Impact and Cost Effectiveness of Videonystagmography.

OBJECTIVE: Videonystagmography (VNG) is a commonly ordered test to evaluate patients with vestibular complaints. To date, there are no evidence-based guidelines for evaluating patients presenting with vestibular symptoms. This study evaluates the cost effectiveness of VNG and the impact of VNG findings on patient management. METHODS: Patient charts were reviewed from 3 institutions to collect the pre- and post-VNG ICD-9/10 diagnosis and treatment plan. VNG findings were recorded to calculate the incidence of abnormal findings and the incidence of change in diagnosis and/or treatment plan. The cost effectiveness of VNG was estimated based on these calculations. RESULTS: A total of 120 patient charts were reviewed. 69/120 (57.5%; 95% CI: 48.2%-66.5%) patients had abnormal findings on their VNG. A change in diagnosis was noted in 24/120 (20.0%; 95% CI: 13.3%-28.3%) patients. A change in treatment plan was noted in 62/120 (51.7%; 95% CI: 42.4%-60.9%) patients, and 11/120 (9.2%; 95% CI: 4.7%-15.8%) had a change in diagnosis that led to change in treatment plan. Using the average Medicare reimbursement for VNG, the cost effectiveness analysis showed a cost of $869.57 per VNG with abnormal findings and a cost of $5454.55 per VNG that lead to a change in diagnosis and treatment plan. CONCLUSIONS: VNG findings may not result in changes in clinical diagnosis. However, VNG is impactful at influencing treatment plan changes. VNG results are beneficial for counseling patients, guiding treatment plans, and managing patient expectations. When there is a clear indication, VNG testing can be cost effective in managing patients presenting with vestibular symptoms.

Cost-effective analysis of unilateral vestibular weakness investigation.

OBJECTIVES: To evaluate the cost-effectiveness of obtaining a magnetic resonance imaging (MRI) in patients with abnormal electronystagmography (ENG) or videonystagmography (VNG) results. STUDY DESIGN: Retrospective chart review. SETTINGS: Academic specialty center. PATIENTS: Patients presenting with vertigo between January 1, 2010, and August 30, 2013. METHODS: Patients who fit the following abnormal criteria were included in the study: unilateral caloric weakness (≥20%), abnormal ocular motor testing, and nystagmus on positional testing. Patients with abnormal findings who then underwent MRI with gadolinium were evaluated. RESULTS: Of the 1,996 charts reviewed, there were 1,358 patients who met the inclusion criteria. The average age of these patients was 62 years (12-94 yr). The male:female ratio was approximately 1:2. Of the 1,358 patients, 253 received an MRI with the following pathologies: four vestibular schwannomas, three subcortical/periventricular white matter changes suspicious for demyelinating disease, four acute cerebellar/posterior circulation infarct, two vertebral artery narrowing, one pseudomeningocele of internal auditory canal, and two white matter changes indicative of migraines. The positive detection rate on MRI was 5.5% based on MRI findings of treatable pathologies causing vertigo. Average cost of an MRI is $1,200, thereby making the average cost of identifying a patient with a positive MRI finding $15,180. CONCLUSION: In our study, those patients with a positive MRI had a constellation of symptoms and findings (asymmetric sensorineural hearing loss, tinnitus, vertigo, and abnormal ENG/VNG). Cost-effectiveness can be improved by ordering an MRI only when clinical examination and VNG point toward a central pathology. Clinical examination and appropriate testing should be factored when considering the cost-effectiveness of obtaining an MRI in patients with abnormal ENG/VNG findings.

Decision and cost analysis in acoustic neuroma diagnosis.

Demonstrating improved outcomes and cost containment are current health care imperatives. For many diseases, competing diagnostic tests are available. Each has a direct economic cost and indirect costs based on missed disease. It is often difficult to determine the most efficient testing strategy for a given patient. Clinical Decision Analysis can optimise diagnostic strategies to maximise cost-effectiveness. Analytic techniques are developed to allow analysis of diagnostic strategies that include multi-test protocols. The test parameters required for modelling these strategies are derived from a literature analysis.

Clinical and financial audit of diagnostic protocols for lesions of the cerebellopontine angle.

OBJECTIVE: To assess the diagnostic efficiency and costs of protocols used for investigating patients with suspected lesions of the cerebellopontine angle. DESIGN: Prospective evaluation of tests of auditory brain stem responses and acoustic reflex thresholds, electronystagmography, and calorics. Positive test results were confirmed or refuted by high resolution computed tomography with intravenous enhancement. SETTING: Single general otolaryngology clinic in a teaching hospital. PATIENTS: 270 consecutive patients with sensorineural hearing loss requiring investigation to exclude a lesion of the cerebellopontine angle. MAIN OUTCOME MEASURES: Estimated costs of various diagnostic protocols and performance in detecting tumours of the cerebellopontine angle. RESULTS: Protocols including tests of auditory brain stem responses and acoustic reflex thresholds as sifting tests before computed tomography were clinically acceptable and presented considerable savings over the use of computed tomography in all patients (74,000 pounds or 84,000 pounds v 122,000 pounds). The use of electronystagmography and calorics could not be justified on clinical or financial grounds. CONCLUSIONS: Audiological tests of auditory brain stem responses and acoustic reflex thresholds followed by computed tomography constitute the most cost effective protocol for determining suspected lesions of the cerebellopontine angle. IMPLICATIONS: The cost effectiveness of diagnostic protocols should be evaluated throughout the health service.

Acoustic neuroma: a cost-effective approach.

A cost-effective approach to the diagnosis and treatment of acoustic neuromas continues to evolve as diagnostic methods improve. In the past 7 months, since gadolinium-enhanced magnetic resonance imaging (MRI) has become available in our practice, our screening and presurgical workup has changed. The purpose of this article is to outline the current philosophy of the senior authors in relation to acoustic neuroma management on the basis of 72 patients diagnosed from July 1988 to February 1989. With more sensitive diagnostic means, older less sensitive studies may be eliminated from the routine workup, thus maintaining cost-effectiveness while preserving the highest standard of patient care. The body of this article will review our current use of the many available diagnostic options and emphasize a cost-effective approach.

Developing a computer laboratory for neurotologic diagnosis.

The authors, with the help of a community hospital engineering staff, constructed a modern neurotological testing facility capable of performing on-line computer measurements of vestibulo-oculomotor, visual vestibulo-oculomotor, smooth pursuit, saccade, and optokinetic reflexes. The laboratory was built from component parts and uses a Digital Corporation laboratory computer. Programs from the UCLA Human Vestibular Laboratory were modified to work with the new laboratory. Construction and program modification cost $60,000 and was completed in seven months. The laboratory was working at full capacity six months after construction testing patients with suspected neurotologic and neurologic disorders. The procedures of construction as well as the financial and safety problems are discussed.

The value and cost analysis of the ENG as of 1978.

The use of ENG in office practice and its use as a helpful, time-saving procedure is discussed. The following practical clinical questions are answered: 1. Is the vestibular mechanism normal or abnormal? 2. Is the vestibular pathology peripheral or central? 3. Is the peripheral disease right or left sided? Cost analysis of ENG in office practice is presented.