Johns Hopkins App Offers Clinicians New Tool to Combat Dizziness and Vertigo Misdiagnosis

Each year in the United States, over 17 million patients visit clinicians for dizziness, which affects 11% of U.S. adults and 35% of adults over age 40. Symptoms can be severe, leading to nearly 5 million emergency department (ED) visits annually. While inner ear diseases are the most common underlying factor, strokes are the most dangerous cause of vertigo, representing an estimated 4% of all ED dizziness visits. 

“It can be difficult for clinicians to distinguish between inner ear diseases and strokes,” says Rodney Omron, M.D., M.P.H., VertiGuide app creator and co-lead of the Education Core, Johns Hopkins Armstrong Institute Center for Diagnostic Excellence. “Strokes can cause weakness on one side of the body or trouble speaking. Because both strokes and inner ear diseases can cause dizziness, there is a risk that a diagnostic mistake can happen, leading to patients receiving the wrong treatments or no treatments at all.” 

Led by experts from the Armstrong Institute Center for Diagnostic Excellence, the Neuro-Visual and Vestibular Disorders Division, and the Department of Emergency Medicine, VertiGuide is part of a multifaceted program at Johns Hopkins to improve diagnosis of dizziness and vertigo and to reduce the serious harms that can occur when the root cause is missed or misdiagnosed. 

Omron says doctors mistake inner ear problems for stroke during 30% of patient visits across care settings. When a stroke causes dizziness, the patient is mistakenly thought to have an inner ear condition 40% of the time, which contributes to diagnostic errors and serious harms. Prompt and accurate diagnosis and treatment for patients with dizziness could prevent serious harms for tens of thousands of people who have strokes each year and short-term illness for more than 1 million patients with inner ear disease, while simultaneously saving an estimated $1 billion in the United States each year. 

“I hope to offer clinicians a resource that summarizes the evidence so they can be more certain in the bedside diagnosis of dizziness,” Omron says. “VertiGuide can be helpful both for overall training for clinicians who are less familiar with diagnosis and treatment and for using as a refresher for those who are more experienced but want to confirm how to perform a certain maneuver or review some of the evidence-based guidelines featured in the app.” 

VertiGuide, the new, free app that functions offline, is intentionally made for clinicians to quickly access actionable educational guides and resources to aid in the decision-making process across specialties. The app’s researchers designed VertiGuide to address some of the challenges associated with the appropriate diagnosis and care of patients with vertigo and dizziness, by organizing diagnostic evidence into an easy-to-follow series of decision nodes that are based on published guidelines. This straightforward layout helps users to appropriately identify benign vertigo with the right diagnostic tests and treatments. Combined with instructional videos for clinicians new to diagnosing the cause of dizziness and a pull-down resource menu for immediate refreshers on how to do a particular maneuver, the app’s algorithm places evidence to recognize a central cause of vertigo that needs urgent attention right at the clinician’s fingertips. 

Omron was the education dissemination point of contact for the Guidelines for Reasonable and Appropriate Care in the Emergency Department 3 (GRACE-3), evidence-based recommendations released in March 2023 for care of patients with acute dizziness and vertigo in the emergency department. Omron encouraged his colleagues to consider developing a tool to make the GRACE-3 guidelines accessible to a broader audience, leading to work on VertiGuide starting in April 2022. 

Omron says the app offers some of the best tools available all in one place to aid in improving diagnostic excellence. Unlike other applications that summarize evidence-based algorithms for the assessment of patients who report feeling dizzy, VertiGuide follows the GRACE-3 guidelines and additionally incorporates three other proven diagnostic frameworks: STANDING (Spontaneous Nystagmus Direction Head Impulse Test), ATTEST (Associated Symptoms Timing and Triggers examination Signs, Additional Testing as Needed), and TiTrATE (Timing, Triggers, and Targeted Exams). Because these physical examination elements focused on eye movement-based diagnosis are not commonly used in routine emergency medicine practice, their incorporation into practice is aspirational and represents a forward-looking policy to improve care. 

The Johns Hopkins Center for Diagnostic Excellence funded VertiGuide’s development and creation. The center’s first signature initiative was to tackle stroke misdiagnosis in the Johns Hopkins Hospital emergency department, as stroke is the leading cause of serious harms from diagnostic errors, and the biggest risk for missed stroke is a clinical presentation with dizziness or vertigo. The Center for Diagnostic Excellence provides a collaborative and transdisciplinary environment for clinicians, researchers, engineers and data experts to tackle the challenges of medical misdiagnosis. 

As part of the Johns Hopkins initiative to improve diagnosis of dizziness and vertigo and to reduce the serious harms that can occur, VertiGuide has been beta tested with physicians, patient advocates, residents and medical students at Johns Hopkins and at institutions worldwide. The latest version of VertiGuide is a result of this iterative process and collaboration with leaders in stroke and diagnostic error research. 

“As VertiGuide has morphed though multiple iterations of feedback from mentors like Dr. Jonathan Edlow at Harvard, Dr. David Newman-Toker here at Johns Hopkins, and Dr. Peter Johns from Canada, we have made it applicable to all levels of dizziness understanding to tailor this resource to any type of user,” says Omron. 

Looking ahead, VertiGuide will also be continuously updated as new evidence emerges and standards of care evolve. The app also has a feedback button that clinicians can use to suggest ways to improve the app or to provide positive feedback about how they used it, which opens the door to future improvements clinicians want to see. 

Omron says VertiGuide is ultimately intended to empower clinicians to improve patient quality of life and reduce unnecessary suffering with proven treatments. 

“If we empower physicians to feel more adept at diagnosing and treating these causes, they’ll be able to improve their confidence and ability to care for these patients,” says Omron. 

Although VertiGuide provides clinicians with a range of accessible and actionable resources to aid in the clinician’s decision-making process in taking care of a patient who feels dizzy, researchers emphasize the app should not be used for medical advice, nor is the app meant to replace clinician judgment or to be used as a definitive source. Any maneuvers demonstrated should only be attempted by a trained professional in the appropriate clinical setting. 

VertiGuide was designed for both Apple and Android phones. It is available now in the Apple Store. Android users can sign up to be notified when the app is added to the Google Play Store later this year.