Clinical Practice Guideline for Acute Vertigo ? It’s Time

Alan Desmond
October 5, 2015

There is no current Clinical Practice Guideline (CPG) for acute vertigo, but I think there should be. Based on published research, there are several things that should be done, and some current practices that need to be reconsidered.

A true CPG involves many specialists from a variety of specialties, researching hundreds of applicable peer reviewed journal articles. My “faux” CPG presented below does not live up to that standard, but I hope you find it interesting and that it sparks some interest from one of the related specialty societies.

Statement of the Problem:

For the most part, the data presented below is obtained from the Emergency Department (ED) setting. This is so for two reasons: 1. The ED is a common entry point for a patient suffering acute vertigo, and 2. hospital-based ED’s seem to have better, or at least more accessible, records than do many independently operated primary care offices.

The number of patients seeking medical care for dizziness and vertigo is large and rising, in a population (age 65+) that is also large and rising. The most recent (2010) National Ambulatory Care Survey reveals that “vertigo-dizziness is the fourth most common reason for an ED visit in the 65+ age group for males and the sixth most for females. Kerber et al (2008) report that
vertigo-dizziness presentations accounted for 2.5% of all ED presentations during the 10-year period. from 1995 to 2004, which accounts for an increase of 37% over that period of time.

Costs associated with these patient accounts for approximately four percent of ED expense, with the total estimated to be 4 billion a year in 2011 in the United States. The estimated number of 2011 US ED visits for vertigo-dizziness was 3.9 million. According to Saber Tehrani (2013)The proportion undergoing diagnostic imaging by computed tomography (CT), magnetic resonance imaging (MRI), or both in 2011 was estimated to be 39.9% (39.4% CT, 2.3% MRI). The mean per-ED-dizziness-visit cost was $1,004 in 2011 dollars. The total extrapolated 2011 national costs were $3.9 billion. Neuroimaging was estimated to account for about 12% of the total costs for dizziness visits in 2011 (CT scans $360 million, MRI scans $110 million).”

Kerber et al (2008) report that “The utilization of computerized tomography and magnetic resonance imaging (CT/MRI) increased 169% from 1995 to 2004, which was more than any other test. The rate of central nervous system diagnoses (e.g., cerebrovascular disease or brain tumor) did not increase over time.”

Summary of the Problem

As the population ages, the number of patients presenting with vertigo-dizziness will increase rapidly. The examination of these patients is expensive. There is a trend towards more neuro-imaging in these patients without evidence to support the associated costs.

Next week, we continue with some suggestions (Action Statements) for more efficient/effective care of patients presenting with vertigo-dizziness.

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