Discussion
The COVID-19 pandemic will influence our clinical ENT practice in the
long-term. This gives us an opportunity to explore new ways to care for
our patients. The lockdown measures in the UK have had significant
negative effects on the capacity to deliver healthcare and across the
National Health Service, clinicians have had to adapt to the infection
control and social distancing measures. Increasingly virtual clinics are
being introduced in secondary care e.g. in Orthopaedics there is
evidence that is largely acceptable to patients(14). Even prior to the
COVID-19 outbreak, clinicians in primary care had started adopting
telemedicine and started to investigate how to deliver this in a high
quality, accessible and affordable manner(15). There is evidence that
digital healthcare may be more convenient and patient-centred and
therefore bring many advantages(16). Other studies have shown that
diagnosis of peripheral vestibular pathology e.g. BPPV and vestibular
migraine, made by telephone interview compares favourably with
subsequent diagnoses made by neuro-otologists in the face-to-face
clinic(17). The study described here investigated whether telephone
consultations for patients with dizziness had different outcomes when a
diagnostic questionnaire was used and whether it changed the onward
management of patients. The findings suggest that the questionnaire
helped clinicians make a diagnosis, reduced the need for additional
investigations and reduced telephone follow-up.
A number of questionnaires have been used in the management of dizziness
such as the dizziness handicap inventory (DHI)(13) and the University of
California, Los Angeles Dizziness Questionnaire (UCLA-DQ)(18). The
usefulness of these questionnaires has been reviewed in the literature,
both as a way of assessing patients and assessing effectiveness of
interventions(18, 19). There are relatively fewer studies looking
specifically at using a questionnaire to help diagnose causes of
dizziness(20). The results described above comprise the first report
looking specifically at the usefulness of a questionnaire in telephone
consultations, and is particularly relevant given the increase in
telephone consultations occurring during the COVID-19 pandemic. These
results show that using the Roland dizziness questionnaire (RDQ) as an
adjunct to telephone consultations reduced the need for patients to come
into hospital for face to face consultations and reduced the number of
investigations ordered and reduced the number of telephone follow up
appointments. At our hospital we found that an initial telephone
consultation frees up ENT outpatient capacity for face to face
consultations that can be used for conditions that need visual
assessment, such as patients with hoarseness or suspicion of
cholesteatoma.
However, the results described above do not suggest that the
questionnaire changes the rate of requests for further face-to-face ENT
assessments. This may be because conditions such as Benign Paroxysmal
Positional Vertigo (BPPV), require face-to-face diagnosis and treatment
(Dix-Hallpike and Epley manoeuvres respectively). For other vestibular
pathology e.g. persistent postural-perceptual dizziness (PPPD) there is
evidence that treatment can be delivered by telephone and it is
acceptable to patients(21). Therefore it is possible that in the future
many more treatments, including for conditions such as (BPPV), could be
delivered by tele-medicine as well e.g. by developing devices such as a
cell phone balance trainer(22).
Other studies have described the patient perceptions of telemedicine as
applied to ENT practice during the COVID-19 pandemic(23-25). We did not
include a formal assessment of patient perception and satisfaction with
the telephone consultation in our study. But we did ask both patients
and clinicians about usefulness of the questionnaire in our study. Since
telemedicine has been adopted out of necessity during the COVID-19
pandemic, 46% of patients finding the questionnaire useful, brings us a
big step closer to the acceptance of ‘the new normal’ for patients. In
an even bigger proportion of consultations, 69%, clinicians found the
questionnaire helpful, showing the usefulness of this questionnaire
clinically.