Skip to main content

Main menu

  • Home
  • Current Issue
  • Content
    • Current Issue
    • Early Access
    • Multimedia
    • Podcast
    • Collections
    • Past Issues
    • Articles by Subject
    • Articles by Type
    • Supplements
    • Plain Language Summaries
    • Calls for Papers
  • Info for
    • Authors
    • Reviewers
    • Job Seekers
    • Media
  • About
    • Annals of Family Medicine
    • Editorial Staff & Boards
    • Sponsoring Organizations
    • Copyrights & Permissions
    • Announcements
  • Engage
    • Engage
    • e-Letters (Comments)
    • Subscribe
    • Podcast
    • E-mail Alerts
    • Journal Club
    • RSS
    • Annals Forum (Archive)
  • Contact
    • Contact Us
  • Careers

User menu

  • My alerts

Search

  • Advanced search
Annals of Family Medicine
  • My alerts
Annals of Family Medicine

Advanced Search

  • Home
  • Current Issue
  • Content
    • Current Issue
    • Early Access
    • Multimedia
    • Podcast
    • Collections
    • Past Issues
    • Articles by Subject
    • Articles by Type
    • Supplements
    • Plain Language Summaries
    • Calls for Papers
  • Info for
    • Authors
    • Reviewers
    • Job Seekers
    • Media
  • About
    • Annals of Family Medicine
    • Editorial Staff & Boards
    • Sponsoring Organizations
    • Copyrights & Permissions
    • Announcements
  • Engage
    • Engage
    • e-Letters (Comments)
    • Subscribe
    • Podcast
    • E-mail Alerts
    • Journal Club
    • RSS
    • Annals Forum (Archive)
  • Contact
    • Contact Us
  • Careers
  • Follow annalsfm on Twitter
  • Visit annalsfm on Facebook
Research ArticleInnovations in Primary Care

Expanding the Use of Botulinum Toxin in Primary Care for Chronic Migraine

Blake Busey
The Annals of Family Medicine January 2019, 17 (1) 85; DOI: https://doi.org/10.1370/afm.2343
Blake Busey
DO
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
  • For correspondence: dr.busey.omt@gmail.com
  • Article
  • Figures & Data
  • eLetters
  • Info & Metrics
  • PDF
Loading

THE INNOVATION

In 2017, the Neurology Department at William Beaumont Medical Center (WBAMC) suffered a loss of clinicians, leaving many patients unable to receive quarterly botulinum toxin injections for chronic migraine headaches. The author developed a program to train and credential primary care clinicians in this specialty procedure.

WHO & WHERE

Department of Primary Care of WBAMC, Fort Bliss, Texas.

HOW

Primary Care and Neurology Departments partnered to train and credential primary care clinicians in botulinum toxin injection for chronic migraine. Chronic migraine is an indication for botulinum toxin therapy shown effective in the Phase 3 REsearch Evaluating Migraine Prophylaxis Therapy (PREEMPT 2) trial1 and confirmed in the Chronic Migraine OnabotulinuM-toxinA Prolonged Efficacy open Label (COMPEL) trial2 as well as a Cochrane review3 with reduction in headache days. The author served as the project champion and developed a 5-component project and curriculum to train primary care clinicians (physicians, physician assistants, and nurse practitioners) within all adult primary care clinics.

The first component was personal development. The author obtained didactic training from Allergan followed by procedural training from a credentialed clinician. The credentials and pharmacy and therapeutics committees granted the author privileges and prescriptive authority, respectively. The author developed standard operating procedures with medication stewardship guidance, a medication supply chain with pharmacy, documentation templates, and a preliminary curriculum.

The second phase was testing and revision. The clinic was used as the prototype for testing and revising the curriculum. The author trained all nursing support on reconstitution, documentation, and coding requirements. For the first month, the team revised the workflow, documentation and coding, and training materials through rapid Plan-Do-Check-Act cycles before initiating training of other clinicians.

The third phase was implementing the curriculum in training and credentialing clinicians. Outlying clinic clinicians attended didactic training before rotating through a procedural day. Over 6 months, the project credentialed 15 clinicians in all 6 outlying medical homes.

The fourth phase was the implementation phase. Trained primary care clinicians scheduled chronic migraine procedures within our system, including those potentially lost to the network. The process recaptured revenue through reduced referral costs, relative value units (RVUs) for the procedure, and medication costs.

The final phase was maintenance and sharing. Other subject matter experts were identified as trainers within each medical home. Additionally, 50 physicians at the 2018 Uniformed Services Academy of Family Physicians national conference were trained through a workshop incorporating this project and didactic training.

LEARNING

This curriculum was developed out of necessity and was a continuous learning experience. Many patients with chronic migraine have concomitant occipital neuralgia leading to further training on occipital nerve blocks. There is a high potential for botulinum toxin diversion so a 2-person verification of proper use and disposal is recommended. Despite strict guidelines, the temptation to expedite the clinical process to qualify for this procedure came to light. Secondarily, retraining and disciplinary action for clinicians that did not adhere to appropriateness criteria was developed. Subsequent iterations of training focused on appropriateness criteria and consequences of nonadherence before initiating procedure. Expansion of this program to satellite sites was met with resistance from specialty clinicians and hospital systems. Changing this paradigm is a diplomatic and administratively tiresome process. Developing and maintaining professional relationships is key to success. The phases of the project described within this manuscript can be adapted to many other specialty procedures in an underserved community or region.

Footnotes

  • Conflicts of interest: author reports none.

  • Supplemental appendix, affiliations, key words, submitted dates, acknowledgments, and references available at http://www.AnnFamMed.org/content/17/1/85/suppl/DC1/.

  • © 2019 Annals of Family Medicine, Inc.
PreviousNext
Back to top

In this issue

The Annals of Family Medicine: 17 (1)
The Annals of Family Medicine: 17 (1)
Vol. 17, Issue 1
January/February 2019
  • Table of Contents
  • Index by author
  • Back Matter (PDF)
  • Front Matter (PDF)
  • In Brief
Print
Download PDF
Article Alerts
Sign In to Email Alerts with your Email Address
Email Article

Thank you for your interest in spreading the word on Annals of Family Medicine.

NOTE: We only request your email address so that the person you are recommending the page to knows that you wanted them to see it, and that it is not junk mail. We do not capture any email address.

Enter multiple addresses on separate lines or separate them with commas.
Expanding the Use of Botulinum Toxin in Primary Care for Chronic Migraine
(Your Name) has sent you a message from Annals of Family Medicine
(Your Name) thought you would like to see the Annals of Family Medicine web site.
CAPTCHA
This question is for testing whether or not you are a human visitor and to prevent automated spam submissions.
4 + 13 =
Solve this simple math problem and enter the result. E.g. for 1+3, enter 4.
Citation Tools
Expanding the Use of Botulinum Toxin in Primary Care for Chronic Migraine
Blake Busey
The Annals of Family Medicine Jan 2019, 17 (1) 85; DOI: 10.1370/afm.2343

Citation Manager Formats

  • BibTeX
  • Bookends
  • EasyBib
  • EndNote (tagged)
  • EndNote 8 (xml)
  • Medlars
  • Mendeley
  • Papers
  • RefWorks Tagged
  • Ref Manager
  • RIS
  • Zotero
Get Permissions
Share
Expanding the Use of Botulinum Toxin in Primary Care for Chronic Migraine
Blake Busey
The Annals of Family Medicine Jan 2019, 17 (1) 85; DOI: 10.1370/afm.2343
Twitter logo Facebook logo Mendeley logo
  • Tweet Widget
  • Facebook Like
  • Google Plus One

Jump to section

  • Article
    • THE INNOVATION
    • WHO & WHERE
    • HOW
    • LEARNING
    • Footnotes
  • Figures & Data
  • eLetters
  • Info & Metrics
  • PDF

Related Articles

  • PubMed
  • Google Scholar

Cited By...

  • In This Issue: Humans of Primary Care Research
  • Google Scholar

More in this TOC Section

  • Reducing Stigma Through Conversations in Primary Care About Unhealthy Alcohol Use
  • Adult ADHD Diagnosis in a Family Medicine Clinic
  • Enhancing First Trimester Obstetrical Care: The Addition of Point-of-Care Ultrasound
Show more Innovations in Primary Care

Similar Articles

Content

  • Current Issue
  • Past Issues
  • Early Access
  • Plain-Language Summaries
  • Multimedia
  • Podcast
  • Articles by Type
  • Articles by Subject
  • Supplements
  • Calls for Papers

Info for

  • Authors
  • Reviewers
  • Job Seekers
  • Media

Engage

  • E-mail Alerts
  • e-Letters (Comments)
  • RSS
  • Journal Club
  • Submit a Manuscript
  • Subscribe
  • Family Medicine Careers

About

  • About Us
  • Editorial Board & Staff
  • Sponsoring Organizations
  • Copyrights & Permissions
  • Contact Us
  • eLetter/Comments Policy

© 2025 Annals of Family Medicine