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.