Abstract
Objective:
To determine adherence to the 2017 American Academy of Otolaryngology-Head & Neck Surgery (AAO-HNS) guidelines for the management and treatment of Benign Paroxysmal Positional Vertigo (BPPV) in primary care and compare whether key recommendations differed by sex, race, or insurance status.
Study Design:
Retrospective chart review
Settings:
26 clinic locations within a single healthcare system
Methods:
Charts of 458 patients diagnosed with BPPV in primary care between 2018-22 were reviewed. Encounters where the diagnosis of BPPV was were identified. From the clinical encounter note demographics, symptomatology, management, and treatment were extracted. Non-parametric analyses were used to identify whether AAO-HNS guidelines differed regarding sex, race or insurance status.
Results:
Of 458 patients, 249 (54.4%) did not receive a diagnostic exam, and only 4 (0.9%) patients received imaging. Regarding treatment, only 51 (11.1%) received the Epley maneuver, with 263 (57.4%) receiving vestibular suppressant medication and 12.4% receiving referral to specialist. In regard to sex, race or insurance status, there was no significant difference in receiving a Dix-Hallpike diagnostic maneuver, Epley maneuver, vestibular suppressant medication, imaging, or referral to a specialist.
Conclusion:
Our data suggests that there continue to be gaps in the adherence to AAO-HNS guidelines; however, these gaps did not differ by sex, race, or insurance status. Care should be taken to increase the use of diagnostic and treatment maneuvers but decrease the use of vestibular-suppressant medications for the treatment of BPPV in primary care.
Keywords: BPPV, adherence, guidelines, primary care
INTRODUCTION
Benign Paroxysmal Positional Vertigo (BPPV) is the most common vestibular disorder encountered in primary care (PC).1 From 2013-2015, an estimated 20.6 million adults presented to an ambulatory visit for dizziness, of which 9.2% received a diagnosis of BPPV.2 BPPV has stereotypic symptomology of short-duration vertigo that is triggered by a change in head and/or body position. BPPV can have debilitating effects on patients such as increased risk of falls and impaired daily activities.3,4 BPPV can be diagnosed via clinical history and bedside testing, with the gold standard diagnostic procedure being the Dix-Hallpike maneuver.4,5 Patients can have complete resolution of symptoms by canalith repositioning maneuvers (CRM) such as the modified Epley maneuver6–8, and CRM is effective in resolving BPPV symptoms in 80% of cases with a single treatment.7,9
Given the stereotypical symptoms and effective diagnostic and treatment options, the American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS) issued clinical practice guidelines in 2008, which were updated in 2017.4,10 These guidelines offer recommendations (or key action statements[KAS]) for both specialists and non-specialist providers with the goal of improving the diagnosis and management of BPPV. KASs from the guidelines are summarized in Table 1. Based on the evidence, a “strong recommendation” was made for the use of a diagnostic Dix-Hallpike Maneuver, and performing or referring to a provider who can perform a CRM. A “recommendation” was made for use of a Supine Roll Test for suspected BPPV if a Dix-Hallpike maneuver is negative and follow-up for outcome assessment in one month. Conversely, “strong recommendations against” was made for the use of imaging for diagnosis and prescription of vestibular suppressant medications for management.4
Table 1.
Key action statements from the AAO-HNS guidelines and reported strength of evidence
| Key Action Statement | Strength of Recommendation1 |
|---|---|
| Clinicians should diagnose BBPV2 with a Dix-Hallpike Maneuver performed toward both sides | Strong Recommendation |
| A Supine Roll test should be used if BPPV is suspected, and the Dix-Hallpike Maneuver is negative | Recommendation |
| Clinicians should not obtain radiographic testing for a patient who meets criteria for diagnosis BPPV | Recommendation (against) |
| Clinicians should treat suspected BPPV, or refer patients to a clinician who can treat BPPV, with a canalith repositioning maneuver | Strong Recommendation |
| Clinicians should not routinely treat BPPV with vestibular suppressant medications | Recommendation (against) |
| Clinicians should reassess patients 1 month after initial observation or treatment period for BPPV | Recommendation |
Strength of evidence was presented in 3 levels ranging from strong recommendation, recommendation, and recommendation (against).
BPPV= Benign Paroxysmal Positional Vertigo
Despite these evidence-based clinical guidelines, they are not consistently implemented, particularly in non-specialist clinics. Most research on the healthcare processes associated with BPPV in non-specialist clinics has focused on the emergency department (ED)5,11–14, with little research on PC setting.1,2,15–18 Research reported in the PC setting has been limited to non-fee for service healthcare systems outside the US18, in Veteran Affairs settings16, or describe processes that predate the AAO-HNS guidelines.1,2,15,17 Data from each of these settings, however, demonstrate that providers do not routinely perform recommended diagnostic tests to diagnose BPPV.5,11,16–18 Additionally, studies performed in the ED have shown limited use of CRMs, 5,11,14 with one population-based study showing that 96.1% of diagnosed BPPV presentations did not receive CRMs.12 Dunlap and colleagues (2019) examined physician adherence to the updated (2017) BPPV guidelines using the National Ambulatory Medical Care Survey data from 2013-2015.2 They stratified the clinical setting by specialty (PC, Otolaryngology, Neurology) and focused on the use of imaging and vestibular suppressant medications in the diagnosis and management of BPPV. They found that imaging was ordered in 5.5% of cases and vestibular suppressant medications were prescribed in 33.8% of cases in the PC setting.2
While there have been studies that explore clinical guideline adherence, little is known about variability in the diagnosis and management of BPPV in PC and if that differs by demographic factors. This is evidenced by a recent systematic review in 2022 focused on disparities in otology, which found that only 1.9% of articles published prior to 2021 examined or discussed results from this framework.19 Adams et al. (2017) investigated variations of vestibular testing in Medicare recipients, based on geographic relation, race, sex, and age.20 They showed that Black Medicare beneficiaries were less likely to receive a diagnosis of dizziness and receive vestibular testing while individuals older than 85 years were less likely to receive vestibular testing.20 Swan et al. (2022) examined factors impacting whether or not veterans with dizziness symptomatology received a diagnosis of dizziness versus a vestibular disorder. They found that Black veterans had significantly reduced odds of receiving a vestibular disorder diagnosis when compared to white individuals.21 Another recent study by Souza et al.22 examined geographic variation in the care of patients with a vestibular disorder, and found that location impacted management. Despite these newer studies and a call to increase research investigating variations in care for BPPV, there have been no further studies investigating whether there are sociodemographic variations in the diagnosis or management of dizziness etiology such as BPPV. Regarding adherence to the BPPV clinical guidelines, there is minimal research examining factors such as sex, race, and insurance status. As the most encountered vestibular diagnosis in the PC setting, identifying any sociodemographic variations in diagnosis and management of BPPV is imperative to understanding gaps in equitable care. This study aims to describe the diagnostic and treatment process of patients diagnosed with BPPV in the PC setting and to determine the extent to which clinical practice guidelines were followed. A secondary aim was to understand if KAS of the AAO-HNS guidelines differed as a function of sex, race, and/or insurance status.
METHODS
This study was a retrospective chart review. The study was approved by the Duke University Institutional Review Board (Pro00109681) as an exempt study with a waiver of informed consent.
Participants and Setting
All adult patients receiving a new diagnosis of BPPV in a PC setting between 2018-2022 were identified (ICD-10 codes: H81.10-H81.13) and a sample of adult patients underwent chart review. A random number generator was used to identify the random sequence of records to review. Patients were seen at one of 26 PC locations (which excluded the ED and urgent care settings) that were distributed across 22 zip codes in 5 counties (4 urban, 1 rural). PC physicians saw 77.3% of the patients whereas Advanced Practice Providers (APPs) saw 22.7%. Patients were excluded if they had received a diagnosis of BPPV prior to 2018, had BPPV symptomatology lasting >1 year or were evaluated in an urgent care or ED setting prior to being seen by their PC for their symptoms. A total of 458 records were included.
Characteristics of the Initial Healthcare Encounter
The first encounter where patients had experienced BPPV/dizziness symptomatology was identified and noted as the initial encounter. From the physician or APP medical note, the following information was extracted: demographic information (age at presentation, biological sex, race, ethnicity, and insurance status),and number of health-related comorbidities (using the active problem list on the initial encounter).
Relative to the 2017 AAO-HNS guideline KASs, the following items were also extracted from the clinic note and documentation: 1) description of dizziness symptomology (time since onset, description of dizziness, duration, and triggers), 2) initial diagnostic evaluation and results, 3) initial treatment/management strategies (e.g., CRM in clinic, at-home exercises, medications) utilized in the PC setting and if applicable, 4) referrals generated. A “not reported” designation was made for any variable not included in a given patient’s medical record. A description of the chart review extraction process can be found in the Supplemental table 1.
Analysis
All data extracted from the medical record was completed by two trained reviewers and was entered into a Research Electronic Data Capture (REDCap) database and exported for analyses.23,24 Counts/percentages and descriptive statistics were performed to summarize the characteristics of the cohort and clinical encounters. To better understand if KASs differed by sex, race, or insurance status Chi-square and Fisher’s exact tests were used. All analyses were run in SPSS (IBM SPSS Version 28)25 and p value <0.007 were considered significant to account for multiple comparisons.
RESULTS
Patient Demographics
Table 2 describes the demographic characteristic of our cohort (n = 458). The age of our cohort ranged from 20-89+ years at presentation. Most of our cohort (67.9%) was female, white (66.2%), and 45.6% had ≥3 comorbidities.
Table 2.
Demographic information of the Benign Paroxysmal Positional Vertigo cohort (n = 458) seen between 2018-2022.
| Study Cohort | |
|---|---|
| Age, mean years (standard deviation) | 56.4 (15.9) |
| Sex n (%) | |
| Female | 311 (67.9%) |
| Male | 147 (32.1%) |
| Other | 1 (0.2%) |
| Race n (%) | |
| White | 303 (66.2%) |
| Black | 107 (23.4%) |
| Asian | 23 (5.0%) |
| Native Hawaiian/Pacific Islander | 1 (0.2%) |
| Other | 8 (1.7%) |
| Not Documented/Not Reported | 16 (3.5%) |
| Ethnicity n (%) | |
| Not Hispanic/Latino | 436 (95.2%) |
| Hispanic/Latino | 18 (3.9%) |
| Not Documented/Unknown | 4 (0.9%) |
| Comorbidities n (%) | |
| 0 | 67 (14.6%) |
| 1-2 | 182 (39.7%) |
| 3 or greater | 209 (45.6%) |
| Insurance Type n (%) | |
| Medicaid | 3 (0.7%) |
| Medicare | 176 (38.4%) |
| Private | 249 (54.4%) |
| Uninsured | 30 (6.6%) |
Characteristics of the Initial Healthcare Encounter
Initial Symptom Presentations
The initial presentation of symptoms are described in table 3. Most patients saw a provider within 4 weeks of experiencing symptoms (80.6%). Vertigo was the most common symptom (85.6%) reported. The duration of symptoms was generally not reported/documented (65.3%); however, 26.0% of patients reported that their symptoms lasted for less than a few minutes consistent with the diagnostic criteria outlined by AAO-HNS.4 Positional changes of the head was reported as a trigger in 45.6% of patients.
Table 3.
Clinical presentation of cohort (n = 458) seen between 2018-2022 at first encounter for Benign Paroxysmal Positional Vertigo symptoms
| Clinical Presentation | Study Cohort Number (%) |
|---|---|
| Symptom Presentation | |
| Acute (<4 weeks) | 369 (80.6%) |
| Intermediate (>4 weeks, to 12 months) | 89 (19.4%) |
| Initial Symptoms | |
| Vertigo | 392 (85.6%) |
| Disequilibrium/Unsteadiness | 41 (9.0%) |
| Lightheadedness | 20 (4.4%) |
| Other | 2 (0.4%) |
| Not Reported | 3 (0.7%) |
| Duration | |
| Less than a Few Minutes | 119 (26.0%) |
| Greater than a Few Minutes | 40 (8.7%) |
| Not Reported/Documented | 299 (65.3%) |
| Trigger | |
| Not Reported/Not Documented | 89 (19.4%) |
| Lying Down | 96 (21.0%) |
| Reaching Up | 4 (0.9%) |
| Positional Changes of the Head | 209 (45.6%) |
| Postural Changes | 194 (42.4%) |
| Other | 12 (2.6%) |
| No Triggers | 22 (4.8%) |
Diagnostic Testing
Table 4 displays the diagnostic exams performed and ordered at the encounter. A total of 45.6% had a Dix-Hallpike maneuver and/or supine roll test performed, 54.4% either did not receive or did not have either test documented. Twenty-six patients (5.7%) received bloodwork (including basic metabolic panel, complete blood count panel, thyroid panel, and/or iron panels). Four patients (0.9%) initially received imaging (2 Magnetic Resonance Images, 1 Computed Tomography scan, and 1 carotid ultrasound).
Table 4.
Diagnostic exams performed for cohort (n = 458) at initial clinical encounter for Benign Paroxysmal Positional Vertigo symptoms between 2018-2022
| Diagnostic Criteria | Study Cohort |
|---|---|
|
| |
| Number (Percent) | |
| Diagnostic Exam 1 | |
| Not Performed | 249 (54.4%) |
| Dix-Hallpike Maneuver | 190 (41.5%) |
| Supine Roll Test | 19 (4.1%) |
| Dix Hallpike Maneuver Results | |
| Positive (No Other Description) | 85 (18.6%) |
| Patient Symptomatic | 25 (5.5%) |
| Provider Observed Nystagmus | 49 (10.7%) |
| Negative | 31 (6.8%) |
| Supine Roll Tests Results | |
| Positive | 2 (0.4%) |
| Patient Symptomatic | 5 (1.1%) |
| Provider Observed Nystagmus | 9 (2.0%) |
| Negative | 3 (0.7%) |
| Additional Diagnostic Tools | |
| Imaging | 4 (0.9%) |
| Bloodwork | 26 (5.7%) |
| Electrocardiogram | 4 (0.9%) |
No patient in the study cohort received multiple diagnostic exams
Treatment/Management
Table 5 describes the treatment and follow-up plans. Only 51 of the 458 patients (11.1%) received a CRM in the PC visit. Treatment offered predominantly included patient instructions on how to perform a modified Epley maneuver at home (53.5%) or prescriptions for vestibular suppressant medications (57.4%). Roughly 46% of the cohort received >1 type of treatment recommendation and the most common combination of treatments were at home modified Epley instructions and a prescription for vestibular suppressants. Only12.4% were referred to a specialty clinic (Physical therapy or Audiology/ENT).
Table 5.
Treatment and follow-up plans for cohort (n = 458) at first encounter for Benign Paroxysmal Positional Vertigo symptoms between 2018-2022
| Treatment and Follow-Up Criteria | Study Cohort |
|---|---|
|
| |
| Number (Percent) | |
| Treatment Recommendations | |
| Observation | 58 (12.7%) |
| Epley Maneuver Performed In Office | 51 (11.1%) |
| Instructions to Perform Epley at Home | 245 (53.5%) |
| Vestibular Suppressant Medication | 263 (57.4%) |
| Referral to Specialist | 57 (12.4%) |
| Number of Treatment Recommendations Per Patient | |
| None | 2 (0.4%) |
| One | 245 (53.5%) |
| Two | 180 (39.3%) |
| Three or more | 31 (6.8%) |
| Follow Up Plans | |
| < 1 month | 40 (8.7%) |
| > 1 month | 41 (9.0%) |
| As Needed | 202 (44.1%) |
| None Needed or Suggested | 135 (29.5%) |
Comparison in Care by Sex, Race, Insurance Status
A comparison of care was made by sex, race, and insurance status type to determine if guideline implementation differed by these demographic characteristics. Table 6 stratifies the main diagnostic and treatment recommendations by sex and demonstrates that there was no difference in the proportion of diagnostic maneuvers administered or diagnostic imaging by sex. When examining the different treatment modalities offered to patients, there again was no sex-based difference regarding any treatment option. The same diagnostic and treatment recommendations via race (Table 7) and insurance status (Table 8) were examined, and no differences were found.
Table 6.
Comparison of diagnostic and treatment recommendation in the primary care setting for Benign Paroxysmal Positional Vertigo by sex
| Diagnostic and Treatment Recommendation | Female1 N (%) | Male2 N (%) | Chi Square3 X2 | P-Value |
|---|---|---|---|---|
| Dix Hallpike | ||||
| Performed | 122 (64.2%) | 68 (35.8%) | 2.03 | p = 0.16 |
| Not Performed | 189 (70.5.%) | 79 (29.5%) | ||
| Supine Roll Test | ||||
| Performed | 12 (63.2%) | 7 (36.8%) | 0.21 | p = 0.63 |
| Not Performed | 299 (68.1%) | 140 (31.9%) | ||
| Epley in Office | ||||
| Performed | 35 (70.6%) | 16 (29.4%) | 0.01 | p = 1.00 |
| Not Performed | 276 (67.6%) | 131 (32.4%) | ||
| Instructions for Epley at Home | ||||
| Given | 167 (68.1%) | 78 (31.9%) | 0.02 | p = 0.92 |
| Not Given | 144 (67.8%) | 69 (32.2%) | ||
| Vestibular Suppressant Medication | ||||
| Prescribed | 183 (69.6%) | 80 (30.4%) | 0.80 | p = 0.42 |
| Not Prescribed | 128 (65.4%) | 67 (34.6%) | ||
| Imaging | ||||
| Performed | 3 (66.7%) | 1 (33.3%) | 0.09 | p = 1.00 |
| Not performed | 308 (67.8%) | 146 (32.2%) | ||
| Referral to specialist | ||||
| Given | 42 (73.7%) | 15 (26.3%) | 1.00 | p = 0.37 |
| Not Given | 269 (67.8%) | 132 (32.2%) |
N = 311
N = 147
For all X2 values, (df1, df2) were (1, 458)
Table 7:
Comparison of diagnostic and treatment recommendation in the primary care setting for Benign Paroxysmal Positional Vertigo by race
| Diagnostic and Treatment Recommendation | White N (%) | Black N (%) | Asian N (%) | Other N (%) | Fisher’s Exact1 | P-Value |
|---|---|---|---|---|---|---|
| Dix Hallpike | ||||||
| Performed | 136 (71.6%) | 38 (20.0%) | 7 (3.7%) | 9 (4.7%) | 4.37 | p = 0.22 |
| Not Performed | 167 (59.9%) | 69 (24.7%) | 16 (6.1%) | 16 (9.3%) | ||
| Supine Roll Test | ||||||
| Performed | 11 (57.9%) | 4 (21.1%) | 1 (5.2%) | 3 (15.8%) | 3.94 | p = 0.22 |
| Not Performed | 292 (66.5%) | 103 (23.5%) | 22 (5.0%) | 22 (5.0%) | ||
| Epley in office | ||||||
| Performed | 35 (68.6%) | 15 (29.4%) | 0 (0.0%) | 1 (2.0%) | 4.78 | p = 0.17 |
| Not Performed | 268 (65.9%) | 92 (22.6%) | 23 (5.7%) | 24 (5.8%) | ||
| Instructions for Epley at Home | ||||||
| Given | 162 (66.1%) | 54 (22.0%) | 14 (5.7%) | 15 (6.1%) | 1.31 | p = 0.74 |
| Not Given | 141 (66.2%) | 53 (24.9%) | 9 (4.2%) | 10 (4.7%) | ||
| Vestibular Suppressant Medication | ||||||
| Prescribed | 160 (62.0%) | 71 (27.5%) | 17 (6.6%) | 10 (3.9%) | 8.70 | p = 0.03 |
| Not Prescribed | 143 (71.5%) | 36 (18.0%) | 6 (3.0%) | 15 (7.5%) | ||
| Imaging | ||||||
| Performed | 2 (50.0%) | 2 (50.0%) | 0 (0.0%) | 0 (0.0%) | 2.01 | p = 0.54 |
| Not performed | 301 (66.3%) | 105 (23.1%) | 23 (5.1%) | 25 (5.5%) | ||
| Referral to specialist | ||||||
| Given | 40 (70.2%) | 10 (17.5%) | 3 (5.3%) | 4 (7.0%) | 1.62 | p = 0.66 |
| Not Given | 263 (65.6%) | 97 (24.2%) | 20 (5.0%) | 21 (5.2%) |
For all X2 values, (df1, df2) were (1, 458)
Table 8:
Comparison of diagnostic and treatment recommendation in the primary care setting for Benign Paroxysmal Positional Vertigo by insurance status
| Diagnostic and Treatment Recommendation | Medicaid N (%) | Medicare N (%) | Private N (%) | Uninsured N (%) | Fisher’s Exact1 | P-Value |
|---|---|---|---|---|---|---|
| Dix Hallpike | ||||||
| Performed | 1 (0.5%) | 65 (34.2%) | 112 (58.9%) | 12 (6.3%) | 3.00 | p = 0.39 |
| Not Performed | 2 (0.7%) | 111 (38.9%) | 137 (48.1%) | 18 (6.3%) | ||
| Supine Roll Test | ||||||
| Performed | 0 (0.0%) | 8 (17%) | 10 (21.3%) | 29 (61.7%) | 0.71 | p = 0.94 |
| Not Performed | 3 (0.7%) | 168 (40.9%) | 239 (58.2%) | 1 (0.2%) | ||
| Epley in office | ||||||
| Performed | 0 (0.0%) | 13 (25.5%) | 35 (68.6%) | 3 (5.9%) | 4.73 | p = 0.18 |
| Not Performed | 4 (1.0%) | 163 (39.9%) | 215 (52.6%) | 27 (6.6%) | ||
| Instructions for Epley at Home | ||||||
| Given | 1 (0.4%) | 83 (33.9%) | 142 (57.9%) | 19 (7.8%) | 5.78 | p = 0.10 |
| Not Given | 2 (0.9%) | 93 (43.7%) | 107 (50.2%) | 11 (5.2%) | ||
| Vestibular Suppressant Medication | ||||||
| Prescribed | 1 (0.4%) | 87 (33.1%) | 155 (58.9%) | 20 (7.6%) | 8.73 | p = 0.02 |
| Not Prescribed | 2 (1.0%) | 89 (45.6%) | 94 (48.2%) | 10 (5.1%) | ||
| Imaging | ||||||
| Performed | 0 (0.0%) | 2 (50.0%) | 2 (50.0%) | 0 (0.0%) | 2.35 | p = 1.00 |
| Not performed | 3 (0.7%) | 174 (38.3%) | 247 (54.4%) | 30 (6.6%) | ||
| Referral to specialist | ||||||
| Given | 1 (1.8%) | 30 (52.6%) | 23 (40.4%) | 3 (5.3%) | 7.50 | p = 0.05 |
| Not Given | 2 (0.5%) | 146 (36.4%) | 226 (56.4%) | 27 (6.7%) |
For all X2 values, (df1, df2) were (1, 458)
DISCUSSION
The goals of this study were to 1) characterize the clinical encounter process of patients diagnosed with BPPV in the PC setting relative to the 2017 AAO-HNS guidelines, and 2) to determine if differences in sex, race, and insurance status existed in KASs for the diagnosis and management. Our results show that clinical care guidelines for BPPV are underutilized in the PC setting and there were no differences in diagnostic procedures or management options as a function of sex, race, or insurance status.
Diagnostic Maneuvers
Despite a strong recommendation by AAO-HNS guidelines to perform a diagnostic maneuver (Dix-Hallpike or Supine roll), our study showed that only 45.6% of the cohort received such initial diagnostic maneuvers when diagnosed with BPPV in PC. This finding is consistent with prior work showing a lack of performance and/or documentation of performance of these maneuvers.6,12,13,18 Of note, among the cases in our cohort where a Dix-Hallpike maneuver was performed, 10.7% of them had documentation of the test result from the procedure (e.g., nystagmus). This lack of documentation is comparable to findings reported in the ED setting by Kerber et. al (2011, 2017)11,26 highlighting that providers were either unable to distinguish or document different forms of nystagmus when performing diagnostic maneuvers to make a clinical diagnosis of BPPV. When examining use of diagnostic maneuvers in terms of sex, race, and insurance status, no statistical difference was noted between the proportion of diagnostic maneuvers performed in our cohort. Overall, our results suggest sub-optimal adherence to guideline recommendations for use of diagnostic maneuvers to diagnose BPPV in the PC setting.
Imaging
The guidelines recommend against the use of radiographic imaging for patients who meet diagnostic criteria for BPPV.4,7 Patients in our cohort rarely received imaging (0.9%) as a diagnostic tool for BPPV. Additionally, there was no difference in imaging between patients as a function of sex, race, and insurance status. Our findings demonstrate most PC providers practice in alignment with the AAO-HNS recommendation to avoid imaging studies in suspected BPPV. This is in agreement with Dunlap and colleagues2 who reported 1.5% of patients seen in the PC setting for BPPV were referred for imaging. Our findings, coupled with the Dunlap study, show less frequent use of imaging in the PC setting relative to reports in the ED setting.4,14 The differences in rates of image studies ordered between the ED and PC settings are important to recognize because methods that target improved implementation of the guidelines in one setting (e.g., PC) may not be the most appropriate in another setting (e.g., ED).
Treatment Options
According to the 2017 guidelines, a strong recommendation was made the use of CRMs or referrals to specialists for repositioning procedures.4 As expected,5,12,14,18 completion of CRMs were limited. Only 11.1% of our cohort received the modified Epley maneuver during the initial PC visit, while >50% of our cohort received instructions on how to perform the maneuver at home. Although the guidelines do not directly recommend at-home treatments for BPPV, prior research has demonstrated that the use of at-home treatment can be effective in conjunction with instructions.27–29 However, at-home treatments have demonstrated lower success rates than in-clinic performance and may result in additional visits to the ED or a specialist.30–32 Therefore, in the case of at-home treatment, a clear follow-up plan with the provider may be indicated. Interestingly, 82.3% of our cohort was not given specific follow-up recommendations and there was limited documentation in medical records on symptom resolution. These findings indicate that the low utilization of the modified Epley maneuver may be an opportunity area for improving outcomes of patients in PC.
Medications
More than 50% of our cohort were prescribed vestibular suppressant medication for their symptoms. Although medication was often prescribed in conjunction with instructions for at-home Epley maneuvers, the 2017 clinical guidelines strongly recommend against use of vestibular suppressants. This finding was similar to results of a 2016 systematic review, which found a high percentage (58%) of patients with suspected BPPV received medication for treatment.1 However, recent work has reported a decline in such medication use in the PC setting.2,15 Medication recommendations among our cohort did not differ as a function of sex, race, and insurance status. Despite the overall improved national trends in avoiding medications for the treatment of BPPV, our cohort demonstrated high use of such medications, suggesting that continued education on medication use for the treatment of BPPV is warranted.
Guideline Adherence and Improvement Measures
Our study suggests implementation gaps between recommended best practice for BPPV and actual care practices in the PC setting. These gaps identified at our institution reflect similar gaps and inefficiencies documented in the ED literature related to use of the maneuvers for diagnosis and treatment. In summary, we identified key clinical recommendations that can be improved in the PC setting and these include specific history documentation, documentation of the diagnostic exam performed with associated test results, use of CRM as opposed to medication for the treatment of BPPV, increased provider utilization of a follow-up plan, and documentation symptom resolution. Our study found little use of diagnostic imaging for suspected BPPV, suggesting that implementation strategies to reduce imaging are unnecessary.
In the ED setting, Kerber et al. found that educational resources, including in-person teaching sessions, online models and apps, increased providers’ awareness of guidelines for BPPV diagnosis and increased the utility of best practices.14 Many may argue that PC providers may not have the additional time to complete training or educational BPPV modules due to substantial clinical responsibilities. Alternate methods to increase implementation of guidelines for diagnosing and treating BPPV may be explored. In light of successes with telehealth during the COVID-era,33–35 telehealth and novel first-line provider/specialist interactions is one potential avenue. Studies have examined the use of technology for BPPV treatment, with the most recent study showing combination use of video-oculography, telemedicine and artificial intelligence to help correctly identify dizziness and lead to favorable outcomes.30,32,36 In this system, the onus of work would not be solely on PC providers but could use a collaborative environment via telehealth. Regarding a follow-up plan, one potential solution is the use of an automated medical record messaging that follows up with patients diagnosed with and treated for BPPV to improve documentation of resolution of symptoms. This may be particularly useful given that the majority of our cohort received instructions for self-administered at home treatment. Among patients with unresolved symptoms, this type of system could also potentially trigger referral to a specialist. Prospective clinical trials are needed to evaluate and determine which set of implementation strategies and tools may be most efficacious in optimizing adherence to these guidelines in the PC setting.
Limitations
Although our study provides information on care processes in PC, the insight gained is from a single tertiary care institution (albeit includes 26 different PC sites) and may not generalize to the broader PC setting. Second, given the retrospective nature of the study, it is possible that for some patients care was provided, but not documented (e.g., performing a Dix-Hallpike without documentation). Third, this study focused on individuals who were diagnosed with BPPV in the PC setting and does not include those with BPPV who may have received an undifferentiated dizziness diagnosis. Their care pathways are likely different from the care pathways described for BPPV and may result in differences not examined in this study. Finally, this study was not designed to assess diagnostic accuracy in the PC setting. As such, we cannot speculate on the extent to which BPPV was accurately diagnosed. Clinical trials in PC are necessary to overcome some of these weaknesses; however, the knowledge gained from this study highlights important areas of opportunity to improve adherence to best-practice for diagnosing and managing BPPV.
CONCLUSION
Our study shows that there are gaps in the implementation of best practice in the diagnosis and management of BPPV in the PC setting as defined by the AAO-HNS guidelines, but that these gaps did not differ as a function of sex, race, or insurance status. Our results suggest the need for improved adherence to KASs for the diagnosis and treatment for BPPV. We must work to increase the use of diagnostic maneuvers, use of and access to CRM for treatment, and ensure follow-up with patients to confirm symptom resolution following treatment. A set of tailored implementation strategies are needed to improve adherence to these guidelines in the PC setting; however, additional research is necessary.
Supplementary Material
Supplemental Table 1: Description of the chart review process including variables and their description.
Acknowledgements:
We would like to acknowledge Dr. Nosayaba Osazuwa-Peters for his input during study design related to health equity.
Funding Source:
None. Amanda Del Risco is supported by a National Institutes of Health R25 grant (1R25DC020172-01) and Drs. Riska and Smith serve as mentors for this training grant. Kristal M. Riska is a salaried employee of Duke University. Sherri L. Smith is a salaried employee of Duke University and the Department of Veterans Affairs.
Footnotes
Conflict of Interest Declaration: The authors do not have any conflict of interest related to this work. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Supplemental Table 1: Description of the chart review process including variables and their description.