Thomas S.D. Getchius

Summary of evidence-based guideline update: Evaluation and management of concussion in sports Report of the Guideline Development Subcommittee of the American Academy of Neurology

Objective: To update the 1997 American Academy of Neurology (AAN) practice parameter regarding sports concussion, focusing on 4 questions: 1) What factors increase/decrease concussion risk? 2) What diagnostic tools identify those with concussion and those at increased risk for severe/prolonged early impairments, neurologic catastrophe, or chronic neurobehavioral impairment? 3) What clinical factors identify those at increased risk for severe/prolonged early postconcussion impairments, neurologic catastrophe, recurrent concussions, or chronic neurobehavioral impairment? 4) What interventions enhance recovery, reduce recurrent concussion risk, or diminish long-term sequelae? The complete guideline on which this summary is based is available as an online data supplement to this article. Methods: We systematically reviewed the literature from 1955 to June 2012 for pertinent evidence. We assessed evidence for quality and synthesized into conclusions using a modified Grading of Recommendations Assessment, Development and Evaluation process. We used a modified Delphi process to develop recommendations. Results: Specific risk factors can increase or decrease concussion risk. Diagnostic tools to help identify individuals with concussion include graded symptom checklists, the Standardized Assessment of Concussion, neuropsychological assessments, and the Balance Error Scoring System. Ongoing clinical symptoms, concussion history, and younger age identify those at risk for postconcussion impairments. Risk factors for recurrent concussion include history of multiple concussions, particularly within 10 days after initial concussion. Risk factors for chronic neurobehavioral impairment include concussion exposure and APOE ε4 genotype. Data are insufficient to show that any intervention enhances recovery or diminishes long-term sequelae postconcussion. Practice recommendations are presented for preparticipation counseling, management of suspected concussion, and management of diagnosed concussion.

The American Academy of Neurology's Top Five Choosing Wisely recommendations

Objective: To discuss the American Academy of Neurology (AAN)’s Top Five Recommendations in the Choosing Wisely campaign promoting high-value neurologic medicine and physician–patient communication. The AAN published its Top Five Recommendations in February 2013 in collaboration with the American Board of Internal Medicine Foundation and Consumer Reports. Methods: A Choosing Wisely Working Group of 10 AAN members was formed to oversee the process and craft the evidence-based recommendations. AAN members were solicited for recommendations, the recommendations were sent out for external review, and the Working Group members (article authors) used a modified Delphi process to select their Top Five Recommendations. Results and recommendations: The Working Group submitted 5 neurologic recommendations to the AAN Practice Committee and Board of Directors; all 5 were approved by both entities in September 2012. Recommendation 1: Don’t perform EEGs for headaches. Recommendation 2: Don’t perform imaging of the carotid arteries for simple syncope without other neurologic symptoms. Recommendation 3: Don’t use opioids or butalbital for treatment of migraine, except as a last resort. Recommendation 4: Don’t prescribe interferon-b or glatiramer acetate to patients with disability from progressive, nonrelapsing forms of multiple sclerosis. Recommendation 5: Don’t recommend carotid endarterectomy for asymptomatic carotid stenosis unless the complication rate is low (,3%). Neurology 2013;81:1004–1011 GLOSSARY AAN 5 American Academy of Neurology; ABIMF 5 American Board of Internal Medicine Foundation; CEA 5 carotid endarterectomy;GDP5 gross domestic product;MS5multiple sclerosis; PPMS5 primary progressive multiple sclerosis;RRMS5 relapsing-remitting multiple sclerosis; SPMS 5 secondary progressive multiple sclerosis. Alzheimer disease, Parkinson disease, stroke, and multiple sclerosis affect approximately 15 million people and account for more than

Evidence-based guideline summary: Evaluation, diagnosis, and management of congenital muscular dystrophy: Report of the Guideline Development Subcommittee of the American Academy of Neurology and the Practice Issues Review Panel of the American Association of Neuromuscular & Electrodiagnostic Medicine.

290 billion in health care spending annually in the United States. The number of people with these neurologic disorders is expected to increase, likely resulting in increased health care spending. Each year, US health care spending increases, putting additional pressure on the national economy and individual consumers. According to estimates from the Centers for Medicare & Medicaid Services, the United States spent

Practice guideline update summary: Mild cognitive impairment: Report of the Guideline Development, Dissemination, and Implementation Subcommittee of the American Academy of Neurology

2.7 trillion (17.9% of the gross domestic product [GDP]) on health care in 2011. If the growth of health care expenditures is not curtailed, health care spending is projected to constitute 25% of the GDP by 2025, according to the Congressional Budget Office. The Institute of Medicine estimates that

Opioid Use Among Adolescent Patients Treated for Headache

750 billion was spent on wasted medical services, including unnecessary services, inefficiently delivered services, and missed prevention opportunities, in 2009 alone. The rising cost of health care and wasteful spending often affect the consumer directly through increased deductibles and copayments and indirectly through deductions from wages or lost wage increases. From the Neurology Department, Los Angeles Medical Center (A.M.L.-G.), Southern California Kaiser Permanente Medical Group (S.B.P.), Los Angeles; Department of Research & Evaluation (A.M.L.-G.), Kaiser Permanente Southern California, Pasadena; California Pacific Neurosciences Institute (W.E.A.), San Francisco; Department of Neurology (M.J.A.), University of Maryland School of Medicine, Baltimore; Massachusetts General Hospital (A.B.C.), Harvard Medical School, Cambridge; Geisinger Medical Center (M.A.E.), Danville, PA; Humboldt Neurological Medical Group, Inc. (D.J.I.), Eureka, CA; American Academy of Neurology (A.B., R.L., A.G., T.G.), Minneapolis, MN; and University of Kansas Medical Center (G.S.G.), Kansas City. Go to Neurology.org for full disclosures. Funding information and disclosures deemed relevant by the authors, if any, are provided at the end of the article. 1004

The Impact of Social Media on Dissemination and Implementation of Clinical Practice Guidelines: A Longitudinal Observational Study

Objective: To delineate optimal diagnostic and therapeutic approaches to congenital muscular dystrophy (CMD) through a systematic review and analysis of the currently available literature. Methods: Relevant, peer-reviewed research articles were identified using a literature search of the MEDLINE, EMBASE, and Scopus databases. Diagnostic and therapeutic data from these articles were extracted and analyzed in accordance with the American Academy of Neurology classification of evidence schemes for diagnostic, prognostic, and therapeutic studies. Recommendations were linked to the strength of the evidence, other related literature, and general principles of care. Results: The geographic and ethnic backgrounds, clinical features, brain imaging studies, muscle imaging studies, and muscle biopsies of children with suspected CMD help predict subtype-specific diagnoses. Genetic testing can confirm some subtype-specific diagnoses, but not all causative genes for CMD have been described. Seizures and respiratory complications occur in specific subtypes. There is insufficient evidence to determine the efficacy of various treatment interventions to optimize respiratory, orthopedic, and nutritional outcomes, and more data are needed regarding complications. Recommendations: Multidisciplinary care by experienced teams is important for diagnosing and promoting the health of children with CMD. Accurate assessment of clinical presentations and genetic data will help in identifying the correct subtype-specific diagnosis in many cases. Multiorgan system complications occur frequently; surveillance and prompt interventions are likely to be beneficial for affected children. More research is needed to fill gaps in knowledge regarding this category of muscular dystrophies.

Can outcomes in Duchenne muscular dystrophy be improved by public reporting of data

Objective To update the 2001 American Academy of Neurology (AAN) guideline on mild cognitive impairment (MCI). Methods The guideline panel systematically reviewed MCI prevalence, prognosis, and treatment articles according to AAN evidence classification criteria, and based recommendations on evidence and modified Delphi consensus. Results MCI prevalence was 6.7% for ages 60–64, 8.4% for 65–69, 10.1% for 70–74, 14.8% for 75–79, and 25.2% for 80–84. Cumulative dementia incidence was 14.9% in individuals with MCI older than age 65 years followed for 2 years. No high-quality evidence exists to support pharmacologic treatments for MCI. In patients with MCI, exercise training (6 months) is likely to improve cognitive measures and cognitive training may improve cognitive measures. Major recommendations Clinicians should assess for MCI with validated tools in appropriate scenarios (Level B). Clinicians should evaluate patients with MCI for modifiable risk factors, assess for functional impairment, and assess for and treat behavioral/neuropsychiatric symptoms (Level B). Clinicians should monitor cognitive status of patients with MCI over time (Level B). Cognitively impairing medications should be discontinued where possible and behavioral symptoms treated (Level B). Clinicians may choose not to offer cholinesterase inhibitors (Level B); if offering, they must first discuss lack of evidence (Level A). Clinicians should recommend regular exercise (Level B). Clinicians may recommend cognitive training (Level C). Clinicians should discuss diagnosis, prognosis, long-term planning, and the lack of effective medicine options (Level B), and may discuss biomarker research with patients with MCI and families (Level C).

Practice guideline recommendations summary: Disease-modifying therapies for adults with multiple sclerosis: Report of the Guideline Development, Dissemination, and Implementation Subcommittee of the American Academy of Neurology

PURPOSE To determine the pervasiveness of opioid prescribing for adolescents with headache and patient and provider characteristics associated with likelihood of opioid prescribing. METHODS This observational cohort analysis used commercial medical and pharmacy claims between January 1, 2007 and December 31, 2008. Included were adolescents (13-17 years of age) with newly diagnosed headache, ≥2 distinct claims for headache, and ≥12 months health plan eligibility preindex and postindex. Adolescents with a trauma diagnosis at any point were excluded. The primary outcome was current practice patterns, measured by a number of opioid claims, a percentage of patients prescribed opioids, a number of opioid prescriptions per year, a length of opioid therapy, and a frequency of specific comorbidities. A secondary outcome characterized providers and practice settings, comparing patients who received opioids with those who did not. RESULTS AND CONCLUSIONS Of 8,373 adolescents with headache, 46% (3,859 patients) received an opioid prescription. Nearly half (48%) received one opioid prescription during follow-up; 29% received ≥3 opioid prescriptions. Of those with opioid prescriptions, 25% (977 patients) had a migraine diagnosis at index date. Among adolescents who received opioids, 28% (1,076 adolescents) had an emergency department (ED) visit for headache during follow-up versus 14% (608 adolescents) who did not receive opioids (p < .01). ED visits with a headache diagnosis during follow-up were strongly correlated with opioid use after adjusting for other covariates (odds ratio, 2.02; 95% confidence interval, 1.79-2.29). Despite the treatment guidelines recommending against their use, a large proportion of adolescents with headache were prescribed opioids. ED visits were strongly correlated with opioid prescriptions.

Comprehensive systematic review summary: Disease-modifying therapies for adults with multiple sclerosis: Report of the Guideline Development, Dissemination, and Implementation Subcommittee of the American Academy of Neurology

Background Evidence-based clinical practice guidelines (CPGs) are statements that provide recommendations to optimize patient care for a specific clinical problem or question. Merely reading a guideline rarely leads to implementation of recommendations. The American Academy of Neurology (AAN) has a formal process of guideline development and dissemination. The last few years have seen a burgeoning of social media such as Facebook, Twitter, and LinkedIn, and newer methods of dissemination such as podcasts and webinars. The role of these media in guideline dissemination has not been studied. Systematic evaluation of dissemination methods and comparison of the effectiveness of newer methods with traditional methods is not available. It is also not known whether specific dissemination methods may be more effectively targeted to specific audiences. Objective Our aim was to (1) develop an innovative dissemination strategy by adding social media-based dissemination methods to traditional methods for the AAN clinical practice guidelines “Complementary and alternative medicine in multiple sclerosis” (“CAM in MS”) and (2) evaluate whether the addition of social media outreach improves awareness of the CPG and knowledge of CPG recommendations, and affects implementation of those recommendations. Methods Outcomes were measured by four surveys in each of the two target populations: patients and physicians/clinicians (“physicians”). The primary outcome was the difference in participants’ intent to discuss use of complementary and alternative medicine (CAM) with their physicians or patients, respectively, after novel dissemination, as compared with that after traditional dissemination. Secondary outcomes were changes in awareness of the CPG, knowledge of CPG content, and behavior regarding CAM use in multiple sclerosis (MS). Results Response rates were 25.08% (622/2480) for physicians and 43.5% (348/800) for patients. Awareness of the CPG increased after traditional dissemination (absolute difference, 95% confidence interval: physicians 36%, 95% CI 25-46, and patients 10%, 95% CI 1-11) but did not increase further after novel dissemination (physicians 0%, 95% CI -11 to 11, and patients -4%, 95% CI -6 to 14). Intent to discuss CAM also increased after traditional dissemination but did not change after novel dissemination (traditional: physicians 12%, 95% CI 2-22, and patients 19%, 95% CI 3-33; novel: physicians 11%, 95% CI -1 to -21, and patients -8%, 95% CI -22 to 8). Knowledge of CPG recommendations and behavior regarding CAM use in MS did not change after either traditional dissemination or novel dissemination. Conclusions Social media-based dissemination methods did not confer additional benefit over print-, email-, and Internet-based methods in increasing CPG awareness and changing intent in physicians or patients. Research on audience selection, message formatting, and message delivery is required to utilize Web 2.0 technologies optimally for dissemination.

Reconciling the clinical practice guidelines on Bell palsy from the AAO-HNSF and the AAN

Objective: To review current approaches for obtaining patient data in Duchenne muscular dystrophy (DMD) and consider how monitoring and comparing outcome measures across DMD clinics could facilitate standardized and improved patient care. Methods: We reviewed annual standardized data from cystic fibrosis (CF) clinics and DMD care guidelines and consensus statements; compared current approaches to obtain DMD patient data and outcome measures; and considered the best method for implementing public reporting of outcomes, to drive improvements in health care delivery. Results: Current methods to monitor DMD patient information (MD STARnet, DuchenneConnect, and TREAT-NMD) do not yet provide patients with comparative outcome data. The CF patient registry allows for reporting of standard outcomes across clinics and is associated with improved CF outcomes. A similar patient registry is under development for the Muscular Dystrophy Association (MDA) clinic network. Suggested metrics for quality care include molecular diagnosis, ambulatory status and age at loss of ambulation, age requiring ventilator support, and survival. Conclusions: CF longevity has increased by almost 33% from 1986 to 2010, in part due to a CF patient registry that has been stratified by individual care centers since 1999, and publically available since 2006. Implementation of outcome reporting for MDA clinics might promote a similar benefit to patients with DMD.