Implementation of Evidence-Based Practice for Benign Paroxysmal Positional Vertig

描述(由申请人提供)：在诊断和治疗良性阵发性位置性眩晕(BPPV)的证据基础与这些过程在现实世界医学中的使用之间存在着巨大的差距。拟议的研究试图通过实施多方面的执行战略来缩小这一差距。BPPV是最常见的外周前庭疾病，会导致致残症状。这种紊乱是由自由漂浮的颗粒进入内耳的半圆形管道(“通道”)引起的。BPPV的诊断使用一种简单而可靠的定位试验，即Dix-Hallpike试验(DHT)。治疗，管结石重新定位手法(CRM)，在床边几分钟内完成。随机接受CRM的BPPV患者在24小时内的治愈率为80%，而随机接受假操作的患者只有10%。然而，这些指南支持的过程(由美国耳鼻喉科学会-头颈调查和美国神经病学学会发布的指南)尚未充分传播到常规实践中。在几个不同的环境中，这些进程被充分利用。一项以人群为基础的急诊科研究的初步结果发现，在头晕的表现中，3.9%(3525人中的137人)进行了DHT，0.2%(3525人中的8人)进行了CRM。在被主治医师诊断为BPPV的患者中，78%没有DHT，96.1%没有CRM。事实上，其他检查(例如头部CT扫描)和治疗(例如药物)更常用于被诊断为BPPV的ED患者--这一发现进一步突显了效率低下。ED提供者已将眩晕主题列为成人患者决策支持开发的首要任务。来自调查人员的其他初步数据表明，急诊科医生对BPPV的管理支持有很高的需求。这个项目的目标是在教育部门实施BPPV流程。中心假设是，多方面的战略将增加BPPV过程的使用。在该项目的具体目标1中，研究人员将开发一种基于理论的、多方面的BPPV行为和教育策略(包括基于网络的多媒体护理点临床工具)。在具体目标2中，将使用先前验证的基于Vignette的研究方法，使用随机对照试验来测试决策辅助对指南一致性实践模式和BPPV知识的影响。在具体目标3中，调查人员将采用交错登记随机试验设计，在社区ED环境中实施和评估实施战略对BPPV过程使用的影响。探索性结果包括ED效率和护理成本。对于这个项目，已经组建了一支杰出的跨学科团队(神经学家、耳鼻喉科医生、社区和学术急救医学医生、行为科学家、实施专家、成本分析师和技术开发人员)。总体而言，该团队在多个领域拥有广泛的内容专业知识，并拥有成功的行为干预项目的历史。

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.