When patients arrive in the Emergency Department with the complaint of dizziness or vertigo, there is a 40 to 50% chance that a cranial CT will be ordered. When that same patient is evaluated through telehealth by a specialist with advanced knowledge and skill in evaluating dizziness and vertigo, there is only a 2% chance that a cranial CT will be ordered. This is a startling, depressing and exciting statistic that should get the attention of anyone concerned about the costs of healthcare.
I think I am mixing idioms here, but I sometimes feel like whenever I address the inefficiencies and obstacles vestibular patients often face before getting effective care, I feel like I am diving into the Sisyphean task of Tilting at Windmills. When science and evidence fail to convince, you might as well give Greek mythology and classic Spanish literature a shot.
Seven years ago, I did a four part blog titled : Clinical Practice Guideline for Acute Vertigo? It’s Time
In 2017, I updated some statistics provided by more recent research from Dr. David Newman-Toker : Acute Vertigo: Benign or Stroke?
Practice Guidelines for Acute Vertigo Long Overdue
If you have the time and interest, please click on the links mentioned above. If not, let me summarize:
- CT scans are a bad idea for identifying emerging posterior fossa stroke and/or identifying the cause of acute vertigo
- There is no movement towards a Clinical Practice Guideline for acute vertigo
- The HINTS exam, in the hands of an experienced examiner is far superior to CT scans or even MRI for early detection of posterior fossa stroke
So, the facts haven’t changed. What about the acceptance of those facts? I ran across a funny expression about the evolution of acceptance of new scientific ideas. The process is as follows: “1. We don’t believe you. 2. It’s not important. 3. We knew it all along. 4. Yes, but we will call it something else” (Chadwick-Dearing-Oliver.org).
I would say that regarding the acceptance of using a brief physical exam such as the HINTS prior to imaging for acute vertigo, we are in the second stage.
Some front line clinicians are resistant to changing their approach for a variety of reasons. While other front line clinicians whom have adopted the HINTS exam see the obvious benefits to them (quicker test results), the patient (more accurate test results and better chance at a specific diagnosis), and the health care system (more than 90% reduction in unnecessary imaging).
Standard of care and best practice often conflict. There are a number of factors that account for physicians prioritizing standard of care over best practice. Standard of care, in a court of law, refers to minimally acceptable “reasonable” practice. There is no legal consequence to performing outdated, ineffective, costly tests or procedures, as long as a small percentage of peers are doing the same.
There are many, but limited, benefits to having a Clinical Practice Guideline for acute vertigo. Multiple specialties agree on best practice, and they offer a measure of liability protection in the event of a missed diagnosis. In a fee for service health care system, there is no direct disincentive to performing excessive imaging. In a capitated system, there is incentive to minimize wasteful testing with increased emphasis on efficiency and cost effectiveness.
Since the Clinical Practice Guideline for BPPV came out in 2008, there has been a measurable increase in awareness and availability of effective treatment, and a reduction in the use of meclizine for BPPV. Is it possible that a Clinical Practice Guideline for acute vertigo could result in more accurate diagnosis and more effective treatment, while at the same time dramatically reducing cost? There is only one way to find out.