HSC Section 8_April 2017

The goal of initiating a quality improvement project was

to alter the clinical practice paradigm for vestibular disorders

away from a physician-centric model. Barriers to this are

patient and clinician acceptance of a potential nonphysician-

based assessment and treatment encounter, limited evi-

dence demonstrating efficacy and efficiency of such a pro-

gram, anduncertainty in key areas of the clinical pathway used

for guiding decisionmaking. The results of this study can pro-

vide evidence for patients and referring clinicians as to the di-

agnostic accuracy of pre-encounter questionnaires and the po-

tential improvement in clinical efficiency. Clinical efficiency

is becoming an important metric used to evaluate clinician

quality. Time tonext appointment, enough time spentwith the

patient, and clinic on-time performance are all metrics being

used by health care systems to measure the quality of ser-

vices. Structured systems for triaging patients into those re-

quiring a physician evaluationvs ancillary clinicians have been

effective. In a primary care setting, access to the practice in-

creased by almost 30% and more than 80% of patients tri-

aged to a nonphysician cliniciandidnot need to follow-upwith

a physician.

Similarly, using a structured questionnaire as

support for medical decision making for viral respiratory in-

fection showed thatmilitarymedics could reduce the need for

physician referrals by 37%.

Conclusions

The outcomes in this study have been used in our institution

to improve access by using ancillary clinicians. For example,

patients with BPPV can be seen within 1 week for vestibular

therapy without waiting for a physician appointment. A simi-

lar triagemodel involving vestibular disorders has shown high

patient satisfaction, likely due to simultaneous evaluation and

treatment.

In our practice, patients with substantial head-

ache component and prediction of vestibular migraine are of-

feredneurological consultationas a best first assessment. Free-

ing the otolaryngologist’s schedule fromnonotologic patients

with vestibular disordersmay allow faster access for those pre-

dicted to have Ménière’s disease or other otologic conditions.

ARTICLE INFORMATION

Published Online:

February 25, 2016.

doi

: 10.1001/jamaoto.2015.3663 .

Author Contributions:

Drs Friedland and Tarima

had full access to all of the data in the study and

take responsibility for the integrity of the data and

the accuracy of the data analysis.

Study concept and design:

Friedland.

Acquisition, analysis, or interpretation of data:

Friedland, Tarima, Erbe, Miles.

Drafting of the manuscript:

Friedland, Tarima.

Critical revision of the manuscript for important

intellectual content:

Friedland, Tarima, Erbe, Miles.

Statistical analysis:

Friedland, Tarima.

Obtained funding:

Friedland, Tarima.

Administrative, technical, or material support:

Friedland, Erbe, Miles.

Study supervision:

Friedland.

Conflict of Interest Disclosures:

None reported.

Funding/Support:

This project was supported by

the National Center for Advancing Translational

Sciences, National Institutes of Health (NIH),

through grant No. 8UL1TR000055.

Role of the Funder/Sponsor:

The NIH had no role

in the design and conduct of the study; collection,

management, analysis, and interpretation of the

data; preparation, review, or approval of the

manuscript; and decision to submit the manuscript

for publication.

Disclaimer:

The contents of this article are solely

the responsibility of the authors and do not

necessarily represent the official views of the NIH.

Additional Contributions:

Neil Shepard, PhD, and

Scott Eggers, MD, Mayo Clinic, Rochester,

Minnesota, provided the vestibular disorders

questionnaire and allowed it to be described in this

article. No compensation was provided to them.

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Research

Original Investigation

Statistical Model for the Prediction of Common Vestibular Diagnoses

JAMA Otolaryngology–Head & Neck Surgery

April 2016 Volume 142, Number 4

(Reprinted)

jamaotolaryngology.com