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Emergency Physician Attitudes, Preferences, and Risk Tolerance for Stroke as a Potential Cause of Dizziness Symptoms.

Kene MV, Ballard DW, Vinson DR, Rauchwerger AS, Iskin HR, Kim AS - West J Emerg Med (2015)

Bottom Line: A substantial minority of EPs used the Epley maneuver (49%) and HINTS (head-thrust test, gaze-evoked nystagmus, and skew deviation) testing (30%); however, few EPs reported confidence in these tests' bedside application (35% and 16%, respectively).Respondents favorably viewed applying a properly validated clinical prediction rule for assessment of immediate and 30-day stroke risk, but indicated it would have to reduce stroke risk to <0.5% to be clinically useful.A clinical prediction rule would have to achieve a 0.5% post-test stroke probability for acceptability.

View Article: PubMed Central - PubMed

Affiliation: The Permanente Medical Group ; Kaiser Permanente Fremont Medical Center, Department of Emergency Medicine, Fremont, California.

ABSTRACT

Introduction: We evaluated emergency physicians' (EP) current perceptions, practice, and attitudes towards evaluating stroke as a cause of dizziness among emergency department patients.

Methods: We administered a survey to all EPs in a large integrated healthcare delivery system. The survey included clinical vignettes, perceived utility of historical and exam elements, attitudes about the value of and requisite post-test probability of a clinical prediction rule for dizziness. We calculated descriptive statistics and post-test probabilities for such a clinical prediction rule.

Results: The response rate was 68% (366/535). Respondents' median practice tenure was eight years (37% female, 92% emergency medicine board certified). Symptom quality and typical vascular risk factors increased suspicion for stroke as a cause of dizziness. Most respondents reported obtaining head computed tomography (CT) (74%). Nearly all respondents used and felt confident using cranial nerve and limb strength testing. A substantial minority of EPs used the Epley maneuver (49%) and HINTS (head-thrust test, gaze-evoked nystagmus, and skew deviation) testing (30%); however, few EPs reported confidence in these tests' bedside application (35% and 16%, respectively). Respondents favorably viewed applying a properly validated clinical prediction rule for assessment of immediate and 30-day stroke risk, but indicated it would have to reduce stroke risk to <0.5% to be clinically useful.

Conclusion: EPs report relying on symptom quality, vascular risk factors, simple physical exam elements, and head CT to diagnose stroke as the cause of dizziness, but would find a validated clinical prediction rule for dizziness helpful. A clinical prediction rule would have to achieve a 0.5% post-test stroke probability for acceptability.

No MeSH data available.


Related in: MedlinePlus

Ideal posttest probability for a CPR to be useful in evaluating patients with dizziness.a,ba9 missing responsesbSurvey question 8: first two choices were not an option for the question about clinical utilityMRA-magnetic resonance angiogramMRI-magnetic resonance imagingCT-computed tomography
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f4-wjem-16-768: Ideal posttest probability for a CPR to be useful in evaluating patients with dizziness.a,ba9 missing responsesbSurvey question 8: first two choices were not an option for the question about clinical utilityMRA-magnetic resonance angiogramMRI-magnetic resonance imagingCT-computed tomography

Mentions: Responses for target post-test probability for a clinical prediction rule on dizziness and stroke, including the non-numeric choices of “Decline to answer,” “I would not get a CT (or MRI) scan to evaluate posterior circulation stroke, ” and “A clinical prediction rule will never be as useful as neuroimaging” are presented in Figure 4, with the distribution of responses clustered around 0.25%–1% post-test probability of stroke, for those who identified a target post-test probability. Missing responses were low (0–3%), but we did observe a 10% decline-to-answer rate for questions relating to desired post-test probability, and this may have biased our results. Regarding using a clinical prediction rule to forgo neuroimaging in a patient with dizziness, 4% and 6%, respectively, of respondents marked that a clinical prediction rule would never be as useful as neuroimaging (CT or MRI). Fifty respondents (14%) reported that they would not obtain a CT to evaluate posterior circulation stroke as a cause of dizziness. Of those respondents who did indicate a numeric ideal post-test probability for a clinical prediction rule, at the median, respondents reported they would require a post-test probability of stroke of 0.5% for a clinical prediction rule to be clinically useful, to support not obtaining a head CT, or to support not obtaining MRI.


Emergency Physician Attitudes, Preferences, and Risk Tolerance for Stroke as a Potential Cause of Dizziness Symptoms.

Kene MV, Ballard DW, Vinson DR, Rauchwerger AS, Iskin HR, Kim AS - West J Emerg Med (2015)

Ideal posttest probability for a CPR to be useful in evaluating patients with dizziness.a,ba9 missing responsesbSurvey question 8: first two choices were not an option for the question about clinical utilityMRA-magnetic resonance angiogramMRI-magnetic resonance imagingCT-computed tomography
© Copyright Policy - open-access
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC4644052&req=5

f4-wjem-16-768: Ideal posttest probability for a CPR to be useful in evaluating patients with dizziness.a,ba9 missing responsesbSurvey question 8: first two choices were not an option for the question about clinical utilityMRA-magnetic resonance angiogramMRI-magnetic resonance imagingCT-computed tomography
Mentions: Responses for target post-test probability for a clinical prediction rule on dizziness and stroke, including the non-numeric choices of “Decline to answer,” “I would not get a CT (or MRI) scan to evaluate posterior circulation stroke, ” and “A clinical prediction rule will never be as useful as neuroimaging” are presented in Figure 4, with the distribution of responses clustered around 0.25%–1% post-test probability of stroke, for those who identified a target post-test probability. Missing responses were low (0–3%), but we did observe a 10% decline-to-answer rate for questions relating to desired post-test probability, and this may have biased our results. Regarding using a clinical prediction rule to forgo neuroimaging in a patient with dizziness, 4% and 6%, respectively, of respondents marked that a clinical prediction rule would never be as useful as neuroimaging (CT or MRI). Fifty respondents (14%) reported that they would not obtain a CT to evaluate posterior circulation stroke as a cause of dizziness. Of those respondents who did indicate a numeric ideal post-test probability for a clinical prediction rule, at the median, respondents reported they would require a post-test probability of stroke of 0.5% for a clinical prediction rule to be clinically useful, to support not obtaining a head CT, or to support not obtaining MRI.

Bottom Line: A substantial minority of EPs used the Epley maneuver (49%) and HINTS (head-thrust test, gaze-evoked nystagmus, and skew deviation) testing (30%); however, few EPs reported confidence in these tests' bedside application (35% and 16%, respectively).Respondents favorably viewed applying a properly validated clinical prediction rule for assessment of immediate and 30-day stroke risk, but indicated it would have to reduce stroke risk to <0.5% to be clinically useful.A clinical prediction rule would have to achieve a 0.5% post-test stroke probability for acceptability.

View Article: PubMed Central - PubMed

Affiliation: The Permanente Medical Group ; Kaiser Permanente Fremont Medical Center, Department of Emergency Medicine, Fremont, California.

ABSTRACT

Introduction: We evaluated emergency physicians' (EP) current perceptions, practice, and attitudes towards evaluating stroke as a cause of dizziness among emergency department patients.

Methods: We administered a survey to all EPs in a large integrated healthcare delivery system. The survey included clinical vignettes, perceived utility of historical and exam elements, attitudes about the value of and requisite post-test probability of a clinical prediction rule for dizziness. We calculated descriptive statistics and post-test probabilities for such a clinical prediction rule.

Results: The response rate was 68% (366/535). Respondents' median practice tenure was eight years (37% female, 92% emergency medicine board certified). Symptom quality and typical vascular risk factors increased suspicion for stroke as a cause of dizziness. Most respondents reported obtaining head computed tomography (CT) (74%). Nearly all respondents used and felt confident using cranial nerve and limb strength testing. A substantial minority of EPs used the Epley maneuver (49%) and HINTS (head-thrust test, gaze-evoked nystagmus, and skew deviation) testing (30%); however, few EPs reported confidence in these tests' bedside application (35% and 16%, respectively). Respondents favorably viewed applying a properly validated clinical prediction rule for assessment of immediate and 30-day stroke risk, but indicated it would have to reduce stroke risk to <0.5% to be clinically useful.

Conclusion: EPs report relying on symptom quality, vascular risk factors, simple physical exam elements, and head CT to diagnose stroke as the cause of dizziness, but would find a validated clinical prediction rule for dizziness helpful. A clinical prediction rule would have to achieve a 0.5% post-test stroke probability for acceptability.

No MeSH data available.


Related in: MedlinePlus