HSC Section 8_April 2017

Research Original Investigation

Statistical Model for the Prediction of Common Vestibular Diagnoses

a physician. 20 Similarly, using a structured questionnaire as support for medical decision making for viral respiratory in- fection showed thatmilitarymedics could reduce the need for physician referrals by 37%. 21

The goal of initiating a quality improvement project was to alter the clinical practice paradigm for vestibular disorders away from a physician-centric model. Barriers to this are patient and clinician acceptance of a potential nonphysician- based assessment and treatment encounter, limited evi- dence demonstrating efficacy and efficiency of such a pro- gram, anduncertainty in key areas of the clinical pathway used for guiding decisionmaking. The results of this study can pro- vide evidence for patients and referring clinicians as to the di- agnostic accuracy of pre-encounter questionnaires and the po- tential improvement in clinical efficiency. Clinical efficiency is becoming an important metric used to evaluate clinician quality. Time tonext appointment, enough time spentwith the patient, and clinic on-time performance are all metrics being used by health care systems to measure the quality of ser- vices. Structured systems for triaging patients into those re- quiring a physician evaluationvs ancillary clinicians have been effective. In a primary care setting, access to the practice in- creased by almost 30% and more than 80% of patients tri- aged to a nonphysician cliniciandidnot need to follow-upwith

Conclusions The outcomes in this study have been used in our institution to improve access by using ancillary clinicians. For example, patients with BPPV can be seen within 1 week for vestibular therapy without waiting for a physician appointment. A simi- lar triagemodel involving vestibular disorders has shown high patient satisfaction, likely due to simultaneous evaluation and treatment. 22 In our practice, patients with substantial head- ache component and prediction of vestibular migraine are of- feredneurological consultationas a best first assessment. Free- ing the otolaryngologist’s schedule fromnonotologic patients with vestibular disordersmay allow faster access for those pre- dicted to have Ménière’s disease or other otologic conditions.

13 . López-Escámez JA, López-Nevot A, Gámiz MJ, Moreno PM. Effectiveness of a structured questionnaire for diagnosis of Menière’s disease in the first visit. Acta Otorhinolaryngol Belg . 2000;54 (4):451-458 . 14 . Radtke A, Neuhauser H, von Brevern M, Hottenrott T, Lempert T. Vestibular migraine—validity of clinical diagnostic criteria. Cephalalgia . 2011;31(8):906-913 . 15 . Arroyo-Quiroz C, Kurth T, Cantu-Brito C, Lopez-Ridaura R, Romieu I, Lajous M. Lifetime prevalence and underdiagnosis of migraine in a population sample of Mexican women. Cephalalgia . 2014;34(13):1088-1092 . 16 . Diamond ML. The role of concomitant headache types and non-headache co-morbidities in the underdiagnosis of migraine. Neurology . 2002;58(9)(suppl 6):S3-S9 . 17 . Bittar RS, Lins EM. Clinical characteristics of patients with persistent postural-perceptual dizziness. Braz J Otorhinolaryngol . 2015;81(3):276- 282 . 18 . Ruckenstein MJ, Staab JP. Chronic subjective dizziness. Otolaryngol Clin North Am . 2009;42(1):71-77, ix . 19 . Staab JP. Chronic subjective dizziness. Continuum (Minneap Minn) . 2012;18(5 Neuro- otology):1118-1141 . 20 . Thorn J, Maun A, Bornhöft L, et al. Increased access rate to a primary health-care centre by introducing a structured patient sorting system developed to make the most efficient use of the personnel: a pilot study. Health Serv Manage Res . 2010;23(4):166-171 . 21 . Golan D, Zagetzki M, Vinker S. Acute respiratory infections: can a non-physician practitioner triage and treat patients by using an algorithm? experience in a military primary care clinic. Isr Med Assoc J . 2005;7(9):578-582 . 22 . Kasbekar AV, Mullin N, Morrow C, Youssef AM, Kay T, Lesser TH. Development of a physiotherapy-led balance clinic: the Aintree model. J Laryngol Otol . 2014;128(11):966-971 .

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ARTICLE INFORMATION Published Online: February 25, 2016. doi: 10.1001/jamaoto.2015.3663 .

Author Contributions: Drs Friedland and Tarima had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. Study concept and design: Friedland. Acquisition, analysis, or interpretation of data: Friedland, Tarima, Erbe, Miles. Drafting of the manuscript: Friedland, Tarima. Critical revision of the manuscript for important intellectual content: Friedland, Tarima, Erbe, Miles. Statistical analysis: Friedland, Tarima. Obtained funding: Friedland, Tarima. Administrative, technical, or material support: Friedland, Erbe, Miles. Study supervision: Friedland. Conflict of Interest Disclosures: None reported. Funding/Support: This project was supported by the National Center for Advancing Translational Sciences, National Institutes of Health (NIH), through grant No. 8UL1TR000055. Role of the Funder/Sponsor: The NIH had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication. Disclaimer: The contents of this article are solely the responsibility of the authors and do not necessarily represent the official views of the NIH. Additional Contributions: Neil Shepard, PhD, and Scott Eggers, MD, Mayo Clinic, Rochester, Minnesota, provided the vestibular disorders questionnaire and allowed it to be described in this article. No compensation was provided to them.

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epidemiological survey and patient management in the emergency room. Neurol Sci . 2004;25(suppl 1):S24-S25 .

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