Migraines prevalence in the United States is estimated to be approximately 18% and 6% in women and men respectively. Over 73% of these patients seek out a primary care physician however a recent survey noted almost 70% of PCPs were unfamiliar with management guidelines set by the American Headache Society (AHS). This likely leads to overutilization of specialty referrals resulting in access delay. Due to the shortage of neurologists we reviewed the referral process within Geisinger to identify inefficiencies.

We completed a manual analysis of all referrals from primary care physicians to headache specialists for a period of one month. This was a proof of concept to delineate that the majority of patients being referred to a subspecialist had not exhausted diagnostic or therapeutic options. We later established two pilot sites which would receive education on headache diagnosis, management, and an automated decision support tool within the EHR to assist in determining which patients required a subspecialist level of care. We corroborated our initial findings with an automated analysis to reduce observer bias.

The data suggests that change in specialist referral process can be achieved with appropriate clinical education, implementation of an electronic decision support tool, and standardization of the process.