patients reached, 67% identified that they were experiencing barriers adhering to their prescribed treatment plan. All issues were resolved during the phone call either by the Registered Nurse alone (79%) or by the Registered Nurse in collaboration with the neurologist (21%). All the patients reported finding the phone call helpful in their overall care and confidence in their ability to adhere to the prescribed treatment plan.
Conclusions: The implementation of this nursing initiative has the potential to reduce overall headache burden and support chronic disease self-management principles. It reinforces an individualized treatment model of care to reduce barriers to adherence to therapy plans and promotes self-care among Headache patients.
Migraine represents the second leading cause of years lost to disability according to the Global Burden of Disease Study conducted in 2016.1 The large global prevalence of migraine is accompanied by significant barriers to treatment and poor patient outcomes.2,3 The patient-provider partnership has been demonstrated to be a vital component of a successful migraine management plan.3 In addition, chronic disease management is often the leading contributor to healthcare spending,4 therefore making it vital to develop and refine interventions to assist these populations. Nurses play an important role in educating and counselling patients regarding effective self-management approaches.2 It has previously been shown that a brief nursing intervention combined with phone support improves headache associated disability and self-efficacy.4 Using the principles of chronic disease management,5 the nursing and medical staff at an academic Headache Centre developed an initiative to enhance patient wellness as well as adherence to treatment; with the additional goal of strengthening the patient-provider partnership to promote patient engagement in self-care. The initiative included a follow-up nursing phone call designed to help new patients navigate their prescribed treatment plan and address barriers they were encountering, along with reinforcing a patientâ€™s internal locus of control and self-efficacy, in their chronic disease management.
Patients in the study were Englishâ€speaking children, adolescents and adults, aged 6 - 80 years, referred to the Centre for Headache at the University of Toronto for Headache consultation and had already undergone an initial consultation. A phone call was initiated by the Centre for Headache Registered Nurse (RN), at the approximate midpoint between a patientâ€™s initial neurological appointment and their first scheduled follow-up appointment in the Headache clinic. This follow-up call addressed a series of questions reviewing treatment adherence, medication side effects, supplement/vitamin use and lifestyle management techniques, shown to be effective in a previously published study.3 Medication adjustment was not addressed during the call, unless deemed urgent or potentially serious. The study utilized total population sampling technique of two neurologistsâ€™ schedules from the Headache clinic, to identify initial patient appointments from October 6, 2017 to December 12, 2017. The first neurologist (A) focused primarily on the adultâ€™s aged 30 and older, while the second (B) focused on the pediatric & young adult population, aged 30 and younger. Of the patients selected, 55 came from neurologist A and 56 patients from neurologist B. All initial patients received a follow-up phone call.
No a priori statistical power calculation was conducted, and collected quantitative data was analyzed using simple descriptive statistics. The study was submitted to the Womenâ€™s College Hospital REB who performed an administrative review (REB # 2018-0036-E) after which we were granted an exception.
During the study period 111 patients received a nurse-initiated phone call, approximately three weeks following their initial appointment. Approximately 76% of the sample were females and 24% males, with a mean age of 35. The patients ranged in age from 6 â€“ 80. Of the 111 phone calls placed, 48% successfully reached the patient, resulting in a phone call lasting approximately five to ten minutes in length. Approximately 10% of the patients were unreachable due to incorrect phone number or limited voicemail capabilities and 42% were left a voicemail.
The phone visit was completed with 58% of the patients from neurologist A, versus 42% of the patients from neurologist B. One patient from neurologist A misunderstood that the visit would be conducted via a phone call and arrived in person to the clinic.
For the patients who completed the phone call with the RN, 33% did not identify any difficulties but were very appreciative of the opportunity to review and reinforce treatment strategies. Approximately 67% identified that they were experiencing difficulties with their prescribed treatment plan that could be managed by the RN and neurologist. All of the issues identified during the call were resolved, with 79% being resolved by the RN alone and 21% resolved by the RN in collaboration with the neurologist.
When asked about the satisfaction of the phone call, 100% of patients found the nurse-initiated phone call to be beneficial for their overall care and confidence in their ability to adhere to the prescribed treatment plan.
The nursing intervention developed and implemented in a population of patients experiencing chronic Headache, demonstrated effectiveness, as all identified barriers to treatment were resolved during the phone call interaction. In addressing the barriers faced, and by encouraging lifestyle modification, patients were empowered to better manage their headaches.
The follow-up call identified and resolved all patient barriers that would otherwise have been unresolved until the patient was next seen in follow-up, which could have been 6-8 weeks later. Thus, this suggests that during the first follow-up appointment, an ineffective treatment option would be identified sooner, since poor adherence to therapy would not have been a factor. Improved patient outcomes as a result of optimal Headache management might be achieved in fewer visits with the neurologist.
With all of the patients reached reporting that the phone call was beneficial, regardless of identified barriers, the significant impact of the nursing intervention is clear. Patients who did not describe any concerns or barriers were still able to benefit from the initiative, as the RN was able to review their individualized treatment plan in depth and reinforce their good adherence to therapy. The value of the RN placing a follow up call after the initial neurological consultation demonstrates it to be an effective Headache management support tool for patients with the potential to significantly impact patient outcomes.
The success of this intervention within the Headache population supports the potential generalizability to many other chronic diseases. The capability of the initiative to lead to more productive health care follow ups and fewer overall neurologist visits implies the reduction of unnecessary healthcare resource utilization in chronic disease management.
One clear observation was that there were significantly fewer successful phone call interactions between the RN and the patients from neurologist B, which may suggest that this intervention is not as effective in this younger age group.
The major limitation of the study was that the phone call was scheduled during regular business hours, therefore many patients who were working or in school may have been unable to participate. This may also speak to the patients who were left a voicemail and did not call back. Additionally, a small sample size and modest collection of demographical and Headache history data may limit generalization to other Headache and chronic disease patient populations.
Future projects may include the collection of migraine disability index scores pre and post phone call intervention, to evaluate migraine treatment outcomes and quantify the productivity of follow up appointments. Along with the collection of patient demographics the researcher might be better able to evaluate effectiveness across population groups and pinpoint the most effective way to implement the telephone encounter, thereby allowing for generalizability to other Headache centres and all chronic disease populations.
The implementation of this nursing initiative has the potential to reduce overall Headache burden and support chronic disease self-management principles, while reinforcing an individualized treatment model of care to reduce barriers to adherence and promote self-care among Headache patients.
1. GBD 2016 Disease and Injury Incidence and Prevalence Collaborators. Global, regional, and national incidence, prevalence, and years lived with disability for 328 diseases and injuries for 195 countries, 1990â€“2016: a systematic analysis for the global burden of disease study 2016. Lancet. 2017;390:1211-1259.
2. Moriarty M, Mallick-Searle T. Diagnosis and treatment for chronic migraine. Nurse Pract. 2016;41:18-32.
3. Lagman-Bartolome AM, Lawler V, Lay C. Headache education active-waiting directive: a program to enhance well-being during long referral wait times. Headache. 2018;58:109-117.
4. Leroux E, Beaudet L, Boudreau G, et al. A nursing intervention increases quality of life and self-efficacy in migraine: a 1-year prospective controlled trial. Headache. 2018;58:260-274.
5. Ministry of Health and Long-Term Care. Preventing and Managing Chronic Disease: Ontarioâ€™s Framework. 2007. [cited 3 Jan 2019].
For more information, contact
Kimberly Brigden1 RN, Valerie Lawler1 RN (EC) NP, Christine Lay1 MD
1Centre for Headache, Division of Neurology, Women's College Hospital, University of Toronto, Toronto, Canada
Correspondence: Dr. Christine Lay, Center for Headache, Women's College Hospital, 76 Grenville St., Toronto, ON M5S1B2, Canada; [email protected]
Conflict of Interest: The authors declare no conflicts of interest.
Funding: This study received no funding support.