gms | German Medical Science

Background and status of (inter)national research: Primary care physicians (PCP) report strong barriers in the management of patients with vertigo, dizziness and balance problems (VDB). As a consequence, referral trajectories starting from primary care might be determined by other factors than medical necessity. It has been shown that patients with VDB under usual care conditions often were not able to improve in patient-relevant outcomes, yet that improvement is possible when the causes of VDB are adequately cared for. Referral trajectories may play an important role in whether or not such an improvement can be obtained.

Research question and objective: The objective of this paper was to examine the impact of disease-related and other determinants on referral trajectories of older patients with VDB and to investigate, how these trajectories affect the patients’ functioning, i.e. their ability to perform activity and participation tasks, and health-related quality of life (HRQoL).

Method or hypothesis: Data originates from the longitudinal multicenter study MobilE-TRA, conducted in Bavaria and Saxony, Germany. Referrals to neurologists or Ear-Nose-Throat (ENT) specialists were considered. Referral patterns were visualized using a state sequence analysis. Predictors of referral trajectories were examined using a multinomial logistic regression model. Linear mixed models were calculated to assess the impact of referral on the patients’ HRQoL and functioning.

Results: We identified three patterns of referral trajectories: PCP only, PCP and neurologist, and PCP and ENT. Patients were most frequently managed solely by the PCP without further referral to a neurologist or an ENT specialist. Chances of referral to a neurologist were significantly higher for patients with a neurological comorbidity (OR = 3.22, 95%-CI [1.003; 10.327]) and lower for patients from Saxony (OR = 0.08, 95%-CI [0.013; 0.419]). Patients with a PCP and neurologist referral pattern had a lower HRQoL and lower functioning at baseline assessment. Functioning increased over time for patients with a specific VDB diagnosis (Beta = -1.05, 95%-CI [-1.78; -0.32]). The development of functioning over time in patients with an unspecific diagnosis was significantly worse compared to patients with a specific diagnosis, resulting in a decrease over time for these patients.

Discussion: Referral trajectories were determined by present neurological comorbidity and the regional healthcare characteristics but not by the underlying VDB diagnosis. Referral trajectories affected patients’ HRQoL. Unspecific VDB diagnoses seem to increase the risk of ineffective management and consequently impaired functioning.

Practical implications: Development and implementation of evidence-based standardized care pathways for management and referral of patients with VDB could help PCPs to base referral decision more on disease-related necessities and thus improve the situation of patients with VDB.

Appeal for practice (science and/or care) in one sentence: Trajectories in health care should be considered when examining the impact of health care on patient-relevant outcomes.