Headache service quality evaluation: implementation of quality indicators in primary care in Europe.

BACKGROUND: Lifting The Burden (LTB) and European Headache Federation (EHF) have developed a set of headache service quality indicators, successfully tested in specialist headache centres. Their intended application includes all levels of care. Here we assess their implementation in primary care. METHODS: We included 28 primary-care clinics in Germany (4), Turkey (4), Latvia (5) and Portugal (15). To implement the indicators, we interviewed 111 doctors, 92 nurses and medical assistants, 70 secretaries, 27 service managers and 493 patients, using the questionnaires developed by LTB and EHF. In addition, we evaluated 675 patients' records. Enquiries were in nine domains: diagnosis, individualized management, referral pathways, patient education and reassurance, convenience and comfort, patient satisfaction, equity and efficiency of headache care, outcome assessment and safety. RESULTS: The principal finding was that Implementation proved feasible and practical in primary care. In the process, we identified significant quality deficits. Almost everywhere, histories of headache, especially temporal profiles, were captured and/or assessed inaccurately. A substantial proportion (20%) of patients received non-specific ICD codes such as R51 ("headache") rather than specific headache diagnoses. Headache-related disability and quality of life were not part of routine clinical enquiry. Headache diaries and calendars were not in use. Waiting times were long (e.g., about 60 min in Germany). Nevertheless, most patients (> 85%) expressed satisfaction with their care. Almost all the participating clinics provided equitable and easy access to treatment, and follow-up for most headache patients, without unnecessary barriers. CONCLUSIONS: The study demonstrated that headache service quality indicators can be used in primary care, proving both practical and fit for purpose. It also uncovered quality deficits leading to suboptimal treatment, often due to a lack of knowledge among the general practitioners. There were failures of process also. These findings signal the need for additional training in headache diagnosis and management in primary care, where most headache patients are necessarily treated. More generally, they underline the importance of headache service quality evaluation in primary care, not only to identify-quality failings but also to guide improvements. This study also demonstrated that patients' satisfaction is not, on its own, a good indicator of service quality.

Tick-borne encephalitis in Latvia 1973-2009: epidemiology, clinical features and sequelae.

BACKGROUND AND PURPOSE: To report a 37-year observational experience in Latvia relating the incidence of human tick-borne encephalitis (TBE) and its clinical manifestations, to the field abundance of ticks. METHODS: Tick abundance was measured by standard flagging techniques. Incidence of human tick-borne disease was derived from Public Health reporting data. Clinical and follow-up data were determined from hospital cohorts from 1973 to 2009. RESULTS: Two TBE incidence peaks in the mid-1970s and the 1990s correlated with increased field abundance of ticks. Increased human TBE in the 1970s was associated with higher field abundance of both Ixodes ricinis and I. Persulcatus. The 1990s peak was particularly associated with I. ricinus, the species predominating in western/central Latvia, and with other factors, including changed agricultural land usage. Proportions of patients with meningitic or focal forms of TBE were similar in the two outbreaks and the intervening periods. Meningeal irritation occurred in 90%, altered consciousness in 19%, ataxia in 34%, seizures in 9%, bulbar features in 2-3% and limb weakness in 15% with shoulder amyotrophy predominating in 5%. Annual mortality varied from 0 to 1.3% and was not related to the overall incidence of TBE. Follow-up for 1-13 years of a cohort of 100 patients revealed long-term sequelae in over 50%, more commonly in those suffering focal forms of acute TBE. CONCLUSIONS: Clinical features and mortality of the 1970s and 1990s TBE outbreaks were similar and did not point to a change in virulence.

Clinical features of double infection with tick-borne encephalitis and Lyme borreliosis transmitted by tick bite.

BACKGROUND: In Latvia and other endemic regions, a single tick bite has the potential to transmit both tick-borne encephalitis (TBE) and Lyme borreliosis. OBJECTIVE: To analyse both the clinical features and differential diagnosis of combined tick-borne infection with TBE and Lyme borreliosis, in 51 patients with serological evidence, of whom 69% had tick bites. RESULTS: Biphasic fever suggestive of TBE occurred in 55% of the patients. Meningitis occurred in 92%, with painful radicular symptoms in 39%. Muscle weakness occurred in 41%; in 29% the flaccid paralysis was compatible with TBE. Only two patients presented with the bulbar palsy typical of TBE. Typical Lyme borreliosis facial palsy occurred in three patients. Typical TBE oculomotor disturbances occurred in two. Other features typical of Lyme borreliosis detected in our patients were distal peripheral neuropathy (n = 4), arthralgia (n = 9), local erythema 1-12 days after tick bite (n = 7) and erythema chronicum migrans (n = 1). Echocardiogram abnormalities occurred in 15. CONCLUSIONS: Patients with double infection with TBE and Lyme borreliosis fell into three main clinical groups: febrile illness, 3 (6%); meningitis, 15 (30%); central or peripheral neurological deficit (meningoencephalitis, meningomyelitis, meningoradiculitis and polyradiculoneuritis), 33 (65%). Systemic features pointing to Lyme borreliosis were found in 25 patients (49%); immunoglobulin (Ig)M antibodies to borreliosis were present in 18 of them. The clinical occurrence of both Lyme borreliosis and TBE vary after exposure to tick bite, and the neurological manifestations of each disorder vary widely, with considerable overlap. This observational study provides no evidence that co-infection produces unusual manifestations due to unpredicted interaction between the two diseases. Patients with tick exposure presenting with acute neurological symptoms in areas endemic for both Lyme borreliosis and TBE should be investigated for both conditions. The threshold for simultaneous treatment of both conditions should be low, given the possibility of co-occurrence and the difficulty in ascribing individual neurological manifestations to one condition or the other.