The economic burden of vertigo and dizziness in the United States

Abstract

BACKGROUND:

Vertigo and dizziness are extremely common conditions in the adult population and therefore place a significant social and economic burden on both patients and the healthcare system. However, limited information is available for the economic burden of vertigo and dizziness across various health care settings.

OBJECTIVE:

Estimate the economic burden of vertigo and dizziness, controlling for demographic, socioeconomic, and clinical comorbidities.

METHODS:

A retrospective analysis of data from the Medical Expenditures Panel Survey (2007–2015) was performed to analyze individuals with vertigo or dizziness from a nationally representative sample of the United States. Participants were included via self-reported data and International Classification of Diseases, 9th Revision Clinical Modification codes. A cross-validated 2-component generalized linear model was utilized to assess vertigo and dizziness expenditures across demographic, socioeconomic and clinical characteristics while controlling for covariates. Costs and utilization across various health care service sectors, including inpatient, outpatient, emergency department, home health, and prescription medications were evaluated.

RESULTS:

Of 221,273 patients over 18 years, 5,275 (66% female, 34% male) reported either vertigo or dizziness during 2007–2015. More patients with vertigo or dizziness were female, older, non-Hispanic Caucasian, publicly insured, and had significant clinical comorbidities compared to patients without either condition. Furthermore, each of these demographic, socioeconomic, and clinical characteristics lead to significantly elevated costs due to having these conditions for patients. Significantly higher medical expenditures and utilization across various healthcare sectors were associated with vertigo or dizziness (p < 0.001). The mean incremental annual healthcare expenditure directly associated with vertigo or dizziness was $2,658.73 (95% CI: 1868.79, 3385.66) after controlling for socioeconomic and demographic characteristics. Total annual medical expenditures for patients with dizziness or vertigo was $48.1 billion.

CONCLUSION:

Vertigo and dizziness lead to substantial expenses for patients across various healthcare settings. Determining how to limit costs and improve the delivery of care for these patients is of the utmost importance given the severe morbidity, disruption to daily living, and major socioeconomic burden associated with these conditions.

Keywords

Otolaryngology vertigo dizziness economic burden incremental burden

1 Introduction

Dizziness and vertigo are extremely common in the adult population, with life-time prevalence estimates for dizziness between 17–30% and vertigo between 3–10% [1]. Wide prevalence ranges may result, at least partially, from selection bias in epidemiological studies surveying specialized clinics rather than the general population [2]. Patients with vertigo and dizziness are primarily treated by primary care providers and specialists with vestibular training [3], but visits to the emergency department (ED) are also commonplace, with estimates between 2.6 million and 3.9 million visits in the United States (US) annually [4 –6].

Dizziness is broadly used to describe multiple sensations such as lightheadedness, presyncope, disequilibrium, and vertigo [7]. It includes myriad pathologies, ranging from benign to life-threatening disruptions in physiological pathways, involving the central nervous, cardiovascular, visual, or vestibular systems, among others [7 –9]. Conversely, vertigo is an illusion of motion due to an asymmetry within the central or peripheral vestibular system and includes: benign paroxysmal position vertigo (BPPV), Ménière’s disease, vestibular neuritis, vestibular migraine, and others [8].

Both vertigo and dizziness can be quite debilitating, disrupting essential activities required for daily living, impairing quality of life, and leading to detrimental effects to work, family, and social interactions [10 –12]. Patients with these symptoms often report significantly higher degrees of suffering and emotional distress, with an elevated risk of having concurrent depression, anxiety, and panic disorders [13 –15].

Vertigo and dizziness place a significant social and economic burden on both individual patients and the US healthcare system. In 2011, the estimated total costs for managing patients with vertigo or dizziness in US EDs was nearly $3.9 billion [6]. However, limited information is available for the economic burden of vertigo and dizziness across other health care settings. Furthermore, vertigo and dizziness each comprise a diverse set of etiologies, but the clinical presentation can overlap significantly. The distinction is not always clear for either patients or clinicians [16, 17], which can lead to misclassification bias, issues in coding within epidemiological studies, and ultimately higher healthcare costs associated with diagnosis. The present study utilizes a nationally representative sample to estimate the combined economic burden of vertigo and dizziness for adults in the US across various healthcare service sectors while controlling for demographic and socioeconomic characteristics.

2 Methods

2.1 Data source and population

Nine years of data were extracted from the Medical Expenditure Panel Survey (MEPS) for the years 2007–2015. MEPS is nationally representative of the US civilian, non-institutionalized population and is administered by the Agency for Healthcare Research and Quality (AHRQ) to assess health care service patterns in the United States. MEPS utilizes a stratified random sampling procedure to select and follow participants for two years whereby participants complete five questionnaires via computer-assisted personal interviews. MEPS then collects data for demographic characteristics, visit dates, diagnosis and procedure codes, charges, and payments from healthcare providers and pharmacies, by telephone. More detail on the survey structure of MEPS can be found elsewhere [18, 19].

In order to analyze expenditures related to vertigo and dizziness, we linked demographic, medical condition, and events files for each year. Patients with vertigo and dizziness were identified with International Classification of Diseases, 9th Revision Clinical Modification (ICD-9-CM) codes (Supplementary Table 1). We then utilized MEPS clinical classification (CC) codes, which are aggregates of ICD-9-CM codes, for vertigo and which also includes dizziness; details of CC codes can be found online [20]. Combining vertigo and dizziness into a single group is not uncommon and a similar organizational structure is utilized for The National Hospital Ambulatory Medical Care Survey (NHAMCS) database [21].

The present study was a retrospective analysis examining the primary outcome measures of healthcare expenditures and healthcare utilization. For each patient, total expenditures and visit count were assessed in aggregate and for each individual healthcare service sector, including inpatient, outpatient, emergency room, home health visits, and prescription drug usage; third-party payments and out-of-pocket costs were recorded. All expenditures were adjusted to 2015 US dollars using the Consumer Price Index of the US Bureau and Labor Statistics for all urban consumers [22].

Demographic and socioeconomic information included self-identified sex, race/ethnicity, age, education, income level, insurance status, and geographic location. Race/ethnicity included non-Hispanic Caucasian, Hispanic, African-American, American-Indian, and Asian. Age was divided into the following brackets: 18–34, 35–65, and 65 years and older. Categories for education were no degree obtained, high school diploma or equivalent, some college and a bachelor’s degree or higher. Income was defined in relation to the 2015 federal poverty level (FPL) and included: poor (<100% FPL), near poor (100–124% FPL), low income (125–199% FPL), middle income (200–399% FPL), and high income (>399% FPL). Insurance status was stratified by private (which includes patients with concurrent Medicare coverage), public (Medicare or Medicaid without private insurance), and uninsured. Geographic location was defined by US Census Bureau regions (Northeast, South, Midwest, and West). Comorbidities were graded on a point-based system according to the Charlson Comorbidity Index [23], as defined by ICD-9-CM diagnoses of various conditions, details of the algorithms can be found in detail elsewhere [24].

The present study was approved for exemption status by the University Hospitals Cleveland Medical Center Institutional Review Board (study number: 20190346).

2.2 Statistical analysis

Demographic and socioeconomic characteristics of patients with and without vertigo or dizziness were compared via Scott chi-square analyses. Logistic regression modeling was utilized to estimate healthcare expenditure ratios for patients with and without dizziness or vertigo, adjusting for age, sex, self-reported race/ethnicity, insurance coverage, education, income level, geographic region, modified Charlson comorbidity indices, and time period (2007–2009, 2010–2012, and 2013–2015). All of the tables in the study summarize annual averages from 2007 to 2015, which were derived using person-level weights provided by the AHRQ, and extrapolated to the civilian non-institutionalized US population.

A two-part regression model was used to estimate the incremental expenditures of patients with vertigo or dizziness while controlling for demographic and socioeconomic covariates. Incremental expenditures are defined as expenditures directly attributable to vertigo and dizziness after controlling for covariates. This two-part model consists of a logistic regression model to predict the likelihood of non-zero expenditures and a generalized linear model with a gamma distribution and log-link function to address the positive skewedness of expenditure data and adjust for estimates of total medical expenditures [25, 26]. A gamma-distribution model is more accurate than a log ordinary least squares model due to reduced normality and homoscedasticity assumptions [26]. This two-step regression model is commonly used for the analysis of healthcare data because it accounts for zero expenditures and right skewedness [27]. Expenditures and utilization for each health care setting (inpatient, outpatient, emergency room, home health, prescription medication) were compared for patients with and without vertigo or dizziness using Wilcoxon rank sum tests. A likelihood ratio test was used to determine the effect of changes in expenditures over time.

To account for the complex sampling of MEPS, all standard errors were estimated using the R survey package, which bases calculations on person-level weights, clustering, and stratification data. P values of 0.05 were considered significant and statistical analyses were performed using R (R Foundation, Vienna, Austria).

3 Results

This study included a total of 221,273 MEPS respondents between 2007–2015. There were 5,275 patients with self-reported vertigo or dizziness (2.4% of the entire sample; 66% female and 34% male) and 215,998 patients without either condition (53% female and 47% male) (Table 1). More individuals with vertigo or dizziness were female (66% vs 53%), over 65 years old (35% vs 16%), non-Hispanic Caucasian (53% vs 44%), from the Midwest (22% vs 19%), had public insurance (32% vs 22%), and reported scores greater than four on the Charlson comorbidity index (19% vs 8%) compared with patients without either condition (p < 0.001 for all).

Table 1
Weighted demographic and socioeconomic characteristics of US adults with and without vertigo and dizziness

Characteristic Vertigo/dizziness, N = 5275 Without vertigo/dizziness, N = 215998 p-value

Sex <0.001

Female 3504 (66%) 115022 (53%)

Male 1771 (34%) 100976 (47%)

Age group <0.001

18–34 696 (13%) 69014 (32%)

35–65 2718 (52%) 112755 (52%)

65+ 1861 (35%) 34229 (16%)

Race <0.001

Non-Hispanic Caucasian 2813 (53%) 95637 (44%)

Hispanic 1140 (22%) 57662 (27%)

African American 824 (16%) 42038 (19%)

Native American 100 (1.9%) 4305 (2.0%)

Asian 398 (7.5%) 16356 (7.6%)

Geographic region <0.001

Northeast 921 (18%) 33746 (16%)

Midwest 1155 (22%) 41026 (19%)

South 1772 (34%) 81236 (38%)

West 1405 (27%) 58165 (27%)

Income level <0.001

Poor (<100% of FPL) 1014 (19%) 39153 (18%)

Near poor (100–124% of FPL) 378 (7.2%) 12814 (5.9%)

Low income (125–199% of FPL) 831 (16%) 35669 (17%)

Middle income (200–399% of FPL) 1457 (28%) 65196 (30%)

High income (>399% of FPL) 1595 (30%) 63166 (29%)

Insurance coverage <0.001

Private 3018 (57%) 123586 (57%)

Public 1705 (32%) 47386 (22%)

Uninsured 552 (10%) 45026 (21%)

Educational attainment <0.001

No degree 963 (22%) 35751 (21%)

High school degree 1149 (27%) 51014 (29%)

Some college education 943 (22%) 37542 (22%)

College degree 1279 (30%) 49609 (29%)

Charlson comorbidity index <0.001

0 2550 (48%) 152856 (71%)

1 555 (11%) 16517 (7.6%)

2 872 (17%) 23962 (11%)

3 286 (5.4%) 5357 (2.5%)

4+ 1012 (19%) 17306 (8.0%)

Year <0.001

2007–2009 1649 (31%) 68190 (32%)

2010–2012 1682 (32%) 73905 (34%)

2013–2015 1944 (37%) 73903 (34%)

Characteristic	Vertigo/dizziness, N = 5275	Without vertigo/dizziness, N = 215998	p-value
Sex			<0.001
Female	3504 (66%)	115022 (53%)
Male	1771 (34%)	100976 (47%)
Age group			<0.001
18–34	696 (13%)	69014 (32%)
35–65	2718 (52%)	112755 (52%)
65+	1861 (35%)	34229 (16%)
Race			<0.001
Non-Hispanic Caucasian	2813 (53%)	95637 (44%)
Hispanic	1140 (22%)	57662 (27%)
African American	824 (16%)	42038 (19%)
Native American	100 (1.9%)	4305 (2.0%)
Asian	398 (7.5%)	16356 (7.6%)
Geographic region			<0.001
Northeast	921 (18%)	33746 (16%)
Midwest	1155 (22%)	41026 (19%)
South	1772 (34%)	81236 (38%)
West	1405 (27%)	58165 (27%)
Income level			<0.001
Poor (<100% of FPL)	1014 (19%)	39153 (18%)
Near poor (100–124% of FPL)	378 (7.2%)	12814 (5.9%)
Low income (125–199% of FPL)	831 (16%)	35669 (17%)
Middle income (200–399% of FPL)	1457 (28%)	65196 (30%)
High income (>399% of FPL)	1595 (30%)	63166 (29%)
Insurance coverage			<0.001
Private	3018 (57%)	123586 (57%)
Public	1705 (32%)	47386 (22%)
Uninsured	552 (10%)	45026 (21%)
Educational attainment			<0.001
No degree	963 (22%)	35751 (21%)
High school degree	1149 (27%)	51014 (29%)
Some college education	943 (22%)	37542 (22%)
College degree	1279 (30%)	49609 (29%)
Charlson comorbidity index			<0.001
0	2550 (48%)	152856 (71%)
1	555 (11%)	16517 (7.6%)
2	872 (17%)	23962 (11%)
3	286 (5.4%)	5357 (2.5%)
4+	1012 (19%)	17306 (8.0%)
Year			<0.001
2007–2009	1649 (31%)	68190 (32%)
2010–2012	1682 (32%)	73905 (34%)
2013–2015	1944 (37%)	73903 (34%)

After adjusting for survey-level weights to establish nationally-representative estimates, the prevalence of vertigo or dizziness was 2.73%. The mean annual health-related expenditures for patients with dizziness or vertigo was nearly two times greater than for patients without these conditions (Dizziness or vertigo: $9,655.39; 95% CI: 8,835.63, 10,475.15; without dizziness or vertigo: $5,282.14; 95% CI: 5,165.02, 5,399.25). The mean incremental annual healthcare expenditures attributable to dizziness or vertigo was $2,658.73 (95% CI: 1868.79, 3385.66) after controlling for socioeconomic and demographic covariates. Total annual medical expenditures for patients with dizziness was $48.1 billion, $13.2 billion of which can be attributed directly to the incremental economic burden of dizziness/vertigo after extrapolating based on prevalence-based estimates for patients between 2007–2015.

After controlling for sociodemographic factors and clinical comorbidities, cost of health care, denoted by the expenditure ratio, was 1.38 (95% CI: 1.24, 1.54, p < 0.001) times greater for patients with dizziness or vertigo than without (Table 2). This multivariate regression model demonstrated that vertigo or dizziness diagnoses are associated with elevated costs for nearly every demographic, socioeconomic, and clinical subgroup analyzed within the present study. For instance, the expenditure ratio for individuals between 18–34 years with vertigo/dizziness was 1.92 (95% CI: 1.34–2.73, p < 0.001) compared to 18–34-year old individuals without this diagnosis, indicating 1.92 times greater health care costs due to vertigo/dizziness. Moreover, these diagnoses lead to expenditure ratios of 1.90 (95% CI: 1.28–2.81, p < 0.001) in Native American and 1.51 (95% CI: 1.13–2.02, p = 0.006) in African American individuals compared to 1.33 (95% CI: 1.17–1.50, p < 0.001) in Caucasian individuals. Individuals with vertigo/dizziness from the Northeast demonstrated an expenditure ratio of 1.52 (95% CI: 1.27–1.83, p < 0.001), which was the greatest amongst the geographic regions studied.

Table 2

Two-part regression model for the incremental effects of health expenditures for US adults with vertigo or dizziness

Characteristic	With Vertigo/dizziness	95% Confidence Interval	p-value
	(Reference: Individuals without vertigo/dizziness
Condition	1.38	1.24, 1.54	<0.001
Age group
18–34	1.92	1.34–2.73	<0.001
35–65	1.45	1.22–1.73	<0.001
65+	1.18	1.09–1.27	<0.001
Sex
Female	1.26	1.15–1.37	<0.001
Male	1.64	1.32–2.04	<0.001
Race/ethnicity
Non-Hispanic Caucasian	1.33	1.17–1.50	<0.001
Hispanic	1.58	1.20–2.09	0.001
African American	1.51	1.13–2.02	0.006
Native American	1.90	1.28–2.81	0.002
Asian	1.18	0.88–1.58	0.30
Geographic region
Northeast	1.52	1.27–1.83	<0.001
Midwest	1.17	1.03–1.33	0.018
South	1.43	1.14–1.81	0.003
West	1.39	1.15–1.68	<0.001
Income level
Poor (<100% of FPL)	1.39	1.11–1.74	0.005
Near poor (100–124% of FPL)	1.76	0.98–3.16	0.060
Low income (125–199% of FPL)	1.54	1.21–1.96	<0.001
Middle income (200–399% of FPL)	1.35	1.17–1.56	<0.001
High income (>399% of FPL)	1.27	1.13–1.43	<0.001
Insurance coverage
Private	1.54	1.21–1.96	<0.001
Public	1.35	1.17–1.56	<0.001
Uninsured	1.27	1.13–1.43	<0.001
Educational attainment
No degree	1.57	1.11–2.22	0.011
High school degree	1.42	1.21–1.68	<0.001
Some college education	1.46	1.17–1.83	0.001
College degree	1.21	1.08–1.36	0.002
Charlson comorbidity index
0	1.60	1.34–1.89	<0.001
1	1.16	0.94–1.42	0.200
2	1.39	1.10–1.77	0.006
3	1.27	0.89–1.81	0.2
4+	1.05	0.92–1.20	0.5
Year
2007–2009	1.27	1.11–1.45	<0.001
2010–2012	1.45	1.19–1.77	<0.001
2013–2015	1.44	1.21–1.71	<0.001

The multivariate model utilized to examine intra-group differences for individuals with vertigo/dizziness amongst various demographic, socioeconomic, and clinical groups also identified significant discrepancies (Table 3). For example, cost increased with age, as the expenditure ratio was 1.35 (95% CI: 1.05, 1.74, p = 0.021) and 1.59 (95% CI: 1.22, 2.06, p < 0.001) times greater for individuals between 35–65 and over 65 years, respectively, compared to individuals 18–34 years. Males had 1.09 times the cost of care as females, but this was not statistically significant (p = 0.40). While Hispanics, African Americans, and Asians experienced lower overall costs of care compared to non-Hispanic Caucasians, the comparison was only statistically significant for Asians and non-Hispanic Caucasians (adjusted odds ratio [aOR]: 0.61; 95% CI: 0.47, 0.80, p < 0.001). Patients in the Northeast reported significantly higher expenditure ratios compared to the Midwest (aOR: 0.70; 95% CI: 0.56, 0.87, p = 0.001), the South (aOR: 0.76; 95% CI: 0.61, 0.95, p = 0.180) and the West (aOR: 0.77; 95% CI: 0.61, 0.97, p = 0.028). No statistically significant differences in expenditure ratios were reported for differing income levels. The expenditure ratio for uninsured patients was 0.41 times the cost of privately insured patients (95% CI: 0.25, 0.65, p < 0.001), but no statistically significant differences were found between privately and publicly insured patients. No statistically significant differences were reported based on educational attainment. Cost of care was significantly higher for patients with higher Charlson comorbidity indices (1 point aOR: 1.34; 95% CI: 1.08, 1.67, p = 0.009; 2 points aOR: 1.85; 95% CI: 1.49, 2.31, p < 0.001; 3 points aOR: 2.25; 95% CI: 1.58, 3.19, p < 0.001; 4 + points aOR 2.62; 95% CI: 2.20, 3.12, p < 0.001) compared to 0 points. No statistically significant differences were reported based on time period (2007–2009, 2010–2012, 2013–2015).

Table 3

Two-part regression model for the incremental effects of health expenditures for US adults with vertigo or dizziness

Characteristic	Expenditure ratio	95% CI	p-value
Age group
18–34	Reference
35–65	1.35	1.05, 1.74	0.021
65+	1.59	1.22, 2.06	<0.001
Sex
Female	Reference
Male	1.09	0.90, 1.33	0.40
Race/ethnicity
White	Reference
Hispanic	0.81	0.63, 1.04	0.10
Black	0.94	0.76, 1.17	0.60
Native American	1.51	0.99, 2.30	0.055
Asian	0.61	0.47, 0.80	<0.001
Geographic region
Northeast	Reference
Midwest	0.70	0.56, 0.87	0.001
South	0.76	0.61, 0.95	0.018
West	0.77	0.61, 0.97	0.028
Income level
Poor (<100% of FPL)	Reference
Near poor (100–124% of FPL)	1.16	0.73, 1.82	0.50
Low income (125–199% of FPL)	1.01	0.78, 1.31	>0.9
Middle income (200–399% of FPL)	0.83	0.66, 1.04	0.10
High income (>399% of FPL)	0.87	0.69, 1.09	0.20
Insurance coverage
Private	Reference
Public	0.94	0.76, 1.17	0.60
Uninsured	0.41	0.26, 0.65	<0.001
Educational attainment
No degree	Reference
High school degree	0.92	0.71, 1.19	0.50
Some college education	0.99	0.74, 1.33	>0.9
College degree	0.87	0.67, 1.12	0.30
Charlson comorbidity index
0	Reference
1	1.34	1.08, 1.67	0.009
2	1.85	1.49, 2.31	<0.001
3	2.25	1.58, 3.19	<0.001
4+	2.62	2.20, 3.12	<0.001
Year
2007–2009	Reference
2010–2012	1.04	0.87, 1.25	0.7
2013–2015	1.12	0.94, 1.34	0.2

Patients with vertigo or dizziness had significantly higher medical expenditures across every healthcare sector explored in the present study, which included inpatient, outpatient, emergency room, home health, and prescription medication expenditures, compared to patients without these conditions (Inpatient: $3,937 vs 2,978; Outpatient: $1,153 vs $807; ED: $702 vs $415; Home health: $855 vs $456; Prescription medications: $3,443 vs $2,214; p < 0.001 for all, Table 4). Additionally, the mean number of annual visits per patient was higher for each of these healthcare sectors for patients with vertigo or dizziness compared to those without either condition (Inpatient: 0.32 vs 0.22; Outpatient: 1.52 vs 0.91; ED: 0.66 vs 0.39; Home health: 0.69 vs 0.31; p < 0.001 for all, Table 5). Moreover, patients with vertigo or dizziness had 15 more medication refills compared to those without these conditions (40 vs 25, p < 0.001).

Table 4

Total mean expenditures for various healthcare sectors

Mean expenditures [SD]	Vertigo/dizziness ($)	Without vertigo/dizziness ($)	p-value
Inpatient	3,937 [15,436]	2978 [13,848]	<0.001
Outpatient	1153 [4,676]	807 [4,677]	<0.001
Emergency room	702 [2,068]	415 [1,806]	<0.001
Home health	855 [4,906]	456 [4,698]	<0.001
Prescription medications	3,443 [8,397]	2214 [10,830]	<0.001

Table 5

Annual mean visits to various healthcare sectors and prescription medication refills

Visits/refills [SD]	Vertigo/dizziness ($)	Without vertigo/dizziness ($)	p-value
Inpatient	0.32 [0.81]	0.22 [0.64]	<0.001
Outpatient	1.52 [5.15]	0.91 [4.57]	<0.001
Emergency room	0.66 [1.25]	0.39 [0.91]	<0.001
Home health	0.69 [3.16]	0.31 [2.13]	<0.001
Prescription medications	40 [51]	25 [38]	<0.001

After utilizing a multivariate regression model to control for covariates, vertigo and dizziness were associated with significantly higher expenditure ratios for the cost of emergency room visits (aOR: 1.55; 95% CI: 1.38–1.73, p < 0.001) and prescription medication refills (aOR: 1.21; 95% CI: 1.06–1.39, p = 0.006), but not for inpatient, outpatient, and home health costs (Table 6). Additionally, after controlling for covariates, dizziness and vertigo were associated with significantly elevated odds of utilizing all five healthcare sectors evaluated: inpatient (aOR: 1.16; 95% CI, 1.08–1.25), outpatient (aOR: 1.34; 95% CI: 1.17–1.54), emergency room (aOR: 1.52; 95% CI: 1.44–1.60), home health (aOR: 1.22; 95% CI: 1.06–1.42), and prescription medication refills (aOR: 1.20; 95% CI: 1.15–1.25) (p < 0.001 for all, Table 7).

Table 6

Expenditure ratios for various healthcare sectors, controlling for socioeconomic, demographic, and clinical comorbid factors

Mean expenditures [SD]	Expenditure ratio	p-value
[95% Confidence Interval]
Inpatient	1.07 [0.93, 1.23]	0.40
Outpatient	1.22 [0.99, 1.49]	0.057
Emergency room	1.55 [1.38, 1.73]	<0.001
Home health	1.05 [0.83, 1.32]	0.70
Prescription medications	1.21 [1.06, 1.39]	0.006

Table 7

Odds ratios for visits to various healthcare settings and for prescription medication refills

Visits/refills [SD]	Odds Ratio [95% CI]	p-value
Inpatient	1.16 [1.08, 1.25]	<0.001
Outpatient	1.34 [1.17, 1.54]	<0.001
Emergency room	1.52 [1.44, 1.60]	<0.001
Home health	1.22 [1.06, 1.42]	<0.001
Prescription medications	1.20 [1.15, 1.25]	<0.001

4 Discussion

This study highlights the significant costs incurred by patients suffering from vertigo and dizziness. We report a 1.38-fold annual incremental increase in cost of care for patients with vertigo and dizziness after controlling for demographic and socioeconomic factors. With an annual total economic burden estimated at $48.1 billion, $13.3 billion directly attributable to vertigo and dizziness, the impact of vertigo and dizziness on patients and the healthcare system is substantial. The prevalence of vertigo and dizziness in our sample was 2.73%, which is lower than estimates from previous studies [28, 29]. Thus, the financial burden of vertigo and dizziness to the economy may be even more profound than the estimates reported herein.

While our model controls for costs related to socio-economics, demographics, and concurrent comorbidities, our estimate for total burden does not account for indirect costs secondary to lost productivity, unemployment, occupational disability, or premature death [11, 30]. Vertigo and dizziness correlate with imbalance, vision impairment, and a 12-fold increased risk of falls [31], which may lead to anticipation anxiety and fear of future falls [32 –34]. We report that patients who are older or have a higher number of concurrent comorbidities face elevated costs of care for vertigo and dizziness, which likely exacerbates the stress and anxiety that these disease processes cause. Patients with vertigo or dizziness may experience a loss of autonomy and restriction in activity [35], which contributes to the social burden of these pathologies. Agrawal et al (2017) estimated the life-time economic burden in patients with vertigo due to loss in quality of life to be $64,929 USD per patient [12]. It can take years to adequately diagnose and manage patients with vertigo and dizziness appropriately given the wide variety of possible etiologies, which may further contribute to the economic burden of these diseases.

Vertigo and dizziness are fairly non-specific conditions with diverse etiologies. We estimate that the mean annual expenditures directly attributable to vertigo and dizziness was roughly $2,658.73 for patients. Other studies have examined the direct annual costs associated with other non-specific conditions like childhood headaches ($623), migraines ($2,916), and mood disorders ($6,591) [36 –38].

Both vertigo and dizziness compel broad differential diagnoses and diagnosing patients properly can be expensive and prolonged. In a retrospective cohort study in Germany, patients with vertigo reported an average of 3.2 diagnostic measures and the majority of patients receiving multiple consultations prior to referral for long-term management [39]. In the United States, Ahsan et al. (2013) reported that of 1,681 patients with dizziness, 48% received neuroimaging, totaling nearly $1 million in charges [40]. However, only 0.74% of those scans yielded clinically significant pathologies requiring intervention.

Although studies have determined the economic burden of patients with vertigo and dizziness receiving care in emergency departments in the United States [6], a complete analysis examining the economic burden across multiple health care domains and settings has not yet been performed. Capturing the breadth of management options for patients with vertigo and dizziness is essential given the wide variety of possible etiologies that lead to vertigo and dizziness and the extensive clinical work-up that follows [4 , 41]. Our study highlights the significant increase in per-patient expenditures and utilization for inpatient, outpatient, and home health care visits in addition to the emergency department, indicating that within each setting, having vertigo or dizziness contributes significantly to costs.

Our findings also demonstrate that patients with vertigo or dizziness have both increased utilization and costs associated with prescription medications. However, polypharmacy is also a major cause of vertigo, dizziness, and falls in older patients [42]. Therefore, while additional medications may alleviate symptoms of vertigo or dizziness, extreme caution must be exercised when prescribing additional medications; polypharmacy may lead to symptom exacerbation and increased utilization of subsequent services.

When examining whether specific demographic segments observe higher costs associated with vertigo and dizziness, lower expenditure ratios were reported for Asian patients when compared to non-Hispanic Caucasian patients. Previous research has shown that Caucasian patients have higher costs for otolaryngologic services in some healthcare settings compared to minority groups [43]. Additionally, patients from the Northeast reported significantly higher costs compared to patients from the West, South, and Midwest, which requires further analysis and an in-depth scrutiny of the patient population, management practices, and availability of vestibular specialists in the Northeast compared to other regions. Uninsured patients reported significantly lower expenditure ratios compared to privately insured patients, which may signify a discrepancy in clinical management practices for this particularly vulnerable segment of the population. Further research should examine whether the lower healthcare costs observed here are associated with inferior care for uninsured patients.

5 Limitations

The MEPS database represents the US civilian population and excludes prisoners, nursing home residents, and individuals within other institutional contexts [44]. While most patient reports, including expenditures and service utilization, are validated by the AHRQ and physicians, there is the opportunity that recall bias influenced the responses of some patients while completing surveys. Furthermore, the costs attributable to specific medications, labs, and imaging were not available while determining the overall cost for relevant settings.

6 Conclusion

Vertigo and dizziness are associated with substantial increases in the cost and utilization of annual health-related services across a variety of healthcare settings. With significant morbidity and compromised quality of life related to dizziness and vertigo, it is essential to strategize how best to manage patients with these conditions to ameliorate the substantial individual and societal burden. Further research should evaluate implementing clinical guidelines directed at optimizing the cost-effectiveness of delivering diagnostic and treatment modalities for patients with vertigo and dizziness.

IRB: This study qualified for Institutional Review Board exempt research by the University Hospitals Cleveland Medical Center (Approval number: 20190346)

Conflicts of interest

Dr. Sarah E. Mowry: The author has done consulting work for Stryker, and has received a travel grant from Cochlear and Medel. The rest of the authors do not have any interests to declare.

Funding

None.

Footnotes

The supplementary material is available in the electronic version of this article: .

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