The challenges of managing vestibular disorders: a qualitative study of clinicians’ experiences associated with low referral rates for vestibular rehabilitation

Abstract

To explore clinicians' perspectives influencing the under-diagnosis and management of patients with vestibular impairment (VI). Data were collected using open-ended, semi-structured interviews with 18 clinical providers from primary care, neurology, otolaryngology and audiology affiliated with the Veterans Administration Medical Center in Atlanta, Georgia, from January to September 2007. Topics discussed included healthcare experiences for dizzy patients with possible VI, and perceived barriers and facilitators for clinical practice according to published guidelines. The constant comparison method was used for qualitative content analysis. Clinicians rarely, if ever, diagnosed VI themselves or were aware of vestibular rehabilitation as the appropriate treatment for vestibular disorders. They infrequently performed bedside tests for positional nystagmus or vestibular hypofunction to identify VI and almost never performed canalith repositioning. Not uncommonly, they ordered a wide variety of diagnostic tests, such as neuroimaging, cardiac studies and audiograms, prior to make referral to a specialist, if they made referral at all. Perceived barriers to identifying VI in patients and giving treatment consistent with published recommendations commonly included lack of knowledge and training, perceived time constraints in clinic and difficulties with dizzy patients giving vague descriptions of their symptoms. Perceptions of lacking knowledge in caring for patients with possible VI were experienced by clinicians both in primary and specialty care. Clinicians were frequently unaware of the concept of vestibular rehabilitation. Many wanted to learn more to improve healthcare delivery for their patients. Education appears necessary not only for enhancing patient therapeutic benefit, but also for minimising costs for unnecessary physician hours and diagnostic tests.