Diagnostic accuracy and usability of the EMBalance decision support system for vestibular disorders in primary care: proof of concept randomised controlled study results

Doris-Eva Bamiou, Dimitris Kikidis, Thanos Bibas, Nehzat Koohi, Nora Macdonald, Christoph Maurer, Floris L Wuyts, Berina Ihtijarevic, Laura Celis, Viviana Mucci, Leen Maes, Vincent Van Rompaey, Paul Van de Heyning, Irwin Nazareth, Themis P Exarchos, Dimitrios Fotiadis, Dimitrios Koutsouris, Linda M Luxon, Doris-Eva Bamiou, Dimitris Kikidis, Thanos Bibas, Nehzat Koohi, Nora Macdonald, Christoph Maurer, Floris L Wuyts, Berina Ihtijarevic, Laura Celis, Viviana Mucci, Leen Maes, Vincent Van Rompaey, Paul Van de Heyning, Irwin Nazareth, Themis P Exarchos, Dimitrios Fotiadis, Dimitrios Koutsouris, Linda M Luxon

Abstract

Background: Dizziness and imbalance are common symptoms that are often inadequately diagnosed or managed, due to a lack of dedicated specialists. Decision Support Systems (DSS) may support first-line physicians to diagnose and manage these patients based on personalised data.

Aim: To examine the diagnostic accuracy and application of the EMBalance DSS for diagnosis and management of common vestibular disorders in primary care.

Methods: Patients with persistent dizziness were recruited from primary care in Germany, Greece, Belgium and the UK and randomised to primary care clinicians assessing the patients with (+ DSS) versus assessment without (- DSS) the EMBalance DSS. Subsequently, specialists in neuro-otology/audiovestibular medicine performed clinical evaluation of each patient in a blinded way to provide the "gold standard" against which the + DSS, - DSS and the DSS as a standalone tool (i.e. without the final decision made by the clinician) were validated.

Results: One hundred ninety-four participants (age range 25-85, mean = 57.7, SD = 16.7 years) were assigned to the + DSS (N = 100) and to the - DSS group (N = 94). The diagnosis suggested by the + DSS primary care physician agreed with the expert diagnosis in 54%, compared to 41.5% of cases in the - DSS group (odds ratio 1.35). Similar positive trends were observed for management and further referral in the + DSS vs. the - DSS group. The standalone DSS had better diagnostic and management accuracy than the + DSS group.

Conclusion: There were trends for improved vestibular diagnosis and management when using the EMBalance DSS. The tool requires further development to improve its diagnostic accuracy, but holds promise for timely and effective diagnosis and management of dizzy patients in primary care.

Trial registration number: NCT02704819 (clinicaltrials.gov).

Keywords: Decision support system; Diagnosis; Dizziness; Randomised control trial.

Conflict of interest statement

The authors declare that they have no competing interest.

© 2021. The Author(s).

Figures

Fig. 1
Fig. 1
A–E provide some example screenshots for the history and examination taking process with the DSS. A DSS guided history taking—questions regarding vertigo and instability; B DSS guided history taking—questions regarding general symptoms; C, D, E Examples of DSS guided clinical examination with videos/instructions
Fig. 2
Fig. 2
The flowchart depicts the patient progression through the phases of the EMBalance study, from screening to follow-up
Fig. 3
Fig. 3
Agreement percentage between specialists and non-specialists with and without DSS in management plan
Fig. 4
Fig. 4
Patient referral (percentage) for management in + DSS and − DSS group. NR no referral, R referral

References

    1. Colledge NR, Wilson JA, Macintyre CC, MacLennan WJ. The prevalence and characteristics of dizziness in an elderly community. Age Ageing. 1994;23:117–120.
    1. Hobeika CP. Equilibrium and balance in the elderly. Ear Nose Throat J. 1999;78:558–566.
    1. Kovacs E, Wang X, Grill E. Economic burden of vertigo: a systematic review. Health Econ Rev. 2019;9(1):37.
    1. von Brevern M, Radtke A, Lezius F, et al. Epidemiology of benign paroxysmal positional vertigo: a population based study. J Neurol Neurosurg Psychiatr. 2007;78:710–715.
    1. Bronstein AM, Golding JF, Gresty MA, et al. The social impact of dizziness in London and Siena. J Neurol. 2010;257:183–190.
    1. Harun A, Oh ES, Bigelow R, Agrawal Y. Vestibular function testing in individuals with cognitive impairment: our experience with sixty participants. Clin Otolaryngol. 2017;42:772–776.
    1. Harun A, Oh ES, Bigelow RT, Studenski S, Agrawal Y. Vestibular impairment in dementia. Otol Neurotol. 2016;37:1137–1142.
    1. Royal College of Physicians. Hearing and balance disorders: achieving excellence in diagnosis and management. Report of a working party. London: Author; 2008
    1. Pavlou M, Davies RA, Bronstein AM. The assessment of increased sensitivity to visual stimuli in patients with chronic dizziness. J Vestib Res. 2006;16:223–233.
    1. Neuhauser HK, Radtke A, von Brevern M, Lezius F, Feldmann M, Lempert T. Burden of dizziness and vertigo in the community. Arch Intern Med. 2008;168:2118–2124.
    1. Zwergal A, Dieterich M. Vertigo and dizziness in the emergency room. Curr Opin Neurol. 2020;33:117–125.
    1. Caplan L, Chung CS, Wityk R, et al. New England medical center posterior circulation stroke registry: I. Methods, data base, distribution of brain lesions, stroke mechanisms, and outcomes. J Clin Neurol. 2005;1:14–30.
    1. Savitz SI, Caplan LR. Vertebrobasilar disease. N Engl J Med. 2005;352:2618–2626.
    1. Jensen MB, St Louis EK. Management of acute cerebellar stroke. Arch Neurol. 2005;62:537–544.
    1. Tarnutzer AA, Lee SH, Robinson KA, et al. ED misdiagnosis of cerebrovascular events in the era of modern neuroimaging: a meta-analysis. Neurology. 2017;88:1468–1477.
    1. Newman-Toker DE, Edlow JA. TiTrATE: a novel, evidence-based approach to diagnosing acute dizziness and vertigo. Neurol Clin. 2015;33:577–599.
    1. Kattah JC, Talkad AV, et al. HINTS to diagnose stroke in the acute vestibular syndrome: three step bedside oculomotor examination more sensitive than early MRI diffusion-weighted imaging. Stroke. 2009;40:3504–3510.
    1. Scuffham P, Chaplin S, Legood R. Incidence and costs of unintentional falls in older people in the United Kingdom. J Epidemiol Community Health. 2003;57:740–744.
    1. Garg AX, Adhikari NK, McDonald H, Rosas-Arellano MP, Devereaux PJ, Beyene J, et al. Effects of computerized clinical decision support systems on practitioner performance and patient outcomes: a systematic review. JAMA. 2005;293:1223–1238.
    1. Keen PGW, Morton MS. Decision support systems: an organizational perspective. Reading: Addison-Wesley; 1978.
    1. Eom S, Kim E. A survey of decision support system applications. J Oper Res Soc. 2006;57:1264–1278.
    1. Shim JP, Warkentin M, Courtney JF, Power DJ, Sharda R, Carlsson C. Past, present, and future of decision support technology. Decis Support Syst. 2002;33:111–126.
    1. Walton RT, Gierl C, Yudkin P, Mistry H, Vessey MP, Fox J. Evaluation of computer support for prescribing (CAPSULE) using simulated cases. BMJ. 1997;315:791–795.
    1. Shortliffe EH. Computer programs to support clinical decision making. JAMA. 1987;258:61–66.
    1. Shaikh AG, Bronstein A, Carmona S, et al. Consensus on virtual management of vestibular disorders: urgent versus expedited care. Cerebellum. 2021;20:4–8.
    1. Shah MU, Lotterman S, Roberts D, Eisen M. Smartphone telemedical emergency department consults for screening of nonacute dizziness. Laryngoscope. 2019;129:466–469.
    1. Exarchos TP, Rigas G, Bibas A, Kikidis D, Nikitas C, Wuyts FL, et al. Mining balance disorders’ data for the development of diagnostic decision support systems. Comput Biol Med. 2016;77:240–248.
    1. Feil K, Feuerecker R, Goldschagg N, Strobl R, Brandt T, von Müller A, Grill E, Strupp M. Predictive capability of an iPad-based medical device (me dx) for the diagnosis of vertigo and dizziness. Front Neurol. 2018;27(9):29.
    1. Filippopulos FM, Huppert D, Brandt T, Hermann M, Franz M, Fleischer S, Grill E. J Neurol. 2020;267:45–50.
    1. Exarchos TP, Bellos C, Bakola I, Kikidis D, Bibas A, Koutsouris D, Fotiadis DI. Management and modeling of balance disorders using decision support systems: the EMBALANCE project. Adv Exp Med Biol. 2015;820:61–67.
    1. Rammazzo L, Kikidis D, Anwer A, Macdonald N, Kyrodimos E, Maurer C, Wuyts F, Luxon L, Bibas A, Bamiou DE. EMBalance—validation of a decision support system in the early diagnostic evaluation and management plan formulation of balance disorders in primary care: study protocol of a feasibility randomised controlled trial. Trials. 2016;17:435.
    1. Bisdorff A, Von Brevern M, Lempert T, Newman-Toker DE. Classification of vestibular symptoms: towards an international classification of vestibular disorders. J Vestib Res. 2009;19:1–13.
    1. Yardley L, Barker F, Muller I, Turner D, Kirby S, Mullee M, Morris A, Little P. Clinical and cost effectiveness of booklet based vestibular rehabilitation for chronic dizziness in primary care: single blind, parallel group, pragmatic, randomised controlled trial. BMJ. 2012;344:2237.
    1. Sczepanek J, Wiese B, Hummers-Pradier E, Kruschinski C. Newly diagnosed incident dizziness of older patients: a follow-up study in primary care. BMC Fam Pract. 2011;12:58.
    1. Chawla N, Olshaker JS. Diagnosis and management of dizziness and vertigo. Med Clin N Am. 2006;90:291–304.
    1. Laurikkala JP, Kentala EL, Juhola M, Pyvkkö IV. A novel machine learning program applied to discover otological diagnoses. Scand Audiol Suppl. 2001;52:100–102.
    1. Luo J, Erbe C, Friedland DR. Unique clinical language patterns among expert vestibular providers can predict vestibular diagnoses. Otol Neurotol. 2018;39:1163–1171.
    1. Zhou C, Zhang L, Jiang X, et al. A novel diagnostic prediction model for vestibular migraine. Neuropsychiatr Dis Treat. 2020;16:1845–1852.
    1. Ribas LM, Rocha FT, Ortega NR, da Rocha AF, Massad E. Brain activity and medical diagnosis: an EEG study. BMC Neurosci. 2013;14:109.
    1. Bhattacharyya N, Gubbels SP, Schwartz SR, Edlow JA, El-Kashlan H, Fife T, Holmberg JM, Mahoney K, Hollingsworth DB, Roberts R, Seidman MD, Steiner RW, Do BT, Voelker CC, Waguespack RW, Corrigan MD. Clinical practice guideline: benign paroxysmal positional vertigo (Update) Otolaryngol Head Neck Surg. 2017;156:S1–S47.
    1. Staab et al (2016) Diagnostic criteria for persistent postural‐perceptual dizziness (PPPD): consensus document of the committee for the classification of vestibular disorders of the Bárány Society.
    1. Bright TJ, Wong A, Dhurjati R, Bristow E, Bastian L, Coeytaux RR, Samsa G, Hasselblad V, Williams JW, Musty MD, Wing L, Kendrick AS, Sanders GD, Lobach D. Effect of clinical decision-support systems: a systematic review. Ann Intern Med. 2012;157:29–43.
    1. Hancock HC, Roebuck A, Farrer M, Campbell S. Fully automatic external defibrillators in acute care: Clinicians’ experiences and perceptions. Eur J Cardiovasc Nurs. 2006;5:214–221.
    1. Overby CL, Devine EB, Abernethy N, McCune JS, Tarczy-Hornoch P. Making pharmacogenomic-based prescribing alerts more effective: a scenario-based pilot study with physicians. J Biomed Inform. 2015;55:249–259.
    1. McDonnell Michelle N, Hillier S (2015) Vestibular rehabilitation for unilateral peripheral vestibular dysfunction. Cochrane Database Syst Rev
    1. Grill E, Strupp M, Müller M, Jahn K. Health services utilization of patients with vertigo in primary care: a retrospective cohort study. J Neurol. 2014;261:1492–1498.
    1. Swartz R, Longwell P. Treatment of vertigo. Am Fam Physician. 2005;71:1115–1122.
    1. Jayarajan V, Rajenderkumar D. A survey of dizziness management in general practice. J Laryngol Otol. 2003;117:599–604.
    1. Sloane PD, Dallara J, Roach C, Bailey KE, Mitchell M, McNutt R. Management of dizziness in primary care. J Am Board Fam Pract. 1994;7:1–8.
    1. Nelson MD, Akin FW, Riska KM, Andresen K, Mondelli SS. Vestibular assessment and rehabilitation: ten-year survey trends of audiologists’ opinions and practice. J Am Acad Audiol. 2016;27:126–140.
    1. Naber CM, Water-Schmeder O, Bohrer PS, Matonak K, Bernstein AL, Merchant MA. Interdisciplinary treatment for vestibular dysfunction: the effectiveness of mindfulness, cognitive-behavioral techniques, and vestibular rehabilitation. Otolaryngol Head Neck Surg. 2011;145:117–124.
    1. Bigelow RT, Semenov YR, du Lac S, Hoffman HJ, Agrawal Y. Vestibular vertigo and comorbid cognitive and psychiatric impairment: the 2008 National Health Interview Survey. J Neurol Neurosurg Psychiatry. 2016;87:367–372.
    1. Godemann F, Schabowska A, Naetebusch B, Heinz A, Ströhle A. The impact of cognitions on the development of panic and somatoform disorders: a prospective study in patients with vestibular neuritis. Psychol Med. 2006;36:99–108.
    1. van der Zaag-Loonen HJ, van Leeuwen RB. Dizziness causes absence from work. Acta Neurol Belg. 2015;115:345–349.
    1. Van Rompaey V, Ward BK, Van Berg R, Van de Heyning P, Sharon JD. The interrelations between different causes of dizziness: a conceptual framework for understanding vestibular disorders. Ann Otol Rhinol Laryngol. 2019;128(9):869–878.
    1. Pore A (2021) Why covid-19 might finally usher in the era of health care based on a patient’s data. MIT Technology review. 2021. . Accessed on 24 Mar 2021

Source: PubMed

Patrocinadores y Colaboradores

Condiciones médicas

Intervenciones de drogas

3
Suscribir