Abstract
This cohort study uses data from the National Ambulatory Medical Care Survey to evaluate the prevalence of patient visits to ambulatory care clinics for benign paroxysmal positional vertigo and whether physicians’ diagnostic and treatment recommendations adhered to clinical practice guidelines over time.
Benign paroxysmal positional vertigo (BPPV), the most common vestibular disorder, is often diagnosed in primary care settings.1 Clinical practice guidelines published by the American Academy of Otolaryngology–Head and Neck Surgery Foundation in 2008 and 2017 recommend against imaging for the diagnosis of BPPV and vestibular suppressant medications for the treatment of BPPV.2,3 Despite these recommendations, physicians’ diagnostic and treatment choices for dizziness vary, with medications being the most frequent treatment prescribed in primary care settings.4 We examined 12 years of data (January 1, 2004, to December 31, 2015) from the National Ambulatory Medical Care Survey to evaluate the prevalence of visits to ambulatory care clinics for BPPV and whether physicians’ diagnostic and treatment recommendations, stratified by specialty, adhered to clinical practice guidelines over time.
Methods
We identified adult visits (patients aged >18 years) for BPPV by International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) diagnosis code (386.11), classified them by physician specialty (primary care, otolaryngology, or neurology), and investigated whether imaging (computed tomography, magnetic resonance imaging, or positron emission tomography) was ordered and whether antivertigo or antiemetic medications were prescribed. To increase the precision of our estimates, we combined the data into 3-year intervals and estimated the number of visits for BPPV, the adjusted prevalence of visits for BPPV (controlling for age, sex, race, ethnicity, reason for visit, and insurance), and the percentage of visits in which imaging was ordered and medications were prescribed. Visits were considered guideline adherent if the physician did not order imaging and did not prescribe antivertigo medications. Data were analyzed from January 1, 2004, to December 31, 2015, using Stata, version 15.1 (Stata Corp) and accounted for the complex survey design.5 This analysis was approved by the University of Pittsburgh Institutional Review Board as an exempt study; patient consent was waived because the study used deidentified health data.
Results
Both the number and prevalence of ambulatory care visits for BPPV increased from 846 860 visits at a rate (SE) of 3.8 (1.0) per 10 000 visits in 2004-2006 to 1.94 million visits at a rate of 8.0 (1.2) per 10 000 visits in 2013-2015 (Table). In 2013-2015, an estimated (SE) 56.6% (6.5%) of the visits were from women, 87.2% (4.8%) were from white patients, 47.4% (7.7%) were to primary care physicians, and the mean (SE) age of patients was 67.1 (2.0) years. Overall, prescription of antivertigo or antiemetic medications decreased from a high estimate (SE) of 50.3% (9.2%) of visits in 2007-2009 to a low of 16.4% (4.5%) of visits in 2013-2015. This change was primarily due to a decrease in mean (SE) primary care physician medication prescription (from 61.2% [11.2%] in 2007-2009 to 20.5% [8.1%] in 2013-2015). The percentage of visits in which imaging was ordered was low, ranging from an estimated (SE) 1.4% (1.5%) in 2005-2006 to 5.8% (2.5%) in 2010-2012, although these estimates had large SEs. Primary care physicians had the lowest adherence to guidelines in 2005-2006 (43.4%), but adherence significantly improved in 2013-2015 (79.5%), reaching rates similar to those of otolaryngologists and neurologists (Figure).
Table. Weighted Estimates of Visits for Benign Paroxysmal Positional Vertigo, Visit Rates, and Visit Characteristics.
| Characteristic | Weighted Estimate, % (SE) | |||
|---|---|---|---|---|
| 2004-2006 | 2007-2009 | 2010-2012 | 2013-2015 | |
| Visits, No. | 864 860 | 1 528 782 | 1 351 561 | 1 896 941 |
| Visit rate per 10 000 visits | 3.8 (1.0) | 6.4 (1.5) | 5.8 (1.1) | 8.0 (1.2) |
| Patient characteristics | ||||
| Age, mean (SE), y | 55.8 (3.6) | 53.9 (2.8) | 61.3 (2.8) | 67.1 (2.0) |
| Female | 65.5 (1.2) | 74.0 (8.1) | 61.1 (8.9) | 56.6 (6.5) |
| White | 84.8 (12.3) | 90.8 (7.1) | 76.7 (7.6) | 87.2 (4.8) |
| Private insurance | 60.6 (11.0) | 70.4 (7.3) | 59.3 (8.7) | 44.9 (7.3) |
| Medicare | 27.2 (9.0) | 23.0 (6.8) | 28.9 (7.2) | 44.6 (7.3) |
| Medicaida | 11.1 (6.8) | 5.9 (4.4) | 2.7 (2.2) | 6.6 (3.3) |
| Other insurancea,b | 0 | 0.7 (0.6) | 2.6 (1.6) | 6.9 (2.9) |
| Physician characteristics | ||||
| Primary care | 45.2 (13.6) | 73.6 (8.3) | 49.7 (9.4) | 47.4 (7.7) |
| Otolaryngology | 36.0 (9.3) | 13.5 (5.3)a | 32.9 (7.3) | 23.2 (5.5) |
| Neurologya | 10.9 (4.5) | 9.2 (4.3) | 14.5 (4.1) | 12.8 (4.8) |
| Other specialtiesa,c | 7.9 (6.2) | 3.7 (2.4) | 2.9 (1.9) | 16.6 (7.2) |
| Imaging ordereda,d | 1.4 (1.5) | 1.3 (0.8) | 5.8 (2.5) | 4.3 (1.8) |
| Medication prescribed | 28.4 (10.0)a | 50.3 (9.2) | 25.9 (9.8)a | 16.4 (4.5) |
The SE was greater than 30% of the estimate.
Other insurance included workers’ compensation, self pay, no charge, other, or unknown.
Other specialties included cardiovascular, general surgery, ophthalmology, or other.
First estimate based on 2005-2006 data only because data were not available in 2004.
Figure. Percentage of Ambulatory Care Visits for Benign Paroxysmal Positional Vertigo (BPPV) That Were Guideline Adherent.
Percentage of visits for BPPV that were guideline adherent across 3-year intervals by physician specialty. There was a significant linear trend for primary care (β coefficient = 0.71; 95% CI, 0.06-1.37). Imaging data were not available for 2004; the SE was greater than 30% of estimates for primary care in 2005-2006.
Discussion
The prevalence of ambulatory care visits for BPPV increased over time, which is likely a result, in part, of increased practitioner awareness and screening for BPPV. Adherence to guidelines by specialists was relatively high during the period examined, while adherence to guidelines by primary care physicians improved. Despite this improvement, antivertigo or antiemetic medications were still prescribed in 20.5% of primary care visits in 2013-2015.
Although this analysis was limited by its reliance on the ICD-9-CM code for diagnosis and physician recommendations that potentially could be for other problems noted during the visit, similar analyses have been used to evaluate adherence to clinical practice guidelines.6 According to guidelines published by the American Academy of Otolaryngology–Head and Neck Surgery Foundation, physicians should provide the appropriate particle repositioning maneuver or refer the patient to a trained health care professional rather than recommend imaging or medication management.2,3 Because primary care physicians are the likely entry point for most patients with BPPV, their understanding of and adherence to the clinical practice guidelines is important. Our results suggest that opportunities remain to improve the value of ambulatory care for patients with BPPV by limiting inappropriate medication prescription.
References
- 1.von Brevern M, Radtke A, Lezius F, et al. Epidemiology of benign paroxysmal positional vertigo: a population based study. J Neurol Neurosurg Psychiatry. 2007;78(7):710-715. doi: 10.1136/jnnp.2006.100420 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2.Bhattacharyya N, Baugh RF, Orvidas L, et al. ; American Academy of Otolaryngology-Head and Neck Surgery Foundation . Clinical practice guideline: benign paroxysmal positional vertigo. Otolaryngol Head Neck Surg. 2008;139(5)(suppl 4):S47-S81. doi: 10.1016/j.otohns.2008.08.022 [DOI] [PubMed] [Google Scholar]
- 3.Bhattacharyya N, Gubbels SP, Schwartz SR, et al. Clinical practice guideline: benign paroxysmal positional vertigo (update). Otolaryngol Head Neck Surg. 2017;156(3_suppl):S1-S47. doi: 10.1177/0194599816689667 [DOI] [PubMed] [Google Scholar]
- 4.Grill E, Penger M, Kentala E. Health care utilization, prognosis and outcomes of vestibular disease in primary care settings: systematic review. J Neurol. 2016;263(suppl 1):S36-S44. doi: 10.1007/s00415-015-7913-2 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 5.National Center for Health Statistics AHCD 2015 NAMCS micro-data file documentation. ftp://ftp.cdc.gov/pub/Health_Statistics/NCHS/Dataset_Documentation/NAMCS/doc2015.pdf. Accessed April 26, 2018.
- 6.Bhattacharyya N, Kepnes LJ. Patterns of care before and after the adult sinusitis clinical practice guideline. Laryngoscope. 2013;123(7):1588-1591. doi: 10.1002/lary.23980 [DOI] [PubMed] [Google Scholar]