title: Use of BPPV processes in emergency department dizziness presentations: a population-based study.
abstract: OBJECTIVE
  A common cause of dizziness, benign paroxysmal positional vertigo (BPPV), is effectively diagnosed and cured with the Dix-Hallpike test (DHT) and the canalith repositioning maneuver (CRM). We aimed to describe the use of these processes in emergency departments (EDs), assess for trends in use over time, and determine provider level variability in use.
  
  
  METHODS
  Prospective population-based surveillance study.
  
  
  METHODS
  Emergency departments in Nueces County, Texas, from January 15, 2008, to January 14, 2011.
  
  
  METHODS
  Adult patients discharged from EDs with dizziness, vertigo, or imbalance documented at triage. Clinical information was abstracted from source documents. A hierarchical logistic regression model adjusting for patient and provider characteristics was used to estimate trends in DHT use and provider-level variability.
  
  
  RESULTS
  A total of 3522 visits for dizziness were identified. A DHT was documented in 137 visits (3.9%). A CRM was documented in 8 visits (0.2%). Among patients diagnosed with BPPV, a DHT was documented in only 21.8% (34 of 156) and a CRM in 3.9% (6 of 156). In the hierarchical model (c-statistic = 0.93), DHT was less likely to be used over time (odds ratio, 0.97; 95% confidence interval, 0.95-0.99), and the provider level explained 50% (intraclass correlation coefficient, 0.50) of the variance in the probability of DHT use.
  
  
  CONCLUSIONS
  Benign paroxysmal positional vertigo is seldom examined for and, when diagnosed, infrequently treated in this ED population. Use of the DHT is decreasing over time and varies substantially by provider. Implementation research focused on BPPV care may be an opportunity to optimize management in ED dizziness presentations.
authors.affiliation: Department of Neurology, University of Michigan Health System, Ann Arbor, Michigan 48109-5322, USA. kakerber@umich.edu
authors.forename: Kevin A
authors.initials: KA
authors.lastname: Kerber
authors.forename: James F
authors.initials: JF
authors.lastname: Burke
authors.forename: Lesli E
authors.initials: LE
authors.lastname: Skolarus
authors.forename: William J
authors.initials: WJ
authors.lastname: Meurer
authors.forename: Brian C
authors.initials: BC
authors.lastname: Callaghan
authors.forename: Devin L
authors.initials: DL
authors.lastname: Brown
authors.forename: Lynda D
authors.initials: LD
authors.lastname: Lisabeth
authors.forename: Thomas J
authors.initials: TJ
authors.lastname: McLaughlin
authors.forename: A Mark
authors.initials: AM
authors.lastname: Fendrick
authors.forename: Lewis B
authors.initials: LB
authors.lastname: Morgenstern
mesh_terms: D065635:Benign Paroxysmal Positional Vertigo; D003939:Diagnostic Techniques, Otological; D004244:Dizziness / Q000175:diagnosis; D004632:Emergency Medical Services; D005260:Female; D006801:Humans; D008875:Middle Aged; D009460:Neurologic Examination / Q000379:methods; D011446:Prospective Studies; D014717:Vertigo / Q000175:diagnosis* / Q000628:therapy