Implementation of Evidence-Based Practice for Benign Paroxysmal Positional Vertig

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DESCRIPTION (provided by applicant): A wide gap exists between the evidence-base for processes to diagnose and treat Benign Paroxysmal Positional Vertigo (BPPV) and the use of these processes in real world medicine. The proposed research seeks to narrow this gap by implementing a multi-faceted implementation strategy. BPPV is the most common peripheral vestibular disorder and causes disabling symptoms. The disorder stems from free-floating particles that enter a semi-circular canal ("canaliths") of the inner ear. BPPV is diagnosed using a simple and reliable positional test, the Dix-Hallpike test (DHT). The treatment, the Canalith Repositioning Maneuver (CRM), is performed in minutes at the bedside. BPPV patients randomized to the CRM have a cure rate of 80% at 24 hours compared with only 10% of patients randomized to a sham maneuver. However, these guideline supported processes (guidelines published by the American Academy of Otolaryngology-Head and Neck Survey and the American Academy of Neurology) have not adequately disseminated into routine practice. The underuse of these processes has been demonstrated in several different settings. Preliminary results from a population-based study of emergency departments (ED) have found that, among dizziness presentations, the DHT was performed in 3.9% (137 of 3,525) and the CRM in 0.2% (8 of 3,525). Among patients diagnosed with BPPV by the treating physician, 78% did not have the DHT and 96.1% did not have a CRM. In fact, other tests (e.g., head CT scans) and treatments (e.g., medicines) are more commonly utilized in ED patients diagnosed with BPPV - a finding that further highlights inefficiencies. ED providers have ranked the topic of vertigo as the #1 priority for decision support development for adult patients. Additional preliminary data from the investigators indicates high demand among ED physicians for management support specifically for BPPV. The goal of this project is to implement BPPV processes in the ED. The central hypothesis is that a multi-faceted strategy will increase the use of BPPV processes. In specific aim 1 of the project, the investigators will develop a theory-based, multi-faceted BPPV behavioral and educational strategy (including a web-based multimedia point of care clinical tool). In specific aim 2, a randomized controlled trial will be ued to test the effect of a decision aid on guideline concordant practice patterns and BPPV knowledge using a previously validated method of vignette-based research. In specific aim 3, the investigators will implement and evaluate, in a community ED setting, the effect of the implementation strategy on the use of BPPV processes using a staggered enrollment randomized trial design. Exploratory outcomes include ED efficiencies and cost of care. For this project, an outstanding trans-disciplinary team has been assembled (neurologists, otolaryngologists, community and academic emergency medicine physicians, behavioral scientists, implementation specialists, cost analyst, and technical developers). Collectively, the team has extensive content expertise across multiple domains and a history of successful behavioral intervention projects.