Analysis of cost and effectiveness of treatment in benign paroxysmal positional vertigo

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Analysis of cost and effectiveness of treatment in benign paroxysmal
positional vertigo
Ya-Li Wang, Min-Ya Wu, Pei-Li Cheng, Shao-Fang Pei, Yi Liu, Ying-Mei Liu
Department of Neurology, the Northern Area of Suzhou Municipal Hospital, Suzhou, Jiangsu 215000, China.
To the Editor: Benign paroxysmal positional vertigo
(BPPV) is one of the most common causes of vertigo.
Recently, the diagnosis and treatment of BPPV have
become areas of increased interest. As such, the levels of
clinical diagnosis and treatment have greatly improved.
While studies have been conducted worldwide examining
the pathogenesis and pathophysiology of BPPV, very few
have focused on the cost of diagnosis and treatment of
BPPV. Therefore, the current study was designed to
analyze the effects and expenditure of the different
treatment strategies for BPPV, according to the effective
screening of BPPV patients, and vertigo classification.
In this survey, 137 BPPV subjects were recruited from the
Department of Emergency and General Neurology of the
Northern Area of Suzhou Municipal Hospital, from
January 2016 to May 2017. Informed consent was
obtained from all of the subjects participating in the
study, and the study was approved by the Ethics
Committee at Suzhou Municipal Hospital. First, all of
the subjects enrolled underwent a detailed clinical history
and general information registration. Second, all of the
subjects were evaluated by a questionnaire of the Dizziness
Handicap Inventory (DHI) sub-scale (5-item and 2-item) to
screen for BPPV.
[1]
Possible BPPV was considered when
the score >12 on the 5-item questionnaire or >6 on the 2-
item questionnaire. Third, Dix-Hallpike and Roll-tests
were conducted to determine the accuracy of BPPV
diagnosis and possible subtype.
[2]
These subject selection
criteria are summarized in Supplementary Table 1, http://
links.lww.com/CM9/A11. Participants were 45 males and
92 females, aged between 25 and 88 years. Comorbid
disease included 44 cases of hypertension, 13 cases of
diabetes, 26 cases of hyperlipidemia, 5 cases of migraine,
and 57 cases of cervical spondylosis.
All of the participants (n=137) were divided into four
groups according to vertigo classification (Level 0: no
dizziness attack or the attacks have stopped; Level I: daily
life is not affected during or after the vertigo; Level II:
forced to stop daily life activities when the dizziness attack
occurs, but can recover quickly; Level III: most of daily life
is affected, but still self-reliant after the dizziness attack;
Level IV: most of daily life is affected, but not self-reliant
after the dizziness attack; and Level V: all of daily life is
affected, patient is not self-reliant after the dizziness attack,
and requires the help of others). Grouping methods are
summarized in Table 1.
In the mild group, subjects were only given drug treatment.
One patient suffered a dizziness attack 1 week after
beginning medication. The patient was administered a
position-induced test that yielded positive results. Thus,
this patient was included in the next highest level of group
(i.e., moderate group). In the moderate group, there were 4
patients who had recurrent and aggravated symptoms after
outpatient treatment, and were thus moved to the severe
group, given both drug and canalith repositioning
procedure (CRP) treatment. For the inpatient group,
patients were divided into drug and CRP treatment group
or drug only treatment groups, as some patients do not
tolerate CRP treatment well.
Patients in the outpatient clinic were given the oral
treatment with a long-acting dose of betahistine and
ginkgo biloba tablets. The inpatient group patients were
given the oral treatment of betahistine and intravenous
drip of vinpocetine and other treatments according to
comorbid diseases.
The Epley or Semont maneuver was used for repositioning
in patients with posterior semicircular BPPV, while the BBQ
roll maneuver or Gufoni maneuver was used for patients
presenting with horizontal semicircular BPPV. Finally, the
anti-Epley maneuver or Gufoni maneuver was used for
repositioning patients with former semicircular BPPV.
[2]
Therapeutic effects were classified into three grades: (1) Cure -
vertigo/dizziness and nystagmus completely disappeared;
Correspondence to: Dr. Ying-Mei Liu, Department of Neurology, the Northern Area
of Suzhou Municipal Hospital, Suzhou, Jiangsu 215000, China
E-Mail: Liuymsz@126.com
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Chinese Medical Journal 2019;132(3)
Received: 26-11-2018 Edited by: Yuan-Yuan Ji
Access this article online
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DOI:
10.1097/CM9.0000000000000063
Correspondence
342

(2) Efficacy-vertigo/dizziness and nystagmus significantly
alleviated; and (3) Ineffective-vertigo/dizziness and nystagmus
did not alleviate, or became worse. Patients were evaluated in
the hospital at 1 week and at 1 month following beginning of
treatment. Outpatient participants were followed up by
telephone or in the outpatient clinic. The total cost for each
group of patients was calculated according to the examina-
tion fee, drug charge, and reposition treatment fee.
Statistical analysis was conducted via SPSS 17.0 (SPSS Inc.,
Chicago, IL, USA). Data were displayed as mean ±
standard deviation. An analysis of variance (ANOVA)
was performed for multiple groups and a t-test was used
for comparison between groups. A Chi-square test was
used to compare counting data. A P<0.05 was considered
to be statistically significant.
The gender of participants among the 4 groups tested was
mostly female, with 58.3%, 70.4%, 66.7%, and 70.5%,
respectively. Unilateral involvement of the semicircular
canal was common. Additionally, no statistically significant
difference was noted in gender, involvement of the
semicircular canal, BPPV type, incidence of migraine, or
diabetes among the 4 groups. There was a significant
difference between the mild and severe groups in comorbid
instances of cervical spondylosis, hyperlipidemia, and
hypertension. However, the incidence of these diseases
was not significantly different when comparing the mild vs.
moderate group and the severe group with/without CRP.
The mean age of the severe group was much older than the
mild and moderate groups. However, there was no
statistically significant difference among the 4 groups
regarding inpatient or outpatient status. In the confirmed
cases, DHI-5 scores rangedfrom 6 to 20 points, with a mean
of 14.6. DHI-2 scores ranged from 4 to 8, with a mean of
6.8. There was no statistical difference in scores among each
group. Clinical features and statistical data are summarized
in Supplementary Table 2, http://links.lww.com/CM9/A11.
Three cases in the first group were cured and 1 cupolithiasis
case exhibited recurrence, prompting movement to the
second group after the 1-week follow-up. At the 1-month
follow-up, ten cases were cured and two cases exhibited
recurrence. In the moderate group, 52 cases were cured after
a week, with six cases presenting as invalid. Four patients
transferred to the hospital group. An additional two cases
were followed-up, and symptoms were reported to be
alleviated by multiple reposition. After a month, 52 cases
were cured, two were relapsed. In the third group, five cases
were cured after a week. After a month, a total of 21 cases
reported being cured, and three were relapsed. In the fourth
group, two cases were cured after a week, 42 cases were
cured after a month, and two were relapsed. The 1-week
cure proportion in the moderate group was higher than that
of the mild group (P<0.001). Similarly, the 1-week cure
proportion in the severe group with CRP was higher than
that of the severe group without CRP (P<0.001). There was
no significant difference among the 4 groups in the 1-month
cure proportion or recurrence proportion (P>0.05;
Table 2).
The range of cost for the diagnosis and treatment of BPPV
paid by members of the mild group was RMB 87.9 to
350.1 Yuan, with a mean total cost of RMB 192.4 Yuan.
In the moderate group, the mean total cost was RMB 364.3
Yuan. The medicine fee in the former 2 groups is RMB
157.4 and 197.5 Yuan, respectively. The mean total cost of
the severe group with CRP was RMB 7788.6 Yuan, of
which the average cost for drug treatment was RMB
2339.0 Yuan. In the severe group without CRP, the
average total cost was RMB 8315.3 Yuan, and the average
cost of drug treatment was RMB 2653.2 Yuan. There was
no statistical difference between the mild and the moderate
group (medicine fee: P=0.999; total cost: P=0.798).
Similarly, there was no statistical difference in the severe
group with or without CRP (medicine fee: P=0.617; total
cost: P=0.325). However, it was obvious that the cost of
the inpatient group was much higher than that of the
outpatient group (medicine fee: P<0.001; total cost:
P<0.001; Table 2).
BPPV is the most common cause of peripheral vestibular
vertigo. BPPV is characterized by transient repeated
vertigo induced by specific head position changes. Due
to its high incidence and recurrence proportion, it exerts a
heavy burden on health care systems and society.
[3]
The diagnosis of BPPV is often confirmed by patient
history, subjective reports of typical symptoms, and
characteristic positional nystagmus during positional
evoking maneuvers. Further, BPPV can be diagnosed
and treated by multiple clinical disciplines. Unfortunately
delay in the diagnosis and treatment of BPPV may result in
increased cost to patients. Therefore, it is very important to
evaluate patients carefully, categorize them into appropri-
ate groups, and execute individualized treatment. To add
to the BPPV literature, the current study sought to examine
the effectiveness and cost of different treatment strategies,
according to the vertigo classification.
It has been reported that the 5- and 2-item questionnaires
extracted from the DHI can effectively screen for BPPV,
[4]
Table 1: The 4 groups and included number in this study
Groups Vertigo classification Number of cases Withdraw
Outpatient group
Mild group with drug therapy 0–I level 14 1
Moderate group with CRP and drug therapy II–III level 57 0
Inpatient group
Severe group with drug therapy IV–V level 24 0
Severe group with CRP and drug therapy IV–V level 42 2
Chinese Medical Journal 2019;132(3) www.cmj.org
343

and that the rate of sensitivity and specificity was 78.2%
and 88.7%, respectively. Therefore, the DHI-5 and DHI-2
were administered to screen BPPV patients in the current
study.
Special auxiliary examinations for participants were
considered unnecessary, except for individuals with other
symptoms, such as cranial nerve abnormality, visual
disturbance, and/or severe headache. Through central
nervous system imaging, potential issues that may cause
vertigo, including cerebrovascular disease, demyelination,
and intracranial tumors can be identified. Lesions in the
brainstem, cerebellum, thalamus, and/or cortex can also
cause vertigo.
[5]
Therefore, in order to exclude central
positional vertigo, imaging should be completed. Results
of the current study suggest that patients at the IV and V
level of vertigo classification should have a craniocerebral
CT or MRI examination performed to prevent misdiag-
nosis.
According to a study by Han et al,
[6]
BPPV symptom
severity depends on the lesion degree in the otolith organs
(elliptical capsule and saccule). If the otolith organs lesions
are light, the body can easily compensate, and thus, the
possibility of self-healing is greater. This is the reason why
drug treatment alone is useful for mild cases. According to
the diagnosis and treatment of BPPV guidelines published
in 2008 by the American Academy of Otolaryngology-
Head and Neck Surgery, it is thought that observation only
is not appropriate for older patients with persistent balance
disorder and dizziness, as they are at high-risk for falls.
Thus, reposition therapy is recommended.
[7]
The 1-week
cure proportion of the moderate group was significantly
higher than that of the mild group (52/57 vs. 3/13). This
data indicates that CRP can help patients recover more
quickly. The second and fourth groups were given drugs
and CRP, but the 1-week cure proportion in the second
group was much higher than that in the fourth group. The
underlying reason may be due to patient age, heavy vertigo
classification, and/or comorbid cervical spondylosis,
hyperlipidemia, and hypertension. In the fourth group
of patients, the clinical symptoms were severe during the
attack, and the position test of seven patients showed
multiple semicircular canal BPPV, which increased the
number of individuals requiring reset. Further, eight
patients exhibited cupolithiasis, which makes it difficult
for the patient to be laid back, requiring multiple instances
of repositioning. This led to a relative increase in costs. In
older patients with many diseases, the degree of otolithiasis
is typically more severe, and residual subjective symptoms
often persist after treatment,
[8]
which further increases
the total cost and the length of treatment. According to
Li et al,
[9]
the total estimated cost was $2009.63 dollars
per patient. In this study, the average total cost was
RMB 192.4, 364.3, 7788.6, and 8051.9 Yuan among the
4 groups. There was a statistically significant difference in
the cost between the outpatient and inpatient groups. The
average cost of the 4 groups was RMB 4165.2 Yuan,
which is significantly less than the average cost of RMB
5012.9 Yuan reported by other surveys.
[10]
In this study, BPPV patients were treated with vertigo
classification. The 0–III level of BPPV patients may be
appropriate to receive treatment as outpatients, which
could decrease the cost drastically and get the similar effect
of hospitalization. However, for the patients with BPPV
level IV and V, it is relatively safer to stay in a hospital,
especially for patients with mixed semicircular canals,
cupolithiasis, strong reaction, and/or difficultly in being
repositioned. Further, hospitalization makes it possible to
closely observe the patient’s heart rate, blood pressure,
emotional response, and residual symptoms, improving
outcomes. Additionally, cooperating with the drug
treatment and providing the reset response in a timely
fashion could ensure the patient completes his/her
treatment safely.
In conclusion, this study shows that the curative effect of
CRP is definite and positive. Results also indicate that
selecting the appropriate treatment based on vertigo
classification could reduce health care costs and save
medical resources. The limitations of the current study,
such as the small number of cases and the short follow-up
time, should be modified in future studies.
Funding
This work was supported by grants from the National
Natural Science Foundation of China (No. 81801253),
Natural Science Foundation of Jiangsu Province
Table 2: Comparison of treatment effects and costs among the four groups
Outpatient group Inpatient group
Groups Mild group
Moderate
group
Severe group with
drug therapy
Severe group with
CRP and drug therapy
1-week cure proportion (n/N) 3/13 52/57 5/24 21/40
1-month cure proportion (n/N) 10/12
∗
52/54
∗
21/24 42/44
∗
1-month recurrence proportion (n/N) 2/12
∗
2/54
∗
3/24 2/44
∗
Medicine fee (RMB Yuan), mean±SD 157.4 ±70.8 197.5±153.2 2653.2 ±1593.9 2338.9±1319.4
Total cost (RMB Yuan), mean±SD 192.4 ±89.6 364.3±148.1 8315.3 ±3110.6 7788.6±2600.8
The 1-week cure proportion in the moderate group was higher than that of the mild group (P<0.001). Similarly, the 1-week cure proportion in the severe
group with CRP was higher than that of the severe group without CRP (P<0.001). The 1-month cure proportion and recurrence proportion did not
differ among the 4 groups (P>0.05). For medicine fee and the total cost, no significant difference was found between either the former or the latter 2
groups, while significant difference existed between the inpatient and the outpatient groups (P<0.001). SD: standard deviation.
∗
One patient from the
mild group was transferred into the moderate group and four patients from the moderate group were transferred into the last group.
Chinese Medical Journal 2019;132(3) www.cmj.org
344

(No. BK20180214), and the Suzhou Project of the Health
Development through Technology & Education (No.
KJXW2017036).
Conflicts of interest
None.
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How to cite this article: Wang YL, Wu MY, Cheng PL, Pei SF, Liu Y,
Liu YM. Analysis of cost and effectiveness of treatment in benign
paroxysmal positional vertigo. Chin Med J 2019;132:342–345. doi:
10.1097/CM9.0000000000000063
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