The Outcome Measure Of Vertigo Severity Based On The Clinical Practicality Of The Chinese Version Dizziness Handicap Inventory

Background:The Dizziness Handicap Inventory(DHI)is the most widely used outcome measure for evaluating the severity and efficacy of vertigo symptoms.Although the Chinese version of DHI had great psychometric properties,the clinical practicability issues such as scale completion and accuracy have not been studied in China,which are important aspects of the effectiveness and accuracy of assessment tools.Currently,the patient-reported vertigo scales used in China are mainly translated from foreign scales.Using open questions to investigate patients is one of the earliest sources of patient-reported scale items,but there is no comprehensive,careful and systematic investigation on vertigo patients in China.DHI only evaluates the changes in patients’ quality of life caused by vertigo symptoms but does not fully understand the characteristics of vertigo episodes and the troubles caused by vertigo symptoms from the perspective of patients.There is also a lack of self-developed tools to evaluate the severity and efficacy of vertigo symptoms.This study takes vertigo as a symptom to discuss its severity and efficacy assessment,hoping to provide some help for the research and development of vertigo symptom assessment tools in line with China’s national conditions.Objective:Chapter 1 Objective:(1)To explore the clinical practicability(scale completion and accuracy)of Chinese-version DHI in clinical use in China;(2)Analyze the problems faced by patients in completing Chinese-version DHI;(3)Analyze the factors affecting the Chinese-version DHI completion degree.Chapter 2 Objective:(1)For the first time in China,open questionnaires will be used to interview patients to investigate the influence of vertigo symptoms on Chinese patients;(2)Compare the contents of vertigo scales commonly used in foreign countries,and analyze the differences in the directions of attention and expression habits of Chinese and Western patients when describing the effects of vertigo.Chapter 3 Objective:To conduct comprehensive and accurate interviews with vertigo patients in China,an in-depth understanding of the symptoms of vertigo patients in the course of the disease,as well as physical and mental feelings,is expected to provide necessary materials for the formation of vertigo symptoms severity and efficacy assessment tools applicable to China.Materials and Methods:In the "Tinnitus,Hearing loss and Vertigo specialist" clinic of Otolaryngology-Head and Neck Surgery,West China Hospital of Sichuan University,adult patients(≥18 years old)with vertigo symptoms as the first chief complaint were included,and patients who were unable or unwilling to cooperate due to various reasons were excluded.Chapter 1 Methods:(1)After determining the version of Chinese-version DHI,a team of physicians was formed to form a unified consensus on the understanding of each item of Chinese-version DHI;Then,for patients who met the inclusion criteria,DHI was first completed by patients(the patient filled out the scale by himself,patient-reported),and then the Chinese-version DHI physician assessment was completed again through face-to-face and one-to-one communication between the clinician and the patient(physician-reported).At the same time,the problems encountered by patients in filling in Chinese-version DHI and the reasons for their failure were recorded.Then,the differences between the two evaluation methods in DHI completion degree and score accuracy(the standard of physician-reported)were compared.(2)To analyze the reasons why some patients could not complete the Chinese version of DHI(3)Analyze the influence of age,gender,employment,educational background,duration of disease,and patient origin on DHI completion degree.Chapter 2 Methods:(1)According to the way that patient-reported scale items were originally formed in foreign countries,physicians gave an open questionnaire to patients with vertigo through one-to-one or face to face: " Please make a list of the difficulties which you have as a result of your vertigo.List them in order of importance,starting with the biggest difficulties.Tell as many of them as you can." Interviews are conducted,and then patient descriptions are recorded and collected in detail point by point according to the sequence of patient descriptions.Hierarchical cluster analysis and importance ratio were used to analyze the influence of vertigo symptoms on Chinese patients,showing the influence of category and proportion of vertigo symptoms.(2)The items of the twelve vertigo assessment scales commonly used abroad are summarized to form the item library,and then the items are classified and summarized according to the contents of the items,and the proportion of each category in the item library is calculated.At the same time,the influence of Chinese vertigo patients’ reports was classified according to the categories formed by foreign scale items,and the percentage of each category in the total influence of Chinese patients’ reports was also calculated.Finally,the percentages of the two groups in each category were compared,to clarify the similarities and differences of the influence of Chinese and foreign vertigo symptoms on patients.Chapter 3 Methods:The phenomenological method in qualitative research is used to capture the real experience of the research object through face-to-face semi-structured interviews.The results are mainly summarized and stated.Different from the commonly used quantitative research in the medical field,the results are presented in a data analysis report.This chapter uses this method to explore the symptoms and physical and mental feelings experienced by patients with vertigo more comprehensively.Maximum difference sampling was used to determine the sample size.Patients with vertigo were interviewed in the consulting room,and the interview time for each patient was 30~60 minutes.Interview outline: what is bothering you about vertigo? How did you feel during the whole vertigo process? what problems would you like the doctor to solve as soon as possible? The seven-step qualitative research phenomenological analysis method of Nancy was used to analyze the data,including the repeated reading of the interview records,extraction of meaningful statements,encoding,summarizing,writing detailed statements,sublimating the topic,and returning to the interviewees for verification.Finally,the researchers integrate the themes so that there is a certain internal connection between the themes.Software used for data recording and analysis in this study included Microsoft Excel 2016,GPower 3.1,IBM SPSS24.0,and Nvivo11.Kolmogorov-Smirnov test was used to analyze the normality of each variable.Continuous data were expressed as mean value and standard deviation,while classified data were expressed as frequency and percentage.Pair t-test,Mann-Whitney U rank-sum test,and Fisher’s Exact test were used to compare the differences between or within groups according to data types,and P< 0.05 was considered to be statistically significant.This study has been approved by the Ethics Committee of Clinical School of Medicine,West China Hospital,Sichuan University(No.499,2019).Results:Chapter 1 Results:From January to September 2019,a total of 144 patients,aged 20-82 years,with an average age of(48.56 ± 13.44)years,were enrolled.There were 48 males and 96 females,with a male-to-female ratio of 1:2.A quarter of the patients had higher education(31 were university students and 5 were graduate students or above);Secondary education accounted for 63.17%(50 cases in junior middle school,41 cases in senior high school)and 11.81%(17 cases in primary school and below),respectively.91.67% from Sichuan Province;53.47% are middle-aged and elderly(41 ~ 60 years old).(2)Completion degree of DHI scale:(1)Overall Completion: Although the completion degree of either self-assessment or physician-reported scale did not reach 100%,the complete degree of physician-reported was higher than that of patient-reported(scale completion degree: patient-reported completion degree 98/144,68.06%;physician-reported scale completion 118/144,81.94%).(2)Among the patients with incomplete DHI,the patient had at least 1incomplete item,at most 9 incomplete items at the patient-reported,and at most 5incomplete items in physician-reported.Of the 25 items in DHI,the most patients failed to complete when patient-reported was item 2(Because of your problem,do you feel frustrated?),17 cases(11.81%),followed by item 4(Does walking down an aisle of a supermarket increase your problem?),15 cases(10.42%);At the time of the review,the most patients did not complete was item 4(Does walking down an aisle of a supermarket increase your problem?),12 cases(8.33%),followed by item 12(Because of your problem,do you avoid heights?),7 cases(4.86%).The low degree of completion of the scale hinders its effectiveness in clinical use.(4)Reasons for lowering the DHI completion:The reason for lowering the DHI completion in the physician-reported is that the patients did not experience the conditions asked in the items after the onset of the disease;In addition to the previous reasons for lowering the physician-reported DHI,the reasons for lowering the DHI completion in patient-reported were also related to the patients’ inability to understand the contents of some items or missing filling in.It indicates that when clinical use of DHI,physicians need to check and verify the completion of patients,to improve the completion of the DHI scale.At the same time,it also indicates that some items of DHI do not apply to the actual situation encountered by Chinese patients,and it is necessary to investigate the impact of vertigo reported by Chinese patients.(5)The factors influencing DHI scale completion:In addition to the items mentioned situations patients encountered and patients can’t understand these two reasons will affect DHI inventory finish,in patients with different age,gender,work or not,degree source does not significantly affect the length of the course of the disease(P > 0.05),suggests that by improving the above factors cannot ascend DHI scale incessantly.(6)Accuracy of patient-reported DHI(1)Total score and grading accuracy: In patients who completed all items of DHI completely(98/144,68.06%),the self-rated score was higher than the medical review score(44.04 ± 21.38 vs 35.94 ± 16.99;P < 0.05),the mean difference was8.10±12.79 points.The total scores of 83 patients(84.69%)were not consistent with the total scores of the medical review,among which 20 patients(20.40%)scored lower than the medical review score by 2 to 20 points.Sixty-three patients(64.29%)scored higher in self-evaluation than in medical evaluation,which ranged from 2 to52 points.According to DHI total light(0 to 30),medium(31 to 60),severe classification standard(61 to 100),69 patients(70.41%)of the patient-reported and physician-reported level at the same level,28 cases(28.57%)patient-reported medical was higher a grade than physician-reported,1 case(1.02%)patient-reported was higher two grades than physician-reported,patient-reported severity easily exaggerated.(2)Specific item accuracy: from the specific items,item 10(Because of your problem,have you been embarrassed in front of others?)And item 21(Because of your problem,do you feel handicapped?),84 patients(85.71%)scored the same in patient-reported and physician-reported;And item 18(Because of your problem,is it difficult for you to concentrate?),51 cases(52.04%)of patient-reported scores were inconsistent with physician-reported scores.This difference will lead to the severity of vertigo symptoms and the inaccuracy of efficacy evaluation results,affect doctor-patient communication and clinical decision-making,and affect the effect of vertigo rehabilitation and treatment.Chapter 2 Results:(1)From June to December 2019,this study used an open questionnaire to investigate a total of 261 patients with vertigo,including 87 males and 174 females(male: female = 1:2),aged 18-92 years,with an average of(48.03±13.53)years.The patients gave a total of 712 reports on the effects of vertigo(hereinafter referred to as the effects of vertigo).Each patient was given a minimum of 1 and a maximum of 8effects,with an average of(2.70±1.38)effects per patient.The number of vertigo affected by patients was not affected by gender and age of patients(P > 0.05).(2)These influences can be divided into 15 themes by hierarchical clustering analysis according to similar categories.Give yourself an emotional burden(29.22%),impact out(16.34%),work(11.50%),and discomfort(9.42%),reduced quality of life(7.34%),fatigue(6.93%),and a burden to the family(3.32%),and limited ability to care for(2.91%),decreased concentration(2.49%)and limited mobile body(2.35%),affect vision(2.08%)and housework(1.80%)and affects social(1.52%),affect appetite(1.39%)and entertainment(1.39%).The effects of vertigo on patients are quite different,but there is an interaction between different themes.(3)According to the order according to the impact on their size,calculate the proportion of importance,importance proportion of three is vertigo attack uncomfortable(importance rate 6.46%,the proportion of 6.95%),influence the work of(importance rate 5.48%,the proportion of 6.43%),and worry about vertigo happening again(importance rate 6.04%,the proportion of 6.21%).All these effects can be divided into three aspects according to clinical communication and expression habits,which are the effect on function/work(299 cases,41.99%),the emotion on mood(231 cases,32.44%),and the physical discomfort caused by vertigo or other effects that patients think vertigo caused(182 cases,25.56%).The results show that vertigo affects many patients,and there can be different classifications according to different classifications.It is not appropriate to evaluate all patients with vertigo with some specific effects of vertigo on some patients,and the assessment items should have a certain generalization.(4)Compared with the twelve items used to evaluate the quality of life of patients with vertigo,the most frequent items in foreign scales were the influence on walking(24%),followed by limited head position change(10%),influence on mood(9%),influence on work(7%)and influence on housework(6%).In this study,the highest frequency given by patients was the influence on mood(32%),the restriction on going out(14%),the influence on work(13%),the influence on walking(9%),and the decrease in quality of life(8%).It can be seen that although the influence of Chinese patient reports is consistent with the items of foreign existing scales in the general classification of content,there are differences in the specific expression and the proportion of different classifications.Therefore,it is not appropriate to use the existing foreign scales to evaluate the situation of Chinese patients.Therefore,it is necessary to develop an evaluation tool for the severity and efficacy of vertigo symptoms suitable for the needs of Chinese clinical patients.Chapter 3 Results:From July to October 2020,through qualitative analysis of the contents of semi-structured interviews with 20 patients with vertigo,the patients’ perplexities and physical and mental feelings of vertigo symptoms can be divided into four themes,mainly centering on repeated episodes of vertigo and the effects caused by vertigo:(1)Motivation of patients: fear of re-occurrence of vertigo;Fear of serious illness;Trying to determine the cause.(2)the psychological experience of vertigo: negative psychological experience-worry,fear,helplessness,and despair;Positive psychological experience-no life-threatening.(3)lack of methods to deal with vertigo: reduce activity;Lack of confidence in treatment-no cause can be identified and treatment only relieves the symptoms(4)the treatment target of vertigo patients: to solve the symptoms(the symptoms of vertigo itself and the accompanying symptoms of vertigo);Avoid reoccurring vertigo.All four subjects are closely related to the onset of vertigo symptoms,so vertigo symptoms are also the object of great concern to patients;In the evaluation of the severity and curative effect of vertigo symptoms,besides the influence caused by vertigo,the characteristics of vertigo symptoms must be evaluated.Conclusions:Chapter 3 Conclusions:(1)Scale completion is the prerequisite for DHI to evaluate vertigo symptoms;The completion degree of the DHI scale was low when patients self-rated it,and the completion degree of the DHI scale could be improved through a medical evaluation.However,since the main reason for the failure of patients is that they did not encounter the situation asked by the item,the improvement of medical evaluation on the completion degree is also limited.To patients’ self-reported scores compared with scores more accurate medical evaluation score,self-reported score in DHI severity score,grade,and specific items have some differences,such differences will cause vertigo symptom severity and curative effect evaluation of the results are not accurate,affect doctor-patient communication and clinical decision,the influence of vertigo rehabilitation and treatment effect.Therefore,it is necessary to understand the situation of vertigo patients in China and to develop accurate and easy-to-use vertigo symptom severity and efficacy assessment tools suitable for Chinese patients’ expression habits.(2)The main reason for reducing the DHI completion degree is that the patients did not encounter the situation asked by the item or could not fully understand the situation described in the item.Therefore,it is necessary to investigate the influence caused by vertigo described by Chinese patients and their expression habits.(3)The completion degree of DHI cannot be improved through strict screening of patients’ age,gender,employment,educational background,duration of disease,and origin of patients.The reasons for the decrease in completion degree are the DHI itself rather than external factors.It is necessary to develop scale items suitable for Chinese patients’ expression habits and cultural thinking.Chapter 2 Conclusions:(1)The influence of vertigo on patients in China includes many aspects of life,which can be roughly divided into the influence on work(daily life),the influence on mood,and other influences.(2)The attention direction and expression habit of Chinese patients on the effect of vertigo are not consistent with the existing scale contents in the west.Patients in China pay more attention to the emotional feeling whole feeling,while the foreign scales focus on specific restrictions on personal life.The contents of foreign scales are not suitable for our country.It is necessary to develop a clinical and practical tool to evaluate the severity and efficacy of vertigo symptoms in line with China’s cultural background,expression habits,patient satisfaction.Chapter 3 Conclusions:The phenomenological method of qualitative research was chosen to study the symptoms and psychosomatic experience of patients experiencing vertigo by using the subjective method of humanistic science and face-to-face semi-structured interview.The results showed that the patients’ motivation,various effects of vertigo on patients,patients’ coping measures,and treatment expectations of vertigo were closely related to the occurrence of vertigo.Therefore,there are two basic parts(the influence of vertigo symptoms on patients and the onset of vertigo symptoms)to evaluate the severity and efficacy of vertigo symptoms.The innovation of this study is the first discussion of the completion and accuracy of the Chinese version DHI,and the use of open questions interviews and semi-structured interviews conducted a detailed comprehensive investigation in patients with vertigo,on the analysis method of combining use research and qualitative research,hope for our country the vertigo symptom severity and curative effect appraisal standards do a bit of depth of the preparation.However,this study only conducted a single-center study on the scale completion and accuracy in the clinical practicability of DHI.In the later stage,other scales or multicenter studies can be carried out to further discuss the clinical practicability of foreign patient-reported vertigo scales in China.Secondly,this study only initially revealed the influence of vertigo expressed by Chinese vertigo patients and the expression habits of Chinese patients.How to use these data to extract meaningful vertigo symptom severity and efficacy evaluation tools remains to be further studied.Finally,this study only conducted interviews and surveys from the perspective of patients,and further studies can be conducted from the perspective of medical staff to research and develop tools for evaluating the severity and efficacy of vertigo symptoms that meet the needs of clinicians and patients in China,and contributing to the treatment and rehabilitation of vertigo patients.