Practice Patterns of Referring Physicians in Management of the Dysphonic Patient

Diagnostic Agreement Among General Practitioners, Residents, and Senior Rheumatologists for Rheumatic Diseases

OBJECTIVE

The aim of this study was to evaluate the concordance of the diagnoses made by senior rheumatologists and those made by residents in rheumatology and by general practitioners (GPs).

METHODS

In this cohort, 497 patients referred by GPs from August 1, 2018 to December 16, 2019 were evaluated first by a second-year resident in rheumatology. After clinical rounds, the diagnoses by senior rheumatologists were assumed as the criterion standard and defined the prevalence of the rheumatic diseases, divided into 5 groups: rheumatoid arthritis, spondyloarthritis, other connective tissue diseases and vasculitis, nonautoimmune rheumatic diseases, and nonrheumatic diseases. The follow-up ended on November 30, 2020. We calculated sensibility, specificity, positive predictive value, negative predictive value, and κ coefficient of the diagnosis by GPs and residents.

RESULTS

The diagnoses were changed for 58% of the referral letters. Diseases of low complexity, such as fibromyalgia and osteoarthritis, accounted for 50% of the diagnoses. Compared with senior rheumatologists, residents in rheumatology had κ > 0.6 for all the groups, whereas GPs had κ < 0.5, with the worst performance for nonautoimmune rheumatic disease (κ = -0.18) and nonrheumatic disease (κ = 0.15). In terms of level of complexity, 46% of the letters were inappropriate.

CONCLUSIONS

We found a poor level of diagnostic agreement between GPs and the rheumatology team. General practitioners had difficulties diagnosing and treating rheumatic diseases, referring patients that should be treated in the primary level of health care. One year of training in rheumatology made residents' skills comparable to those of senior rheumatologists.

Survey of Referral Patterns in Southwestern Mainland China: How Do Pediatricians Manage Children with Dysphonia

OBJECTIVE

Voice disorders are common in children and have a negative impact on their quality of life. However, presently, voice assessment and therapy are inaccessible in most pediatric departments of Mainland China. Thus, referring pediatric patients with voice disorders to otolaryngology is warranted for prompt and appropriate treatment. The purpose of this study is to investigate referral patterns and their influencing factors for pediatricians' managing children with dysphonia in Southwestern Mainland China.

STUDY DESIGN

Observational study.

METHODS

A 28-item questionnaire was designed by multidisciplinary experts, and an anonymous survey was performed online via Wenjuanxing between September 8, 2021 and October 8, 2021. The statistical analyses were performed using the independent sample median test, the linear/logistic regression model, the Kruskal-Wallis test, and Spearman's correlation test to determine any statistically significant relationships between the variables of interest.

RESULTS

Predominantly recruited from institutions in Southwestern China, 368 pediatricians were surveyed. (1) The majority of the pediatricians reported that ≤10% of children sought medical help for voice disorders; (2) only 22.1% of the pediatricians' hospitals had equipment for evaluating voice disorders; (3) 74.6% of the pediatricians would refer children with dysphonia to otolaryngology, and the older pediatricians were more likely to refer their patients than were the younger pediatricians (P = 0.022); (4) in the group that would make a referral (n = 250), the pediatricians who had worked longer (P = 0.037) and practised in the Grade-A tertiary hospitals (P = 0.044) were more likely to trust their experience as a reason for making a referral. For each year worked the probability of referring children with dysphonia depending on the pediatrician's experience increased by 3.4%.

CONCLUSION

Although the pediatricians encountered some barriers to diagnosing voice disorders, their attitude towards making referrals was positive. The age and work duration of the pediatricians and the hospital grade were the influencing factors in the referral patterns. Further publicity of vocal hygiene, ongoing education among Chinese pediatricians and the improvement of referral systems may be most useful for better managing children with dysphonia.

Development of a machine-learning based voice disorder screening tool

OBJECTIVE

Early recognition and referral are crucial for voice disorder management. Limited availability of subspecialists, poor primary care awareness, and the need for specialized equipment impede effective care. Thus, there is a need for a tool to improve voice pathology screening. Machine learning algorithms (MLAs) have shown promise in analyzing acoustic characteristics of phonation. However, few studies report clinical applications of MLAs for voice pathology detection. The objective of this study was to design and validate a MLA for detecting pathological voices.

METHODS

A MLA was developed for voice analysis. Audio samples converted into spectrograms were inputted into a pre-existing VGG19 convolutional neural network (CNN) and image-classifier. The resulting feature map was classified as either pathological or healthy using a Support Vector Machine (SVM) binary linear classifier. This combined MLA was "trained" with 950 sustained "/i/" vowel audio samples from the Saarbrucken Voice Database (SVD), which contains subjects with and without voice disorders. The trained MLA was "tested" with 406 SVD samples to determine sensitivity, specificity, and overall accuracy. External validation of the MLA was performed using clinical voice samples collected from patients attending a subspecialty voice clinic.

RESULTS

The MLA detected pathologies in SVD samples with 98.5% sensitivity, 97.1% specificity and 97.8% overall accuracy. In 30 samples obtained prospectively from voice clinic patients, the MLA detected pathologies with 100% sensitivity, 96.3% specificity and 96.7% overall accuracy.

CONCLUSIONS

This study demonstrates that a MLA using a simple audio input can detect diverse vocal pathologies with high sensitivity and specificity. Thus, this algorithm shows promise as a potential screening tool.

Lansoprazole for persistent throat symptoms in secondary care: the TOPPITS RCT

BACKGROUND

Persistent throat symptoms are commonly attributed to 'laryngopharyngeal reflux'. Despite a limited evidence base, these symptoms are increasingly being treated in primary care with proton pump inhibitors.

OBJECTIVE

To assess the value of proton pump inhibitor therapy in patients with persistent throat symptoms.

DESIGN

This was a double-blind, placebo-controlled, randomised Phase III trial.

SETTING

This was a multicentre UK trial in eight UK ear, nose and throat departments.

PARTICIPANTS

A total of 346 participants aged ≥ 18 years with persistent throat symptoms and a Reflux Symptom Index score of ≥ 10, exclusive of the dyspepsia item, were recruited.

INTERVENTION

Random allocation (1 : 1 ratio) to either 30 mg of lansoprazole twice daily or matched placebo for 16 weeks.

MAIN OUTCOME MEASURE

Symptomatic response (i.e. total Reflux Symptom Index score after 16 weeks of therapy).

RESULTS

A total of 1427 patients were screened and 346 were randomised. The mean age was 52 years (standard deviation 13.7 years, range 20-84 years); 150 (43%) participants were male and 196 (57%) were female; 184 (53%) participants had a mild Reflux Symptom Index minus the heartburn/dyspepsia item and 162 (47%) had a severe Reflux Symptom Index minus the heartburn/dyspepsia item. A total of 172 patients were randomised to lansoprazole and 174 were randomised to placebo.

MAIN OUTCOMES

A total of 267 participants completed the primary end-point visit (lansoprazole, n = 127; placebo, n = 140), of whom 220 did so between 14 and 20 weeks post randomisation ('compliant' group); 102 received lansoprazole and 118 received placebo. The mean Reflux Symptom Index scores at baseline were similar [lansoprazole 22.0 (standard deviation 8.0), placebo 21.7 (standard deviation 7.1), overall 21.9 (standard deviation 7.5)]. The mean Reflux Symptom Index scores at 16 weeks reduced from baseline in both groups [overall 17.4 (standard deviation 9.9), lansoprazole 17.4 (standard deviation 9.9), placebo 15.6 (standard deviation 9.8)]. Lansoprazole participants had estimated Reflux Symptom Index scores at 16 weeks that were 1.9 points higher (worse) than those of placebo participants (95% confidence interval -0.3 to 4.2; padj = 0.096), adjusted for site and baseline severity.

SECONDARY OUTCOMES

Ninety-five (43%) participants achieved a Reflux Symptom Index score in the normal range (< 12) at 16 weeks: 42 (41%) in the lansoprazole group and 53 (45%) in the placebo group. A total of 226 participants completed the end-of-trial follow-up visit (lansoprazole, n = 109; placebo, n = 117), of whom 181 were 'compliant'. The mean Reflux Symptom Index scores at 12 months reduced from baseline in both groups [lansoprazole 16.0 (standard deviation 10.8), placebo 13.6 (standard deviation 9.6), overall 14.7 (standard deviation 10.2)]. A total of 87 (48%) participants achieved a Reflux Symptom Index score in the normal range at 12 months: 33 (40%) in the lansoprazole group and 54 (55%) in the placebo group. Likewise, the Comprehensive Reflux Symptom Score and Laryngopharyngeal Reflux - Health Related Quality of Life total scores and subscales all showed very similar changes in the lansoprazole and placebo cohorts at both 16 weeks and 12 months.

LIMITATIONS

Drop-out rate and compliance are issues in pragmatic clinical trials. The Trial Of Proton Pump Inhibitors in Throat Symptoms (TOPPITS) aimed to detect clinically relevant difference with 90% power. The 346 randomised participants reduced to 283 at the primary end point; 267 completed the primary outcome measure, 220 within the protocol time scale. Despite this, the powers to detect the clinically relevant difference in Reflux Symptom Index score at 16 weeks were 82% (compliant comparison) and 89% (pragmatic comparison). The lack of difference between lansoprazole and placebo is generalisable across NHS clinics.

CONCLUSIONS

Participants on lansoprazole did not report significantly better outcomes than participants on placebo on any of the three patient-reported outcome tools (Reflux Symptom Index, Comprehensive Reflux Symptom Score and Laryngopharyngeal Reflux - Health Related Quality of Life). This multicentre, pragmatic, powered, definitive Phase III trial found no evidence of benefit for patients by treating persistent throat symptoms with lansoprazole.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN38578686 and EudraCT number 2013-004249-17.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 25, No. 3. See the NIHR Journals Library website for further project information.

Appraising Otolaryngology–Head and Neck Surgery Clinical Practice Guidelines for Effective Dissemination and Implementation Design

Objectives

Dissemination and implementation (D&I) science analyzes interventional strategies that aid in spreading scientific knowledge, adopting evidence into practice, and identifying barriers to maximize successful integration of science into practice. This study set out to critically appraise the published D&I strategies of the American Academy of Otolaryngology–Head and Neck Surgery Foundation (AAO-HNSF) Clinical Practice Guidelines (CPGs) and to introduce the theories of D&I science.

Methods

The 15 AAO-HNSF CPGs underwent appraisal by 2 independent reviewers using the Appraisal of Guidelines for Research & Evaluation II (AGREE II) instrument. CPGs were rated over 23 key items in 6 domains. Each item was rated on a 7-point scale from 1 ( strongly disagree) to 7 ( strongly agree). CPGs were rated and quality assessments were performed. Intrarater reliability was assessed.

Results

The overall mean score of the CPGs was 85.2% (95% confidence interval, 83.4%-86.9%). Individual CPG mean scores ranged from 80.4% to 90.9%. Mean interrater reliability was strong. All domains of the AGREE II instrument, except the Applicability domain, scored a mean of 90.7% or better. D&I strategies within the CPGs, as calculated by the Applicability domain score, ranged from 22.9% to 77.1%.

Discussion

There is a paucity of published D&I strategies within the AAO-HNSF CPGs. Nesting a D&I framework, such as the Quality Improvement Framework, within CPGs would allow for identification of barriers to CPG adoption and evaluation of CPG-directed interventions.

Implications for Practice

A D&I framework within the AAO-HNSF CPGs would allow for objective measurement of the overall impact of CPGs on otolaryngology practices.

The Reflux Symptom Index and Symptom Overlap in Dysphonic Patients

OBJECTIVES/HYPOTHESIS

The Reflux Symptom Index (RSI) is a validated quality-of-life instrument that quantifies symptoms associated with laryngopharyngeal reflux (LPR). Many dysphonic patients are managed empirically for reflux. In this study, we examine responses to the RSI in patients with dysphonia attributable to a variety of pathologies.

STUDY DESIGN

Retrospective cohort study.

METHODS

This is an institutional review board-approved study. All patients presented to a tertiary care voice center January 2011 to June 2016 with the chief complaint of dysphonia. Patients were analyzed by 1) diagnosis and 2) treatment modality: surgery, medicine, or voice therapy (VT). Data collected included pre- and postintervention RSI and Voice Handicap Index, demographic, and clinical information. Statistical analysis was performed using SPSS.

RESULTS

Five hundred forty-six dysphonic patients were included. One hundred forty required surgery, 155 were treated with VT alone, and 251 were medically managed (MM). Prior to therapy, 63.4% of surgery patients, 62.5% of VT patients, and 74.6% of MM patients had an abnormal RSI with a score greater than 13. The most common diagnosis for each group was vocal cord paresis/paralysis (surgery), vocal fold atrophy (VT), and LPR (MM). There was a statistically significant improvement in RSI after treatment for each group.

CONCLUSIONS

In patients with dysphonia, pretreatment RSI scores were elevated for a variety of laryngeal pathologies. Scores often improved with directed treatment, regardless of etiology. This highlights the symptom overlap between reflux and nonreflux causes of dysphonia, and the importance of a comprehensive workup for patients with voice complaints.

LEVEL OF EVIDENCE

4 Laryngoscope, 130:2631-2636, 2020.