Effectiveness of care in acute dizziness presentations

European Archives of Oto-Rhino-Laryngology https://doi.org/10.1007/s00405-019-05470-0 OTOLOGY Effectiveness of care in acute dizziness presentations Mikael Granberg Sandlund1 · Anna Diamant1 · Gabriel Granåsen2 · Jonatan Salzer1 Received: 12 March 2019 / Accepted: 9 May 2019 © The Author(s) 2019 Abstract Purpose This study aims to evaluate whether a management algorithm has improved the effectiveness of care for dizzy patients at Umeå University Hospital. Methods This was an interventional study using medical records to collect data for acute dizziness presentations before (period 1, 2012–2014) and after (period 2, 2016–2017) the implementation of a management algorithm. Outcomes were changes in a set of pre-defined effectiveness markers and health economic effects. Results Total n = 2126 and n = 1487 acute dizziness presentations were identified in period 1 and 2, respectively. Baseline characteristics were similar. The proportion of patients undergoing Dix–Hallpike testing increased, 20.8% [95% confidence interval (CI) 18.8–23.0%] vs. 37.7% (95% CI 35.2–40.2%), as did BPPV diagnoses, 7.6% (95% CI 6.6–8.8%) vs. 15.3% (95% CI 13.6–17.3%). Hospitalization became less common, 61.5% (95% CI 59.4–63.6%) vs. 47.6% (95% CI 45.1–50.2%). The proportion undergoing any neuroradiological investigation decreased, 44.8% (95% CI 42.7–47.0%) vs. 36.3% (95% CI 33.8–38.7%) with a shift from CT to MRI, with unchanged sensitivity for diagnosing cerebrovascular causes. The average cost for the care of one dizzy patient decreased from $2561 during period 1 to $1808 during period 2. Conclusions This study shows that the implementation of a management algorithm for dizzy patients was associated with improved effectiveness of care. Keywords Dizziness · Vertigo · Health economics · Management algorithms · Effectiveness of care Introduction Dizziness and vertigo, hereafter termed “dizziness” for practical reasons, [1] are common symptoms presented by patients at emergency departments (EDs) [2]. Several studies have shown that there is room for improvement in the care of dizzy patients. A large proportion of dizzy patients remain undiagnosed [3, 4], patients often revisit the ED several times for the same complaints [4] and the use of neuroradiological investigations is increasing, inflating healthcare spending [5, 6]. Fear of missed strokes among dizzy patients may be one of the factors behind this trend, although * Jonatan Salzer 1 Department of Pharmacology and Clinical Neuroscience, Section of Neurology, Umeå University, SE‑901 87 Umeå, Sweden 2 Department of Public Health and Clinical Medicine, Epidemiology and Global Health Unit, Umeå University, Umeå, Sweden peripheral vestibular, non-neurological cardiovascular, respiratory, metabolic and psychiatric causes are more common causes of dizziness than stroke and TIA according to most reports [3, 4, 6–9]. A retrospective study at Umeå University Hospital covering 2012–14 showed that more than half of ED patients with dizziness remained undiagnosed despite an unusually high degree ( > 60%) of hospitalization; and that few underwent positional testing for the most common peripheral vestibular causes of dizziness [4]. These findings suggested that this hospital had much to gain from measures aiming at increasing the effectiveness of care for dizzy patients. Thus, in the spring of 2015, a management algorithm (“Project Imbalance”) for the care for dizzy patients at Umeå University Hospital was launched. The objectives of the present study were to investigate, compare and report any changes in the effectiveness of care, as defined below, for dizzy patients at Umeå University Hospital after the implementation of this management algorithm for dizziness. 13 Vol.:(0123456789) European Archives of Oto-Rhino-Laryngology Materials and methods Study population and study design This was an interventional study comparing effectiveness of care for dizzy patients before and after the implementation of a management algorithm. All patient visits to the Umeå University Hospital ED, the only hospital serving this catchment area, due to dizziness during 2012–01-01 to 2014–1231 (period 1) vs. 2016–01-01 to 2017–12-31 (period 2) were analyzed. Patients were triaged by ED nurses who identified “dizziness” as the main reason for contact, including vertigo and giddiness (Swedish: “yrsel/svindel”) using the standardized RETTS® (Rapid Emergency Triage and Treatment System) triage system [10]. Exclusion criteria were age below 18 years, classified or missing charts, patients referred to primary care without seeing an ED physician, and if there was no mention of dizziness or similar symptom(s) in the charts. Data extraction Data abstracted from medical charts were age, gender, risk factors for stroke, antiplatelet and anticoagulant medications, past cardiovascular illnesses, diagnostic examinations, associated symptoms and clinical neurological findings, inpatient care data, otolaryngology department consultation, dates, discharge diagnoses and any stroke diagnosis within 90 days after the index ED visit. Data regarding Dix–Hallpike testing were mistakenly only collected for two of the years, 2012–13, during period 1 which is why 2014 was excluded from the comparisons of Dix–Hallpike testing frequencies. Data abstraction for period 1 was performed as previously detailed [4]. For period 2, data were collected by a medical student (MGS) and uncertainties were discussed together with the senior author (JS), a neurologist, who also validated all cerebrovascular diagnoses and acute vestibular syndromes (AVS), including all cases with suspected stroke or AVS, according to study diagnostic criteria (below). Missing data were considered not present. The project received ethical committee approval. Definitions and diagnoses AVS was defined as new (since ≤ 72 h) ongoing and continuous dizziness fulfilling at least two of the following criteria: (a) nystagmus (b) nausea or vomiting (c) gait or balance disturbance during physical examination, and (d) discomfort with head movement. Focal neurological deficits were defined as any sensory or motor deficit(s) including language signs (dysarthria or aphasia), disrupted function of cranial nerves, or neglect. The definition of ataxia was 13 dysmetria during heel–shin- or finger–nose-test, inability to sit unaided, or gait ataxia. Stroke and TIA were defined as sudden onset focal neurological deficit (not better explained by other factors) or acute ischemia or non-traumatic intracerebral or subarachnoidal bleeding seen on computed tomography (CT) or magnetic resonance imaging (MRI). A diagnosis of transient ischemic attack (TIA) required regress of symptoms within 24 h. A neuroradiological investigation was considered “diagnostic” when revealing findings with a plausible association with the presenting symptoms. Similar to period 1 [4], ICD-10 diagnoses for period 2 were left unchanged with the following pre-planned excep (...truncated)