Kevin A Kerber1, Laura Damschroder2, Thomas McLaughlin3, Devin L Brown1, James F Burke1, Steven A Telian4, Alexander Tsodikov5, Angela Fagerlin6, Lawrence C An7, Lewis B Morgenstern8, Jane Forman9, Sandeep Vijan9, Brigid Rowell1, William J Meurer10. 1. Department of Neurology, University of Michigan, Ann Arbor, MI. 2. Implementation Pathways, LLC, Ann Arbor, MI. 3. Department of Emergency Medicine, Christus Spohn Health System, Corpus Christi, TX. 4. Department of Otolaryngology, University of Michigan, Ann Arbor, MI. 5. Department of Biostatistics, School of Public Health, University of Michigan, Ann Arbor, MI. 6. Department of Population Health Sciences, University of Utah, Salt Lake City, UT; Salt Lake City VA Center for Informatics Decision Enhancement and Surveillance, Salt Lake City, UT. 7. Department of Internal Medicine, University of Michigan, Ann Arbor, MI; Center for Health Communication and Research, University of Michigan, Ann Arbor, MI. 8. Department of Neurology, University of Michigan, Ann Arbor, MI; Department of Emergency Medicine, University of Michigan, Ann Arbor, MI. 9. Department of Internal Medicine, University of Michigan, Ann Arbor, MI. 10. Department of Neurology, University of Michigan, Ann Arbor, MI; Department of Emergency Medicine, University of Michigan, Ann Arbor, MI. Electronic address: wmeurer@med.umich.edu.
Abstract
STUDY OBJECTIVE: We evaluated a strategy to increase use of the test (Dix-Hallpike's test [DHT]) and treatment (canalith repositioning maneuver [CRM]) for benign paroxysmal positional vertigo in emergency department (ED) dizziness visits. METHODS: We conducted a stepped-wedge randomized trial in 6 EDs. The population was visits with dizziness as a principal reason for the visit. The intervention included educational sessions and decision aid materials. Outcomes were DHT or CRM documentation (primary), head computedtomography (CT) use, length of stay, admission, and 90-day stroke events. The analysis was multilevel logistic regression with intervention, month, and hospital as fixed effects and provider as a random effect. We assessed fidelity with monitoring intervention use and semistructured interviews. RESULTS: We identified 7,635 dizziness visits during 18 months. The DHT or CRM was documented in 1.5% of control visits (45/3,077; 95% confidence interval 1% to 1.9%) and 3.5% of intervention visits (159/4,558; 95% confidence interval 3% to 4%; difference 2%, 95% confidence interval 1.3% to 2.7%). Head CT use was lower in intervention visits compared with control visits (44.0% [1,352/3,077] versus 36.9% [1,682/4,558]). No differences were observed in admission or 90-day subsequent stroke risk. In fidelity evaluations, providers who used the materials typically reported positive clinical experiences but provider engagement was low at facilities without an emergency medicine residency program. CONCLUSION: These findings provide evidence that an implementation strategy of a benign paroxysmal positional vertigo-focused approach to ED dizziness visits can be successful and safe in promoting evidence-based care. Absolute rates of DHT and CRM use, however, were still low, which relates in part to our broad inclusion criteria for dizziness visits.
RCT Entities:
STUDY OBJECTIVE: We evaluated a strategy to increase use of the test (Dix-Hallpike's test [DHT]) and treatment (canalith repositioning maneuver [CRM]) for benign paroxysmal positional vertigo in emergency department (ED) dizziness visits. METHODS: We conducted a stepped-wedge randomized trial in 6 EDs. The population was visits with dizziness as a principal reason for the visit. The intervention included educational sessions and decision aid materials. Outcomes were DHT or CRM documentation (primary), head computed tomography (CT) use, length of stay, admission, and 90-day stroke events. The analysis was multilevel logistic regression with intervention, month, and hospital as fixed effects and provider as a random effect. We assessed fidelity with monitoring intervention use and semistructured interviews. RESULTS: We identified 7,635 dizziness visits during 18 months. The DHT or CRM was documented in 1.5% of control visits (45/3,077; 95% confidence interval 1% to 1.9%) and 3.5% of intervention visits (159/4,558; 95% confidence interval 3% to 4%; difference 2%, 95% confidence interval 1.3% to 2.7%). Head CT use was lower in intervention visits compared with control visits (44.0% [1,352/3,077] versus 36.9% [1,682/4,558]). No differences were observed in admission or 90-day subsequent stroke risk. In fidelity evaluations, providers who used the materials typically reported positive clinical experiences but provider engagement was low at facilities without an emergency medicine residency program. CONCLUSION: These findings provide evidence that an implementation strategy of a benign paroxysmal positional vertigo-focused approach to ED dizziness visits can be successful and safe in promoting evidence-based care. Absolute rates of DHT and CRM use, however, were still low, which relates in part to our broad inclusion criteria for dizziness visits.
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