Effectiveness of a training intervention to improve the management of vertigo in primary care: a multicentre cluster-randomised trial, VERTAP.

BACKGROUND: Benign paroxysmal positional vertigo (BPPV) is the most common type of vertigo. While BPPV is best treated with canalicular repositioning manoeuvres, they are not routinely performed in primary care (PC). METHODS: To evaluate the effectiveness of blended training (online and face-to-face) on the diagnosis and management of vertigo to improve adherence of family doctors to clinical practice guidelines, we designed a community multicentre cluster-randomised open-label trial with an intervention (IG) and a control (GC) group of 10 primary care teams (PCT) each. Outcome variables will be ICD-10 diagnostic codes (proportion of nonspecific diagnoses such as dizziness and vertigo versus specific diagnoses such as BPPV, vestibular neuritis, and Menière's disease); number of referrals to ENT or neurology specialists; prescription of antivertigo agents; and duration of sick leave due to vertigo. The baseline comparability of the two study groups will be analysed to ensure homogeneity. A description of all baseline variables will be performed. Student's t-test will be used to evaluate the differences between the groups. Logistic regression multivariate analysis will be performed to study the relationship between baseline variables of professionals and centres with outcome variables. DISCUSSION: With the improvement of the diagnosis and management of vertigo by family doctors after this training, we expect an increase in the proportion of specific diagnoses, a decrease in the prescription of antivertigo agents, a decrease in referrals to ENT or neurology specialists and a reduction in the duration of sick leave due to temporary disability. The blended training will be easily expanded within primary care services, since it is mainly delivered online, with a single face-to-face session to ensure that the manoeuvres have been adequately learned. TRIAL REGISTRATION: ClinicalTrials.gov NCT04929444 . Registered June 18, 2021. This protocol has been approved by the Ethics Committee of the Institut Universitari d'Investigació en Atenció Primària Jordi Gol (IDIAP Jordi Gol) with the code 20/004-P. All patient data will be anonymised in agreement with the 2016/679 European Regulation.

Family physicians' ability to detect a physical sign (hepatomegaly) from an unannounced standardized patient (incognito SP).

BACKGROUND: Little is known about the quality of the physical examination and its effectiveness in daily practice. OBJECTIVE: To determine if family physicians (FPs) were able to detect an important physical sign (hepatomegaly) and to relate this result with other measures of quality. METHODS: 57 of 104 invited FPs from the National Health Service of the Southern Barcelona Area agreed to schedule an unannounced Standardized Patient (SP) randomly into their daily practice. The SP presented with hepatomegaly and mild abdominal pain. After the visit clinical notes, medical orders, an audiotape of the visit and a checklist completed by the SP detailing items in the physical examination (PE) were analysed. The attainment of a number of quality standards was assessed. RESULTS: The three major findings that resulted from this study were: (a) only 4 of the 57 FPs who examined the patient detected the hepatomegaly; (b) FPs performed better at history taking (84.24%) than at PE (26.35%); no correlation was found between the two; (c) diagnostic accuracy was associated with older age, years of experience, history taking skills and better performance at requesting diagnostic tests. Most FPs (88%) requested the appropriate tests. FPs who scored better on requesting diagnostic tests spent an average of four minutes more with the patient. None of the participants detected the SP. CONCLUSIONS: Clinical hepatomegaly is difficult to detect, even by well trained FPs. Senior doctors scored better on physical examination.