What is the current status of primary care in the diagnosis and treatment of patients with vertigo and dizziness in Switzerland? A national survey

Abstract

Background: Vertigo and dizziness are among the most frequent presenting symptoms in the primary care physicians' (PCPs) office. With patients facing difficulties in describing their complaints and clinical findings often being subtle and transient, the diagnostic workup of the dizzy patient remains challenging. We aimed to gain more insights into the current state of practice in order to identify the limitations and needs of the PCPs and define strategies to continuously improve their knowledge in the care of the dizzy patient.

Materials and methods: Board-certified PCPs working in Switzerland were invited to participate in an online survey. A descriptive statistical analysis was performed, and prospectively defined hypotheses were assessed using regression analyses.

Results: A vast majority of participating PCPs (n = 152) were familiar with the key questions when taking the dizzy patient's history and with performing provocation/repositioning maneuvers when posterior-canal benign paroxysmal positional vertigo (BPPV) was suspected (91%). In contrast, strong agreement that performing the alternating cover test (21%), looking for a spontaneous nystagmus with fixation removed (42%), and performing the head-impulse test (47%) were important was considerably lower, and only 19% of PCPs were familiar with lateral-canal BPPV treatment. No specific diagnosis could be reached in substantial fractions of patients with acute (35% [25; 50%], median [inter-quartile range]) and episodic/chronic (50% [40; 65.8%]) dizziness/vertigo. Referral to specialists was higher in patients with episodic/chronic dizziness than in acutely dizzy patients (50% [20.3; 75] vs. 30% [20; 50]), with younger PCPs (aged 30-40 years) demonstrating significantly increased odds of referral to specialists (odds ratio = 2.20 [1.01-4.81], p = 0.048).

Conclusion: The assessment of dizzy patients takes longer than that of average patients in most primary care practices. Many dizzy patients remain undiagnosed even after a thorough examination, highlighting the challenges faced by PCPs and potentially leading to frequent referrals to specialists. To address this, it is crucial to promote state-of-the-art neuro-otological examination and treatment techniques that are currently neglected by most PCPs, such as "HINTS" and lateral-canal BPPV treatment. This can help reduce referral rates allowing more targeted treatment and referrals.

Keywords: bedside examination; diagnosis; dizziness; primary care; survey; vertigo.

Figure 1

Response patterns of participating PCPs are shown for a series of questions when taking the dizzy patient's history. For each question, the percentage of PCPs and the level of agreement they indicated (ranging from “disagree at all” to “agreed for sure”) are illustrated. For each question, the number (n) of valid replies is provided in brackets.

Figure 2

Response patterns of participating PCPs are shown for a series of clinical exams when assessing the dizzy patient. For each question, the percentage of PCPs and the level of importance they indicated (ranging from “not important at all” to “very important”) are illustrated. For each question, the number (n) of valid replies is provided in brackets.

Figure 3

PCPs' performance for various scores is illustrated. This included the following scores: timing and triggers (A) asking for the frequency and duration of dizzy spells, triggers (specific body movements/positions, specific situations), accompanying symptoms (23), HINTS (B) performing the head-impulse test, looking for gaze-evoked nystagmus and for skew deviation, HINTS+ (C) HINTS plus looking for new-onset unilateral hearing loss, hearing (D) testing for new-onset hearing loss, performing otoscopy, ataxia of stance and gait (E) assessment of walking on the line (with/without viewing), Romberg test, Unterberger stepping test, subtle oculomotor and vestibular signs (F) performing HINTS and testing for spontaneous nystagmus with both fixation preserved and removed, “essential” in acute vertigo/dizziness (G) testing for HINTS+, assessment of walking on the line (with/without viewing), Romberg test and for spontaneous nystagmus with both fixation preserved and removed, “essential” in episodic/chronic vertigo/dizziness (H) performing provocation maneuvers, the head-impulse test, assessments of walking on the line (with/without viewing), and the Romberg test, “essential” in suspected BPPV (I) asking for timing and triggers and performing provocation maneuvers, superscore acute vertigo/dizziness (J) essential in acute vertigo/dizziness and timing and triggers, superscore for episodic/chronic vertigo/dizziness (K) essential in episodic/chronic vertigo/dizziness and timing and triggers, education (L) analog media (hands-on courses, workshops, national recommendations, and practical recommendations), and digital media (smartphone apps and webinars).

Figure 4

PCPs indicated in what percentage of cases various symptoms and findings will always or frequently trigger further evaluation.