Abstract
Purpose
The purpose of the present investigation was to determine whether there are significant differences in patient/healthcare provider perceptions of patient’s dizziness severity, dizziness disability/handicap, anxiety, and signs of autonomic system activation.
Materials and methods
This was a prospective investigation of 30 patient–provider dyads drawn as a sample of convenience from an otology clinic in a large, tertiary care, medical center. Patients completed both the Dizziness Handicap Inventory (DHI) and the Vestibular Symptom Scale (VSS) prior to vestibular function testing. Providers were instructed to complete the same measures following the patient’s clinic visit from what they estimated was the patient’s point of view. The two measures were analyzed for concordance and discordance.
Results
Patient/provider differences in DHI and VSS vertigo subscale scores were not significantly different. However, difference scores on the VSS anxiety/autonomic subscale indicated that providers significantly under-estimated patient anxiety and symptoms of autonomic system activation.
Conclusions
The results suggest that providers may be missing information pertinent to the role anxiety and autonomic system activation may play in patient visits for complaints of dizziness. We suggest that this problem can be mitigated by administrating to patients prior to their clinic visit a standardized measure that quantifies patient self-report dizziness, vertigo, anxiety and autonomic system arousal. Patterns of response by patients on these measures can enable providers to diagnose correctly dizziness disorders that are rooted in clinically significant anxiety either related to, or unrelated to, a history of vestibular system impairment.
1
Introduction
There is an increasing body of evidence in areas such as arthritis, pain, and cancer that suggests the patient’s health status, self-report symptom severity, disability, and handicap are not always concordant with those of the healthcare provider who must evaluate the patient and manage the condition . Discordant views between the patient and provider on the effect that disease has on a patient may negatively influence patient outcomes, while concordant views result in better patient outcomes . That is, ultimately, it is the view of the provider that is used to formulate the plan of treatment. To date, no studies have been conducted to assess patient-provider concordance and discordance in patients with dizziness and vertigo.
Two psychometrically sound self-report questionnaires for use with dizzy, vertiginous, and unsteady patients are the Dizziness Handicap Inventory (DHI) and Vertigo Symptom Scale (VSS) . The DHI is 25-item self-report questionnaire designed to evaluate self-perceived handicap in dizzy patients . The VSS is a 34-item questionnaire designed to quantify the severity of vertigo and the symptoms of anxiety and autonomic arousal in dizzy patients .
The purpose of this investigation was to extend the use of the DHI and VSS, to measure the concordance/discordance between the patient’s self-report dizziness disability/handicap and dizziness severity, and, the healthcare provider’s estimate of the same.
2
Methods
Subjects were 30 consecutive patients evaluated at the Vanderbilt Bill Wilkerson Center for Otolaryngology and Communication Sciences who consented to participate in this study. The protocol was approved by the Institutional Review Board (IRB #101126) of the Vanderbilt University School of Medicine. Full informed consent was obtained from each patient.
Both the DHI and VSS were mailed to patients prior to their clinic visits. These were collected from the patients at the time of their balance function testing. Patients then were evaluated by their healthcare providers. At the conclusion of the appointment the healthcare provider completed their versions of the DHI and VSS.
2.1
Questionnaires
The DHI is a 25-item self-report questionnaire that provides a method to quantify the impact that dizziness, unsteadiness and vertigo have on a patient’s normal daily activities and psychosocial function . It is significant to note that in order to extend its potential usefulness, the words “dizzy,” “vertigo,” or “unsteady” were not used in the questions. Instead the words, “your problem” were substituted (e.g. “Because of your problem is it difficult for you to concentrate?”). In this manner it was hoped the DHI could be used with all patients who were dizzy, vertiginous or unsteady. Items from the DHI were developed based on case-history reports of patients with dizziness. Each of the 25 questions is answered “yes,” “sometimes,” or “no.” A “yes” response is awarded 4 points, a “sometimes” response is awarded 2 points and a “no” response is awarded 0 points. The maximum score is 100 points representing severe self-report dizziness disability/handicap and the minimum score is zero points representing no self-report dizziness disability/handicap. The DHI as originally conceived consisted of three subscales assessing the functional, emotional and physical effects of dizziness/vertigo on everyday life. Subsequent to the publication of the initial report other investigators showed that the subscale structure does not, in fact, exist . Accordingly, the DHI is best reported as a single total score. The DHI is shown in Appendix A.
The VSS is a 34-item inventory designed to measure symptoms associated with dizziness . The VSS consists of 2 subscales. The vertigo severity subscale (VSS-VER) consists of 19 items that target the physical symptoms associated with vertigo and dizziness (e.g. “unable to stand or walk properly without support”). The anxiety/autonomic symptom scale (VSS-AA) consists of 15 items that assess anxiety and somatic symptoms often reported by dizzy patients (e.g. “heart pounding or fluttering”). Items comprising the VSS were developed based on patient interviews . Patients are asked to respond to each symptom on a 5 point Likert scale about how often they experience each symptom. The scale is anchored on one end with “never” (i.e. 0 points) and on the opposite end with “very often” (i.e. 4 points). Thus, the absolute range of scores for the AA subscale is 0–60 points and the range for the VER subscale is 0–76 points. Alternatively, the VSS subscales can yield normalized scores, ranging from 0 to 4. High scores suggest over-reporting due to excessive attention to physical status, emotional distress, or general concern about health. The VSS is shown in Appendix B.
For each of the patient versions of the DHI and VSS a healthcare provider version was created. For the DHI-p and VSS-p this was accomplished by replacing the word “you” or “your” with the words “my patient.” The healthcare provider versions of the DHI-p and VSS-p are shown in Appendices C and D.
2.2
Statistical analysis
Basic demographic information was gathered for the patients including age and sex. Scores on the DHI and VSS for the patient and healthcare provider were collected and tabulated for analysis. Descriptive statistics were used to characterize the study population. Paired t -tests were used to determine whether there were statistically significant differences between patient and provider ratings. Pearson correlation coefficients were calculated to assess the degree of association between patient’s and provider’s reports.
2
Methods
Subjects were 30 consecutive patients evaluated at the Vanderbilt Bill Wilkerson Center for Otolaryngology and Communication Sciences who consented to participate in this study. The protocol was approved by the Institutional Review Board (IRB #101126) of the Vanderbilt University School of Medicine. Full informed consent was obtained from each patient.
Both the DHI and VSS were mailed to patients prior to their clinic visits. These were collected from the patients at the time of their balance function testing. Patients then were evaluated by their healthcare providers. At the conclusion of the appointment the healthcare provider completed their versions of the DHI and VSS.
2.1
Questionnaires
The DHI is a 25-item self-report questionnaire that provides a method to quantify the impact that dizziness, unsteadiness and vertigo have on a patient’s normal daily activities and psychosocial function . It is significant to note that in order to extend its potential usefulness, the words “dizzy,” “vertigo,” or “unsteady” were not used in the questions. Instead the words, “your problem” were substituted (e.g. “Because of your problem is it difficult for you to concentrate?”). In this manner it was hoped the DHI could be used with all patients who were dizzy, vertiginous or unsteady. Items from the DHI were developed based on case-history reports of patients with dizziness. Each of the 25 questions is answered “yes,” “sometimes,” or “no.” A “yes” response is awarded 4 points, a “sometimes” response is awarded 2 points and a “no” response is awarded 0 points. The maximum score is 100 points representing severe self-report dizziness disability/handicap and the minimum score is zero points representing no self-report dizziness disability/handicap. The DHI as originally conceived consisted of three subscales assessing the functional, emotional and physical effects of dizziness/vertigo on everyday life. Subsequent to the publication of the initial report other investigators showed that the subscale structure does not, in fact, exist . Accordingly, the DHI is best reported as a single total score. The DHI is shown in Appendix A.
The VSS is a 34-item inventory designed to measure symptoms associated with dizziness . The VSS consists of 2 subscales. The vertigo severity subscale (VSS-VER) consists of 19 items that target the physical symptoms associated with vertigo and dizziness (e.g. “unable to stand or walk properly without support”). The anxiety/autonomic symptom scale (VSS-AA) consists of 15 items that assess anxiety and somatic symptoms often reported by dizzy patients (e.g. “heart pounding or fluttering”). Items comprising the VSS were developed based on patient interviews . Patients are asked to respond to each symptom on a 5 point Likert scale about how often they experience each symptom. The scale is anchored on one end with “never” (i.e. 0 points) and on the opposite end with “very often” (i.e. 4 points). Thus, the absolute range of scores for the AA subscale is 0–60 points and the range for the VER subscale is 0–76 points. Alternatively, the VSS subscales can yield normalized scores, ranging from 0 to 4. High scores suggest over-reporting due to excessive attention to physical status, emotional distress, or general concern about health. The VSS is shown in Appendix B.
For each of the patient versions of the DHI and VSS a healthcare provider version was created. For the DHI-p and VSS-p this was accomplished by replacing the word “you” or “your” with the words “my patient.” The healthcare provider versions of the DHI-p and VSS-p are shown in Appendices C and D.
2.2
Statistical analysis
Basic demographic information was gathered for the patients including age and sex. Scores on the DHI and VSS for the patient and healthcare provider were collected and tabulated for analysis. Descriptive statistics were used to characterize the study population. Paired t -tests were used to determine whether there were statistically significant differences between patient and provider ratings. Pearson correlation coefficients were calculated to assess the degree of association between patient’s and provider’s reports.
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