J Neurol DOI 10.1007/s00415-014-7367-y
ORIGINAL COMMUNICATION
Health services utilization of patients with vertigo in primary care: a retrospective cohort study Eva Grill • Michael Strupp • Martin Mu¨ller Klaus Jahn
•
Received: 1 April 2014 / Accepted: 30 April 2014 Ó Springer-Verlag Berlin Heidelberg 2014
Abstract Vertigo and dizziness count among the most frequent symptoms in outpatient practices. Although most vestibular disorders are manageable, they are often underand misdiagnosed in primary care. This may result in prolonged absence from work, increased resource use and, potentially, in chronification. Reliable information on health services utilization of patients with vertigo in primary care is scarce. Retrospective cohort study in patients referred to a tertiary care balance clinic. Included patients had a confirmed diagnosis of benign paroxysmal positional vertigo (BPPV), Menie`re’s disease (MD), vestibular paroxysmia (VP), bilateral vestibulopathy (BVP), vestibular migraine (VM), or psychogenic vertigo (PSY). All previous diagnostic and therapeutic measures prior to the first visit to the clinic were recorded. 2,374 patients were included (19.7 % BPPV, 12.7 % MD, 5.8 % VP, 7.2 % BVP, 14.1 % VM, 40.6 % PSY), 61.3 % with more than two consultations. Most frequent diagnostic measures were magnetic resonance imaging (MRI, 76.2 %, 71 % in BPPV) and electrocardiography (53.5 %). Most frequent therapies were medication (61.0 %) and physical therapy (41.3 %). 37.3 % had received homoeopathic medication (39 % in BPPV), and 25.9 % were treated with betahistine E. Grill (&) M. Mu¨ller Institute for Medical Information Processing, Biometry and Epidemiology, Ludwig-Maximilians-Universita¨t Mu¨nchen, Marchioninistr. 17, 81377 Munich, Germany e-mail: [email protected] E. Grill M. Strupp M. Mu¨ller K. Jahn German Center for Vertigo and Balance Disorders, Ludwig-Maximilians-Universita¨t Mu¨nchen, Munich, Germany M. Strupp K. Jahn Department of Neurology, Ludwig-Maximilians-Universita¨t Mu¨nchen, Munich, Germany
(20 % in BPPV). Patients had undergone on average 3.2 (median 3.0, maximum 6) diagnostic measures, had received 1.8 (median 2.0, maximum 8) therapies and 1.8 (median 1.0, maximum 17) different drugs. Diagnostic subgroups differed significantly regarding number of diagnostic measures, therapies and drugs. The results emphasize the need for establishing systematic training to improve oto-neurological skills in primary care services not specialized on the treatment of dizzy patients. Keywords Primary health care Vertigo Dizziness Utilization Benign paroxysmal positional vertigo
Introduction Vertigo and dizziness belong to the most frequent symptoms in outpatient practices. In 2008, approximately 10 % of the Bavarian population aged 18–74 sought medical attention for vertigo and dizziness [1]. These symptoms are found in a wide variety of vestibular and non-vestibular disorders. Peripheral vestibular disorders are frequent causes of vertigo and dizziness, among those benign paroxysmal positioning vertigo (BPPV) and Menie`re’s disease (MD) [2]. Central vestibular forms of vertigo include cerebrovascular diseases and inflammation with brainstem and cerebellar lesions as well as vestibular migraine. With a high life-time prevalence [3] and high burden of disease [4] vertigo and dizziness can be severely disabling [5] and have high impact on daily life [6, 7]. Although there are effective diagnostic options for most vestibular disorders, under- and misdiagnosis are frequent in primary care [8]. One of the core problems is that, in contrast to other frequent symptoms like headache, back pain or dyspnoea, patients have problems to describe their
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complaints [9]. Even though there are some approaches for defining diagnostic standards, their implementation is challenging since conditions associated with vertigo and dizziness can fall into different medical subspecialties (e.g. general practice, otorhinolaryngology, neurology, psychiatry, ophthalmology and cardiology). To give an example, BPPV and vestibular migraine are the most frequently missed aetiologies of vertigo [8] while MD is less prevalent but over diagnosed [10]. It has been hypothesized that, e.g. expensive imaging techniques are employed even in patients where clinical evaluation alone might have been sufficient [11–13]. In most patients, however, correct diagnosis can be made based on patient history and clinical examination [14]. Optimal management of vertigo and dizziness differs substantially according to the underlying pathology. In rare cases, severe and life-threatening disease requires immediate action. In vestibular disease the various forms can be treated depending on their aetiology. Treatment options include, e.g. physical therapy with liberatory manoeuvres for BPPV and balance training in patients with a vestibular deficit, specific medication for MD, vestibular migraine (VM) and vestibular paroxysmia (VP) and behavioural therapy for somatoform vertigo [15, 16]. Incorrect diagnosis of vestibular disease may result in prolonged absence from work [17], increased health service utilization [18] and, in case of subsequent insufficient therapy, in chronification. Vertiginous symptoms that remain unexplained may cause secondary somatoform vertigo or phobic postural dizziness [19, 20]. Concerns have been raised about the increasing use of neuroimaging and the rising costs associated with multiple consultations, unnecessary visits to the emergency department and inadequate treatment [21, 22]. Arguably, in Germany more than one-third of patients with vestibular disease consult more than one physician for their problems [23]. However, our knowledge on diagnostic and therapeutic modalities and health services utilization of patients with vertigo in primary care is still limited. The aim of the current study was to examine the frequency and determinants of health services utilization of individuals with vertigo or dizziness before their referral to a specialized tertiary balance clinic with an emphasis on cost-intensive instrumental diagnostic procedures. Specifically, we wanted to analyse the differential use of diagnostic and therapeutic measures stratified by age and diagnosis.
Methods Study design, participants and data collection We conducted a retrospective cohort study on a convenience sample of patients referred to a tertiary care vertigo
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and balance clinic between 2011 and 2012. All patients had been seen before by a community-based otorhinolaryngology (ENT) and/or neurology service. We included patients aged 18 or above with a diagnosis confirmed in the tertiary care centre of BPPV, MD, VP, bilateral vestibulopathy (BVP), VM, or psychogenic vertigo (PSY). Participants had given informed written consent. Thereby, this study was restricted to the most frequent and unambiguous diagnoses and to patients presenting with one main diagnosis. Diagnoses were confirmed based on complete neurotological work-up including clinical neurological examination, so called neuro-orthoptic examination including eye movement recording and, if necessary, further imaging techniques and consultation of other medical specialities (e.g., psychiatry or ophthalmology). Participants were asked to fill in the questionnaire on the day they were first presenting to the balance clinic. The study was approved by the local institutional review board. Measures Patients were asked to answer standardized questions on diagnostic and therapeutic measures prior to the referral to the clinic. Questions were mostly closed-ended to avoid recall bias of specifically invasive or memorable procedures. Information on contact with physicians was obtained by asking ‘‘How many times have you seen a physician because of your problems with vertigo, the visit today not included?’’ For diagnostic procedures, a standardized list was provided that contained the most obvious procedures such as electronystagmography/caloric testing, electrocardiography, sonography, X-ray, computerized tomography (CT) or magnetic resonance imaging (MRI) of the brain or spine. For therapies, a standardized list with procedures including medication, physical therapy, psychotherapy, behavioural therapy, surgery, osteopathy, chiropractic and acupuncture was provided. For drugs, generic and brand names of the most frequently used preparations were provided. Statistical analysis Categorical variables were described with percentages and numeric variables with means and medians. To analyse predictors of utilization, the number of diagnostic procedures, the number of therapies and the number of drugs were added up. Since count data tends to be skewed we used log-linear Poisson models to test the association of age, sex and diagnosis and use of health services. SAS statistical software (V9.3, SAS Institute Inc. Cary, NC, USA) was used for all analyses. Statistical significance was set at a two-tailed 5 % level.
J Neurol Table 1 Socio-demographic characteristics of selected patients referred to a specialized tertiary balance clinic
Variable name
Variable level
N
Percent
Lower 95 % confidence limit
Upper 95 % confidence limit
Women
2,336
59.8
57.9
61.8
Satisfied with prior treatment
2,374
21.6
19.9
23.2
Highest educational level obtained University degree
325
15.3
13.8
16.9
Abitur
248
11.7
10.3
13.1
Secondary school
683
32.2
30.2
34.2
Grade school None
809 53
38.1 2.5
36.1 1.8
40.2 3.2
3
0.1
0.0
0.3
161
7.4
6.3
8.6
Still attending school Duration of symptoms \3 months
Results We included 2,374 patients presenting at the clinic (mean age 55.3 years, 59.8 % female). 19.7 % were diagnosed with BPPV, 12.7 % with MD, 5.8 % with VP, with 7.2 % BVP, 14.1 % with VM and 40.6 % with PSY. Sixty-two per cent had had more than two consultations prior to referral. Almost half of the participants had had vertigo for 3–24 months. Socio-demographic characteristics are shown in Table 1. Most frequent diagnostic procedures were magnetic resonance imaging (MRI, 76.2 %) with 82 % of patients having received either MRI or CT scans and electrocardiography (53.5 %). For instance, 71 % of the patients with BPPV and almost 80 % (79.1 %) of patients with PSY had received MRI of brain or cervical spine. The highest number of procedures was applied in VP (mean 3.6), PSY (3.4) and VM (3.3). Most frequent therapies were medication (61.0 %) and physical therapy (41.3 %). Physical therapy was used in BPPV (43.0 %) to the same amount as in PSY (46.6 %). Of all patients, 37.3 % had received homoeopathic medication (39 % in BPPV, 42.3 % in PSY); 25.9 % were treated with betahistine (62.8 % in MD, 20 % in BPPV and in all other conditions). Patients had undergone on average 3.2 (median 3.0, maximum 6) instrumental diagnostic procedures, had received 1.8 (median 2.0, maximum 8) therapies and 1.8 (median 1.0, maximum 17) different drugs. Diagnostic and therapeutic measures stratified by confirmed diagnosis are shown in Tables 2 and 3.
3 months to 2 years
998
46.2
44.1
48.3
[2 years to 10 years
727
33.6
31.6
35.6
[10 years
276
12.8
11.4
14.2
After controlling for other demographic characteristics and for diagnosis, individuals aged 70 and older had received a significantly lower number of different diagnostic procedures (p \ 0.0001) and therapies (p \ 0.0001) and less medication (p \ 0.0001) than younger patients. Women had received significantly more medication (p = 0.0007), more diagnostic procedures (p = 0.001) and a smaller number of different therapies (p = 0.0009) than men. Patients with BPPV and VP had a significantly smaller number of drugs (p \ 0.0001, p = 0.0183); patients with PSY had a significantly larger number of therapies (p \ 0.0001).
Discussion This study offers empirical evidence that optimal diagnosis and therapy for vertigo and dizziness is not being delivered despite frequent patient contacts with the primary care system. We focused on the amount and determinants of health services utilization prior to referral to a tertiary balance clinic, including patients with one of the six most frequent diagnoses (BPPV, MD, VP, BVP, or PSY). While the prevalence of electronystagmography, an arguably reasonable test in any patient with vertigo, was between 50 and 60 %, our data suggest a predominance of imaging procedures with over 80 % of patients receiving neuroimaging (MRI or CT). This is in line with a general tendency towards more neuroimaging, e.g. as observed in emergency departments in the United States without a corresponding increase in central nervous system disorders
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J Neurol Table 2 Diagnostic procedures prior to referral to a specialized tertiary balance clinic BPPV
Meniere’s disease
Vestibular paroxysmia
Psychogenic vertigo
Bilateral vestibulopathy
Vestibular migraine
n
467
301
138
963
170
335
Mean number of procedures (median)
2.8 (3)
3.2 (3)
3.6 (4)
3.4 (3)
2.7 (3)
3.3 (3)
Magnetic resonance imaging
70.7
78.4
79.0
79.1
65.3
72.5
Computed tomography, X-ray
45.4
51.5
57.2
54.0
47.6
55.2
Electrocardiogram
41.5
50.8
60.9
59.0
40.0
47.4
Sonography Electroencephalogram
39.0 30.2
44.5 35.5
51.4 44.9
41.0 42.5
35.3 31.8
42.5 38.8
Procedure (%)
Electronystagmography
52.7
63.8
66.7
60.5
54.1
61.6
Other
10.5
15.0
15.2
21.3
9.4
13.8
[24]. This is understandable—vertigo and dizziness are generally worrying symptoms that warrant clarification to exclude the possibility of serious conditions such as stroke, inflammation (e.g. multiple sclerosis) or neoplasms. Nevertheless, the sole use of CT or MRI to evaluate dizziness is not backed up by evidence [25, 26]; imaging should be preceded by neurological and neuro-otological tests. A study conducted in individuals presenting with dizziness in the emergency department found that only 0.7 % of CT scans and 12.2 % of MRI scans revealed a potential cause of the dizziness [21]. Also, the results of head CT can be inconclusive regarding stroke [27]. The substantial overuse of neuroimaging for BPPV was already previously noted [28]. Thus the routine use of imaging techniques may be part of a general defensive strategy to avoid litigation. Also, with CT and MRI being freely available within the German health system they might be seen as an easy way to accelerate diagnosis. While an economic analysis remains to be developed, the implications for health care resources are evident. Vertigo and dizziness should be evaluated based on patient history and physical exam, eventually supplemented by imaging techniques in the presence of red flag signs. In this case it is discussed to selectively prefer MRI over CT [21]. Consequentially, awareness for rational approaches to patient management in primary care should be raised. Patients of our study presented with a large range of different unsuccessful treatments prior to referral. This is in line with a current analysis from the US which reports that over 35 % of older patients with balance disorders were seen by more than three health professionals and 40 % remain without a clear diagnosis [29]. Medication was also among the most frequently employed therapy options. In contrast to best practice [16, 30] more than 50 % of patients diagnosed with BPPV had been given medication, e.g. antiemetic, antihistamine and anti-inflammatory medication. This corresponds with
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findings from the literature describing predominantly unspecific treatment of BPPV [31] with medication overuse [28, 32]. Although the use of vestibular suppressants can be helpful in the acute stage with severe attacks, nausea and vomiting, they are known to be inappropriate in BPPV on the long run because they have the potential to delay effective treatment [33]. In line with current guidelines [34], over 60 % of patients with Menie`re’s disease were treated with betahistine. However, information on dosage was not obtained in this study. As already pointed out [35, 36], homoeopathy has so far failed to convincingly show its effects in the treatment of vertigo and dizziness. Nevertheless, homoeopathic preparations were frequently reported in our study. This is not surprising; 11.5 % of the German population report the use of homoeopathy. Main reasons are the wish to avoid chemical drugs as much as possible, recommendation of physicians, or unsatisfactory results of conventional medicine [37]. Utilization of complementary medicine therapy options, as we found in one-third of our patients, might, therefore, reflect patient preference, fear of adverse events from other therapies, or unspecific approaches in general. In line with recent findings [29], older patients of our study had received less diagnostic and therapeutic measures and less medication. Although many of the reported measures may not be justified, this could be worrying if age was the sole reason for withholding them. After all, vertigo and dizziness in the old is rarely a consequence of an irreversible ageing of the vestibular and sensory systems. We also found indications of potentially inappropriate medication in patients aged 70 and older. For example, benzodiazepines and antihistaminic agents might rather contribute to the causes of dizziness than cure it. We are aware that our results may have several limitations. As we based our analyses on patients referred to a tertiary academic care centre, this sample might represent patients who were extremely difficult to diagnose and treat.
J Neurol Table 3 Therapies and medication prior to referral to a specialized tertiary balance clinic
BPPV
Meniere’s disease
Vestibular paroxysmia
Psychogenic vertigo
Bilateral vestibulopathy
Vestibular migraine
n
467
301
138
963
170
335
Mean number of therapies (median)
1.5 (1)
1.7 (2)
1.6 (1)
2.0 (2)
1.3 (1)
1.8 (2)
Medication
53.5
81.1
52.9
59.2
50.0
67.2
Physical therapy
43.0
29.2
35.5
46.6
37.1
38.8
Behavioural/ psychotherapy
9.4
8.0
12.3
20.6
8.2
14.6
Surgery
0.9
4.7
2.9
2.4
1.2
2.7
Osteopathy
13.1
11.0
16.7
22.4
11.8
14.3
Chiropractic
6.2
5.6
8.7
11.2
1.8
8.1
Acupuncture
12.0
12.6
16.7
21.2
12.4
15.2
Other
10.7
5.6
8.0
11.4
3.5
9.6
2.7 (3)
1.4 (1)
1.8 (1)
1.4 (1)
1.8 (1)
2.7 18.9
3.6 10.9
8.0 16.1
4.1 16.5
5.4 15.2
Therapy (%)
Mean number of drugs (median) Medication (%) Amitriptyline Acetylsalicylic acid/ clopidogrel
5.4 15.8
Benzodiazepine
3.4
1.7
2.2
6.5
1.8
4.2
Beta-blocker
8.8
9.6
9.4
10.6
11.8
13.4
Betahistine
20.1
62.8
17.4
19.5
18.8
26.3
Carbamazepine/ oxcarbazepine
0.6
0.7
9.4
0.5
2.4
1.8
Serotonin reuptake inhibitor
5.8
4.3
1.4
11.0
4.1
4.2
Cortisone
6.6
24.3
6.5
10.3
7.1
9.6
Dimenhydrinate
9.9
23.9
5.8
9.4
6.5
17.3
Dimenhydrinate/ cinnarizine
10.7
18.3
13.8
13.4
10.0
11.6
Flunarizine
0.4
0.3
2.2
0.8
1.2
1.2
Homoeopathic preparations
33.8
37.2
29.0
42.3
28.2
36.1
Mirtazapine
2.6
3.7
1.4
4.6
3.5
2.7
Sulpiride
3.9
4.3
8.7
9.3
6.5
6.9
Topiramate
0.4
1.3
2.9
0.4
0.6
2.1
Valproate
0.2
0.0
1.4
0.4
1.8
0.6
4-Aminopyridine
0.0
0.0
0.7
0.1
0.6
0.3
Other
11.8
13.3
13.8
15.0
8.8
15.8
It remains possible that this explains the high amount of diagnostic and therapeutic measures and the long duration of symptoms. However, a study of 2,064 patients of primary care practices found that 44 % of patients had had dizziness for between 6 months and 5 years [17]. Likewise, of 100 consecutive elderly outpatients with dizziness only about 30 % received a definite diagnosis [38]. This lends support to the robustness of our results. Also, it has to be acknowledged that patients with severe and life-threatening disease, e.g. with acute stroke, are not referred to the
centre, arguably because they had received imaging and correct diagnosis before and because the waiting time for an appointment at the centre precludes admission of emergency cases. The second limitation is that data were collected by selfreport which is prone to recall bias. Specifically, our analyses showed that among the few records with missing values participants with lower educational status were overrepresented (data not shown). We attenuated this by conservatively replacing missing values by the null value.
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Thus, the reported frequencies are probably underestimating the true extent of the problem. Detailed chart analysis should avoid this problem in future studies. This study suggests that there is still plenty of room for improving the cost-effectiveness of diagnosis and treatment of vertigo. The results emphasize the need for establishing systematic training to increase oto-neurological skills not only in primary care physicians, but also in ENT and Neurology services not specialized in the treatment of dizzy patients. Future studies should look deeper into the knowledge gaps and barriers to rational diagnosis and treatment. Acknowledgments This project was supported by funds from the German Federal Ministry of Education and Research under the Grant code 01 EO 0901. The authors bear full responsibility for the content of this publication. Conflicts of interest On behalf of all authors, the corresponding author states that there is no conflict of interest. Ethical standard All human and animal studies have been approved by the appropriate ethics committee and have therefore been performed in accordance with the ethical standards laid down in the 1964 Declaration of Helsinki and its later amendments.
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ORIGINAL COMMUNICATION
Health services utilization of patients with vertigo in primary care: a retrospective cohort study Eva Grill • Michael Strupp • Martin Mu¨ller Klaus Jahn
•
Received: 1 April 2014 / Accepted: 30 April 2014 Ó Springer-Verlag Berlin Heidelberg 2014
Abstract Vertigo and dizziness count among the most frequent symptoms in outpatient practices. Although most vestibular disorders are manageable, they are often underand misdiagnosed in primary care. This may result in prolonged absence from work, increased resource use and, potentially, in chronification. Reliable information on health services utilization of patients with vertigo in primary care is scarce. Retrospective cohort study in patients referred to a tertiary care balance clinic. Included patients had a confirmed diagnosis of benign paroxysmal positional vertigo (BPPV), Menie`re’s disease (MD), vestibular paroxysmia (VP), bilateral vestibulopathy (BVP), vestibular migraine (VM), or psychogenic vertigo (PSY). All previous diagnostic and therapeutic measures prior to the first visit to the clinic were recorded. 2,374 patients were included (19.7 % BPPV, 12.7 % MD, 5.8 % VP, 7.2 % BVP, 14.1 % VM, 40.6 % PSY), 61.3 % with more than two consultations. Most frequent diagnostic measures were magnetic resonance imaging (MRI, 76.2 %, 71 % in BPPV) and electrocardiography (53.5 %). Most frequent therapies were medication (61.0 %) and physical therapy (41.3 %). 37.3 % had received homoeopathic medication (39 % in BPPV), and 25.9 % were treated with betahistine E. Grill (&) M. Mu¨ller Institute for Medical Information Processing, Biometry and Epidemiology, Ludwig-Maximilians-Universita¨t Mu¨nchen, Marchioninistr. 17, 81377 Munich, Germany e-mail: [email protected] E. Grill M. Strupp M. Mu¨ller K. Jahn German Center for Vertigo and Balance Disorders, Ludwig-Maximilians-Universita¨t Mu¨nchen, Munich, Germany M. Strupp K. Jahn Department of Neurology, Ludwig-Maximilians-Universita¨t Mu¨nchen, Munich, Germany
(20 % in BPPV). Patients had undergone on average 3.2 (median 3.0, maximum 6) diagnostic measures, had received 1.8 (median 2.0, maximum 8) therapies and 1.8 (median 1.0, maximum 17) different drugs. Diagnostic subgroups differed significantly regarding number of diagnostic measures, therapies and drugs. The results emphasize the need for establishing systematic training to improve oto-neurological skills in primary care services not specialized on the treatment of dizzy patients. Keywords Primary health care Vertigo Dizziness Utilization Benign paroxysmal positional vertigo
Introduction Vertigo and dizziness belong to the most frequent symptoms in outpatient practices. In 2008, approximately 10 % of the Bavarian population aged 18–74 sought medical attention for vertigo and dizziness [1]. These symptoms are found in a wide variety of vestibular and non-vestibular disorders. Peripheral vestibular disorders are frequent causes of vertigo and dizziness, among those benign paroxysmal positioning vertigo (BPPV) and Menie`re’s disease (MD) [2]. Central vestibular forms of vertigo include cerebrovascular diseases and inflammation with brainstem and cerebellar lesions as well as vestibular migraine. With a high life-time prevalence [3] and high burden of disease [4] vertigo and dizziness can be severely disabling [5] and have high impact on daily life [6, 7]. Although there are effective diagnostic options for most vestibular disorders, under- and misdiagnosis are frequent in primary care [8]. One of the core problems is that, in contrast to other frequent symptoms like headache, back pain or dyspnoea, patients have problems to describe their
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complaints [9]. Even though there are some approaches for defining diagnostic standards, their implementation is challenging since conditions associated with vertigo and dizziness can fall into different medical subspecialties (e.g. general practice, otorhinolaryngology, neurology, psychiatry, ophthalmology and cardiology). To give an example, BPPV and vestibular migraine are the most frequently missed aetiologies of vertigo [8] while MD is less prevalent but over diagnosed [10]. It has been hypothesized that, e.g. expensive imaging techniques are employed even in patients where clinical evaluation alone might have been sufficient [11–13]. In most patients, however, correct diagnosis can be made based on patient history and clinical examination [14]. Optimal management of vertigo and dizziness differs substantially according to the underlying pathology. In rare cases, severe and life-threatening disease requires immediate action. In vestibular disease the various forms can be treated depending on their aetiology. Treatment options include, e.g. physical therapy with liberatory manoeuvres for BPPV and balance training in patients with a vestibular deficit, specific medication for MD, vestibular migraine (VM) and vestibular paroxysmia (VP) and behavioural therapy for somatoform vertigo [15, 16]. Incorrect diagnosis of vestibular disease may result in prolonged absence from work [17], increased health service utilization [18] and, in case of subsequent insufficient therapy, in chronification. Vertiginous symptoms that remain unexplained may cause secondary somatoform vertigo or phobic postural dizziness [19, 20]. Concerns have been raised about the increasing use of neuroimaging and the rising costs associated with multiple consultations, unnecessary visits to the emergency department and inadequate treatment [21, 22]. Arguably, in Germany more than one-third of patients with vestibular disease consult more than one physician for their problems [23]. However, our knowledge on diagnostic and therapeutic modalities and health services utilization of patients with vertigo in primary care is still limited. The aim of the current study was to examine the frequency and determinants of health services utilization of individuals with vertigo or dizziness before their referral to a specialized tertiary balance clinic with an emphasis on cost-intensive instrumental diagnostic procedures. Specifically, we wanted to analyse the differential use of diagnostic and therapeutic measures stratified by age and diagnosis.
Methods Study design, participants and data collection We conducted a retrospective cohort study on a convenience sample of patients referred to a tertiary care vertigo
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and balance clinic between 2011 and 2012. All patients had been seen before by a community-based otorhinolaryngology (ENT) and/or neurology service. We included patients aged 18 or above with a diagnosis confirmed in the tertiary care centre of BPPV, MD, VP, bilateral vestibulopathy (BVP), VM, or psychogenic vertigo (PSY). Participants had given informed written consent. Thereby, this study was restricted to the most frequent and unambiguous diagnoses and to patients presenting with one main diagnosis. Diagnoses were confirmed based on complete neurotological work-up including clinical neurological examination, so called neuro-orthoptic examination including eye movement recording and, if necessary, further imaging techniques and consultation of other medical specialities (e.g., psychiatry or ophthalmology). Participants were asked to fill in the questionnaire on the day they were first presenting to the balance clinic. The study was approved by the local institutional review board. Measures Patients were asked to answer standardized questions on diagnostic and therapeutic measures prior to the referral to the clinic. Questions were mostly closed-ended to avoid recall bias of specifically invasive or memorable procedures. Information on contact with physicians was obtained by asking ‘‘How many times have you seen a physician because of your problems with vertigo, the visit today not included?’’ For diagnostic procedures, a standardized list was provided that contained the most obvious procedures such as electronystagmography/caloric testing, electrocardiography, sonography, X-ray, computerized tomography (CT) or magnetic resonance imaging (MRI) of the brain or spine. For therapies, a standardized list with procedures including medication, physical therapy, psychotherapy, behavioural therapy, surgery, osteopathy, chiropractic and acupuncture was provided. For drugs, generic and brand names of the most frequently used preparations were provided. Statistical analysis Categorical variables were described with percentages and numeric variables with means and medians. To analyse predictors of utilization, the number of diagnostic procedures, the number of therapies and the number of drugs were added up. Since count data tends to be skewed we used log-linear Poisson models to test the association of age, sex and diagnosis and use of health services. SAS statistical software (V9.3, SAS Institute Inc. Cary, NC, USA) was used for all analyses. Statistical significance was set at a two-tailed 5 % level.
J Neurol Table 1 Socio-demographic characteristics of selected patients referred to a specialized tertiary balance clinic
Variable name
Variable level
N
Percent
Lower 95 % confidence limit
Upper 95 % confidence limit
Women
2,336
59.8
57.9
61.8
Satisfied with prior treatment
2,374
21.6
19.9
23.2
Highest educational level obtained University degree
325
15.3
13.8
16.9
Abitur
248
11.7
10.3
13.1
Secondary school
683
32.2
30.2
34.2
Grade school None
809 53
38.1 2.5
36.1 1.8
40.2 3.2
3
0.1
0.0
0.3
161
7.4
6.3
8.6
Still attending school Duration of symptoms \3 months
Results We included 2,374 patients presenting at the clinic (mean age 55.3 years, 59.8 % female). 19.7 % were diagnosed with BPPV, 12.7 % with MD, 5.8 % with VP, with 7.2 % BVP, 14.1 % with VM and 40.6 % with PSY. Sixty-two per cent had had more than two consultations prior to referral. Almost half of the participants had had vertigo for 3–24 months. Socio-demographic characteristics are shown in Table 1. Most frequent diagnostic procedures were magnetic resonance imaging (MRI, 76.2 %) with 82 % of patients having received either MRI or CT scans and electrocardiography (53.5 %). For instance, 71 % of the patients with BPPV and almost 80 % (79.1 %) of patients with PSY had received MRI of brain or cervical spine. The highest number of procedures was applied in VP (mean 3.6), PSY (3.4) and VM (3.3). Most frequent therapies were medication (61.0 %) and physical therapy (41.3 %). Physical therapy was used in BPPV (43.0 %) to the same amount as in PSY (46.6 %). Of all patients, 37.3 % had received homoeopathic medication (39 % in BPPV, 42.3 % in PSY); 25.9 % were treated with betahistine (62.8 % in MD, 20 % in BPPV and in all other conditions). Patients had undergone on average 3.2 (median 3.0, maximum 6) instrumental diagnostic procedures, had received 1.8 (median 2.0, maximum 8) therapies and 1.8 (median 1.0, maximum 17) different drugs. Diagnostic and therapeutic measures stratified by confirmed diagnosis are shown in Tables 2 and 3.
3 months to 2 years
998
46.2
44.1
48.3
[2 years to 10 years
727
33.6
31.6
35.6
[10 years
276
12.8
11.4
14.2
After controlling for other demographic characteristics and for diagnosis, individuals aged 70 and older had received a significantly lower number of different diagnostic procedures (p \ 0.0001) and therapies (p \ 0.0001) and less medication (p \ 0.0001) than younger patients. Women had received significantly more medication (p = 0.0007), more diagnostic procedures (p = 0.001) and a smaller number of different therapies (p = 0.0009) than men. Patients with BPPV and VP had a significantly smaller number of drugs (p \ 0.0001, p = 0.0183); patients with PSY had a significantly larger number of therapies (p \ 0.0001).
Discussion This study offers empirical evidence that optimal diagnosis and therapy for vertigo and dizziness is not being delivered despite frequent patient contacts with the primary care system. We focused on the amount and determinants of health services utilization prior to referral to a tertiary balance clinic, including patients with one of the six most frequent diagnoses (BPPV, MD, VP, BVP, or PSY). While the prevalence of electronystagmography, an arguably reasonable test in any patient with vertigo, was between 50 and 60 %, our data suggest a predominance of imaging procedures with over 80 % of patients receiving neuroimaging (MRI or CT). This is in line with a general tendency towards more neuroimaging, e.g. as observed in emergency departments in the United States without a corresponding increase in central nervous system disorders
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J Neurol Table 2 Diagnostic procedures prior to referral to a specialized tertiary balance clinic BPPV
Meniere’s disease
Vestibular paroxysmia
Psychogenic vertigo
Bilateral vestibulopathy
Vestibular migraine
n
467
301
138
963
170
335
Mean number of procedures (median)
2.8 (3)
3.2 (3)
3.6 (4)
3.4 (3)
2.7 (3)
3.3 (3)
Magnetic resonance imaging
70.7
78.4
79.0
79.1
65.3
72.5
Computed tomography, X-ray
45.4
51.5
57.2
54.0
47.6
55.2
Electrocardiogram
41.5
50.8
60.9
59.0
40.0
47.4
Sonography Electroencephalogram
39.0 30.2
44.5 35.5
51.4 44.9
41.0 42.5
35.3 31.8
42.5 38.8
Procedure (%)
Electronystagmography
52.7
63.8
66.7
60.5
54.1
61.6
Other
10.5
15.0
15.2
21.3
9.4
13.8
[24]. This is understandable—vertigo and dizziness are generally worrying symptoms that warrant clarification to exclude the possibility of serious conditions such as stroke, inflammation (e.g. multiple sclerosis) or neoplasms. Nevertheless, the sole use of CT or MRI to evaluate dizziness is not backed up by evidence [25, 26]; imaging should be preceded by neurological and neuro-otological tests. A study conducted in individuals presenting with dizziness in the emergency department found that only 0.7 % of CT scans and 12.2 % of MRI scans revealed a potential cause of the dizziness [21]. Also, the results of head CT can be inconclusive regarding stroke [27]. The substantial overuse of neuroimaging for BPPV was already previously noted [28]. Thus the routine use of imaging techniques may be part of a general defensive strategy to avoid litigation. Also, with CT and MRI being freely available within the German health system they might be seen as an easy way to accelerate diagnosis. While an economic analysis remains to be developed, the implications for health care resources are evident. Vertigo and dizziness should be evaluated based on patient history and physical exam, eventually supplemented by imaging techniques in the presence of red flag signs. In this case it is discussed to selectively prefer MRI over CT [21]. Consequentially, awareness for rational approaches to patient management in primary care should be raised. Patients of our study presented with a large range of different unsuccessful treatments prior to referral. This is in line with a current analysis from the US which reports that over 35 % of older patients with balance disorders were seen by more than three health professionals and 40 % remain without a clear diagnosis [29]. Medication was also among the most frequently employed therapy options. In contrast to best practice [16, 30] more than 50 % of patients diagnosed with BPPV had been given medication, e.g. antiemetic, antihistamine and anti-inflammatory medication. This corresponds with
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findings from the literature describing predominantly unspecific treatment of BPPV [31] with medication overuse [28, 32]. Although the use of vestibular suppressants can be helpful in the acute stage with severe attacks, nausea and vomiting, they are known to be inappropriate in BPPV on the long run because they have the potential to delay effective treatment [33]. In line with current guidelines [34], over 60 % of patients with Menie`re’s disease were treated with betahistine. However, information on dosage was not obtained in this study. As already pointed out [35, 36], homoeopathy has so far failed to convincingly show its effects in the treatment of vertigo and dizziness. Nevertheless, homoeopathic preparations were frequently reported in our study. This is not surprising; 11.5 % of the German population report the use of homoeopathy. Main reasons are the wish to avoid chemical drugs as much as possible, recommendation of physicians, or unsatisfactory results of conventional medicine [37]. Utilization of complementary medicine therapy options, as we found in one-third of our patients, might, therefore, reflect patient preference, fear of adverse events from other therapies, or unspecific approaches in general. In line with recent findings [29], older patients of our study had received less diagnostic and therapeutic measures and less medication. Although many of the reported measures may not be justified, this could be worrying if age was the sole reason for withholding them. After all, vertigo and dizziness in the old is rarely a consequence of an irreversible ageing of the vestibular and sensory systems. We also found indications of potentially inappropriate medication in patients aged 70 and older. For example, benzodiazepines and antihistaminic agents might rather contribute to the causes of dizziness than cure it. We are aware that our results may have several limitations. As we based our analyses on patients referred to a tertiary academic care centre, this sample might represent patients who were extremely difficult to diagnose and treat.
J Neurol Table 3 Therapies and medication prior to referral to a specialized tertiary balance clinic
BPPV
Meniere’s disease
Vestibular paroxysmia
Psychogenic vertigo
Bilateral vestibulopathy
Vestibular migraine
n
467
301
138
963
170
335
Mean number of therapies (median)
1.5 (1)
1.7 (2)
1.6 (1)
2.0 (2)
1.3 (1)
1.8 (2)
Medication
53.5
81.1
52.9
59.2
50.0
67.2
Physical therapy
43.0
29.2
35.5
46.6
37.1
38.8
Behavioural/ psychotherapy
9.4
8.0
12.3
20.6
8.2
14.6
Surgery
0.9
4.7
2.9
2.4
1.2
2.7
Osteopathy
13.1
11.0
16.7
22.4
11.8
14.3
Chiropractic
6.2
5.6
8.7
11.2
1.8
8.1
Acupuncture
12.0
12.6
16.7
21.2
12.4
15.2
Other
10.7
5.6
8.0
11.4
3.5
9.6
2.7 (3)
1.4 (1)
1.8 (1)
1.4 (1)
1.8 (1)
2.7 18.9
3.6 10.9
8.0 16.1
4.1 16.5
5.4 15.2
Therapy (%)
Mean number of drugs (median) Medication (%) Amitriptyline Acetylsalicylic acid/ clopidogrel
5.4 15.8
Benzodiazepine
3.4
1.7
2.2
6.5
1.8
4.2
Beta-blocker
8.8
9.6
9.4
10.6
11.8
13.4
Betahistine
20.1
62.8
17.4
19.5
18.8
26.3
Carbamazepine/ oxcarbazepine
0.6
0.7
9.4
0.5
2.4
1.8
Serotonin reuptake inhibitor
5.8
4.3
1.4
11.0
4.1
4.2
Cortisone
6.6
24.3
6.5
10.3
7.1
9.6
Dimenhydrinate
9.9
23.9
5.8
9.4
6.5
17.3
Dimenhydrinate/ cinnarizine
10.7
18.3
13.8
13.4
10.0
11.6
Flunarizine
0.4
0.3
2.2
0.8
1.2
1.2
Homoeopathic preparations
33.8
37.2
29.0
42.3
28.2
36.1
Mirtazapine
2.6
3.7
1.4
4.6
3.5
2.7
Sulpiride
3.9
4.3
8.7
9.3
6.5
6.9
Topiramate
0.4
1.3
2.9
0.4
0.6
2.1
Valproate
0.2
0.0
1.4
0.4
1.8
0.6
4-Aminopyridine
0.0
0.0
0.7
0.1
0.6
0.3
Other
11.8
13.3
13.8
15.0
8.8
15.8
It remains possible that this explains the high amount of diagnostic and therapeutic measures and the long duration of symptoms. However, a study of 2,064 patients of primary care practices found that 44 % of patients had had dizziness for between 6 months and 5 years [17]. Likewise, of 100 consecutive elderly outpatients with dizziness only about 30 % received a definite diagnosis [38]. This lends support to the robustness of our results. Also, it has to be acknowledged that patients with severe and life-threatening disease, e.g. with acute stroke, are not referred to the
centre, arguably because they had received imaging and correct diagnosis before and because the waiting time for an appointment at the centre precludes admission of emergency cases. The second limitation is that data were collected by selfreport which is prone to recall bias. Specifically, our analyses showed that among the few records with missing values participants with lower educational status were overrepresented (data not shown). We attenuated this by conservatively replacing missing values by the null value.
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Thus, the reported frequencies are probably underestimating the true extent of the problem. Detailed chart analysis should avoid this problem in future studies. This study suggests that there is still plenty of room for improving the cost-effectiveness of diagnosis and treatment of vertigo. The results emphasize the need for establishing systematic training to increase oto-neurological skills not only in primary care physicians, but also in ENT and Neurology services not specialized in the treatment of dizzy patients. Future studies should look deeper into the knowledge gaps and barriers to rational diagnosis and treatment. Acknowledgments This project was supported by funds from the German Federal Ministry of Education and Research under the Grant code 01 EO 0901. The authors bear full responsibility for the content of this publication. Conflicts of interest On behalf of all authors, the corresponding author states that there is no conflict of interest. Ethical standard All human and animal studies have been approved by the appropriate ethics committee and have therefore been performed in accordance with the ethical standards laid down in the 1964 Declaration of Helsinki and its later amendments.
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