Emergency Department Utilization After 60-Day Peripheral Nerve Stimulation Versus Usual Care for Refractory Occipital Neuralgia: A Prospective Propensity-Matched Cohort, Difference-in-Differences Analysis
- 1Division of Physiatry, Interventional Pain Medicine, Department of Orthopaedics and Rehabilitation, Yale School of Medicine
Abstract
BackgroundTemporary 60-day percutaneous peripheral nerve stimulation (PNS) can relieve pain in refractory occipital neuralgia (ON), but whether it alters acute healthcare utilization relative to the natural trajectory of the disease is unknown, because prior studies have lacked a concurrent comparator.
MethodsWe performed a secondary analysis of prospectively collected data from a tertiary interventional pain center. Adults with medically refractory ON (primary diagnosis occipital neuralgia, ICD-10-CM M54.81) who underwent 60-day occipital PNS (n = 42) were compared with concurrent patients who were clinically eligible for PNS but were denied insurance authorization and continued optimized non-PNS management (usual care; n = 63). Headache-related emergency department (ED) encounters--index (occipital neuralgia) and non-index (other headache/facial-pain diagnoses)--were ascertained over the 12 months before and after the treatment window via the electronic record and the statewide health information exchange. Patients were 1:1 propensity-matched on a priori confounders (age, sex, baseline total headache-related ED utilization, HIT-6, and baseline headache-medication use). The primary analysis was a difference-in-differences (DiD) comparison of the change in headache-related ED utilization, reported as the additive difference (Hodges- Lehmann estimate, distribution-free 95% CI) and, alongside, as a multiplicative rate ratio (RR).
ResultsThirty-six matched pairs were well balanced. Baseline headache-related ED utilization was nearly identical between matched groups (6.3 vs. 6.2 visits/year). Over the following year, PNS patients utilization fell to 2.5 while usual-care patients rose to 6.9. The DiD was 5.0 fewer headache-related ED visits per patient (95% CI 3.0-6.0; p < 0.001), corresponding to a rate ratio of 0.36 (95% CI 0.27-0.48; p < 0.001). Results were consistent in the full sample, in covariate-adjusted models, and after excluding controls denied for incomplete conservative-therapy trials. The effect was driven by non-index headache visits.
ConclusionsRelative to a concurrent, matched usual-care cohort whose headache-related ED utilization rose over time, 60-day occipital PNS was associated with a substantial reduction in acute-care use, strengthening the case for a role of PNS on healthcare utilization in refractory ON.
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BibTeX
@misc{harris2026emergency,
title = {{Emergency Department Utilization After 60-Day Peripheral Nerve Stimulation Versus Usual Care for Refractory Occipital Neuralgia: A Prospective Propensity-Matched Cohort, Difference-in-Differences Analysis}},
author = {C. W. Harris and E. T. Nguyen and S. M. Limas and S. J. Sheth and R. W. Chow and C. A. Odonkor},
howpublished = {medRxiv},
year = {2026},
month = oct,
doi = {10.64898/2026.10.02.26364550},
url = {https://www.medrxiv.org/content/10.64898/2026.10.02.26364550v1},
note = {CC BY},
}
RIS
TY - UNPB
TI - Emergency Department Utilization After 60-Day Peripheral Nerve Stimulation Versus Usual Care for Refractory Occipital Neuralgia: A Prospective Propensity-Matched Cohort, Difference-in-Differences Analysis
AU - C. W. Harris
AU - E. T. Nguyen
AU - S. M. Limas
AU - S. J. Sheth
AU - R. W. Chow
AU - C. A. Odonkor
PY - 2026
DA - 2026/10/02
PB - medRxiv
DO - 10.64898/2026.10.02.26364550
UR - https://www.medrxiv.org/content/10.64898/2026.10.02.26364550v1
AB - BackgroundTemporary 60-day percutaneous peripheral nerve stimulation (PNS) can relieve pain in refractory occipital neuralgia (ON), but whether it alters acute healthcare utilization relative to the natural trajectory of the disease is unknown, because prior studies have lacked a concurrent comparator. MethodsWe performed a secondary analysis of prospectively collected data from a tertiary interventional pain center. Adults with medically refractory ON (primary diagnosis occipital neuralgia, ICD-10-CM M54.81) who underwent 60-day occipital PNS (n = 42) were compared with concurrent patients who were clinically eligible for PNS but were denied insurance authorization and continued optimized non-PNS management (usual care; n = 63). Headache-related emergency department (ED) encounters--index (occipital neuralgia) and non-index (other headache/facial-pain diagnoses)--were ascertained over the 12 months before and after the treatment window via the electronic record and the statewide health information exchange. Patients were 1:1 propensity-matched on a priori confounders (age, sex, baseline total headache-related ED utilization, HIT-6, and baseline headache-medication use). The primary analysis was a difference-in-differences (DiD) comparison of the change in headache-related ED utilization, reported as the additive difference (Hodges- Lehmann estimate, distribution-free 95% CI) and, alongside, as a multiplicative rate ratio (RR). ResultsThirty-six matched pairs were well balanced. Baseline headache-related ED utilization was nearly identical between matched groups (6.3 vs. 6.2 visits/year). Over the following year, PNS patients utilization fell to 2.5 while usual-care patients rose to 6.9. The DiD was 5.0 fewer headache-related ED visits per patient (95% CI 3.0-6.0; p < 0.001), corresponding to a rate ratio of 0.36 (95% CI 0.27-0.48; p < 0.001). Results were consistent in the full sample, in covariate-adjusted models, and after excluding controls denied for incomplete conservative-therapy trials. The effect was driven by non-index headache visits. ConclusionsRelative to a concurrent, matched usual-care cohort whose headache-related ED utilization rose over time, 60-day occipital PNS was associated with a substantial reduction in acute-care use, strengthening the case for a role of PNS on healthcare utilization in refractory ON.
ER -