The diagnostic accuracy of history taking and physical examination for patients with vertigo in general practice: the VERDI study

Vertigo is a common symptom that increases with age. The impact for patients is
enormous: four out of five patients with vertigo report severely impairing
symptoms, leading to sick leave, medical consultation, interruption of daily
activities, and/or avoidance of leaving the house. In older patients, vertigo
is associated with anxiety, depression, social isolation, and falling. The
economic burden is substantial, due to repeated consultations, excessive use of
diagnostic imaging, emergency care, and decreased productivity.

More than 80% of the patients with vertigo are primarily treated by their
general practitioner (GP) and never referred to a medical specialist. Despite
this therapeutic responsibility, the GP*s diagnostic toolkit has serious
limitations. All recommended tests lack empirical evidence, because a
diagnostic accuracy study on vestibular disease has never been performed in
primary care. This scientific gap was identified and highly prioritized by the
National General Practice Research Agenda (4.5.6 NERVOUS SYSTEM, ICPC N;
priority 3/10; ID 549/554).

With the VERtigo DIagnosis study (VERDI, a famous Italian composer who
experienced frequent episodes of dizziness and died of stroke) we will fill
this gap. We will construct a diagnostic algorithm that enables GPs to identify
more accurately and efficiently underlying causes in patients with vertigo.
This may lead to faster and more targeted treatment, less diagnostic imaging
and referral, less prescribing of antivertigo drugs, and improvement of the
overall outcome for patients with vertigo in general practice.

To investigate the diagnostic accuracy of history taking and physical
examination for patients with vertigo in general practice, in
order to construct an easy-to-use diagnostic algorithm for daily clinical
practice.

Prior to this study, we performed an extensive literature study in order to
identify available diagnostic tests for patients with vertigo in general
practice. The result of this literature was evaluated by a panel of experts on
dizziness/vertigo during an international Delphi procedure. The expert panel
recommended to investigate all diagnostic tests recommended by the Dutch
Guideline on Dizziness and to add three diagnostic bedside tests to the test
procedure.

During the present study, we will perform a diagnostic accuracy study. During
this study, we will compare each index test (and combinations of tests) with
the respective reference standard as recommended by the Bárány Society. We will
focus on five target conditions that account for more than 95% of the vertigo
diagnoses in general practice: 1. benign paroxysmal positional vertigo (BPPV),
2. vestibular neuritis, 3. Meniere*s disease, 4. vestibular migraine, and 5.
central causes of vertigo. With the results we will construct decision rules
per target condition and an overarching easy-to-use diagnostic algorithm for
daily clinical practice.

Participation in the VERDI study does not imply risks. When participating, the
burden is limited. During the physical examination, patients may experience
limited, transient, dizziness-related discomfort that is similar to transient
discomfort when undergoing a regular physical examination by a GP. The
additional test videoelectronystagmography (VNG), which can be considered usual
secondary care and is during VERDI only performed on medical indication, may
cause limited dizziness. Mostly, this will disappear after a few minutes. In
rare cases, the dizziness will persist a bit longer.