Changes in the Workforce Characteristics of Providers Who Care for Adult Patients With Rheumatologic and Musculoskeletal Disease in the United States.

OBJECTIVE: The aim of this study was to describe the adult rheumatology workforce in the United States, assess change in rheumatology providers over time, and identify variation in rheumatology practice characteristics. METHODS: Using national Medicare claims data from 2006 to 2020, clinically active rheumatology physicians and advanced practice providers (APPs) were identified. Each calendar year was used for inclusion, exclusion, and analysis, and providers were determined to be entering, exiting, or stable based upon presence or absence in the prior or subsequent years of data. Characteristics (age, gender, practice type, rural, and region) of rheumatologists were determined for 2019 and in mutually exclusive study periods from 2009 to 2011, 2012 to 2015, and 2016 to 2019. The location of rheumatology practice was determined by billing tax identification and mapped. Demographics of physicians exiting or entering the rheumatology workforce were compared separately to those stable by logistic regression. RESULTS: The clinically active adult rheumatology workforce identified in US Medicare in 2019 was 5,667 rheumatologists and 379 APPs. From 2009 to 2020, the number of rheumatologists increased 23% and the number of APPs increased 141%. There was an increase in female rheumatologists over time, rising to 43% in 2019. Women and those employed by a health care system were more likely to exit, and those in a small practice or in the South were less likely to exit. CONCLUSION: The overall number of clinically active rheumatology providers grew more than 20% over the last decade to a high of 6,036 in 2020, although this rate of growth appears to be flattening off in later years.

Assessment of antibody levels to SARS-CoV-2 in patients with idiopathic inflammatory myopathies receiving treatment with intravenous immunoglobulin.

Antibodies to Severe Acute Respiratory Syndrome-Coronavirus 2 (SARS-CoV-2) have been reported in pooled healthy donor plasma and intravenous immunoglobulin products (IVIG). It is not known whether administration of IVIG increases circulating anti-SARS-CoV-2 antibodies (COVID ab) in IVIG recipients. COVID ab against the receptor binding domain of the spike protein were analyzed using a chemiluminescent microparticle immunoassay in patients with idiopathic inflammatory myopathies (IIM) both receiving and not receiving IVIG (IVIG and non-IVIG group, respectively). No significant differences in COVID ab levels were noted between IVIG and non-IVIG groups (417 [67-1342] AU/mL in IVIG vs 5086 [43-40,442] AU/mL in non-IVIG, p = 0.11). In linear regression models including all post-vaccination patient samples, higher number of vaccine doses was strongly associated with higher COVID ab levels (2.85 [1.21, 4.48] log AU/mL, regression coefficient [Formula: see text] [95% CI], p = 0.001), while use of RTX was associated with lower ab levels (2.73 [- 4.53, - 0.93] log AU/mL, [Formula: see text][95%CI], p = 0.004). In the IVIG group, higher total monthly doses of IVIG were associated with slightly higher COVID ab levels (0.02 [0.002-0.05] log AU/mL, p = 0.04). While patients on IVIG did not have higher COVID ab levels compared to the non-IVIG group, higher monthly doses of IVIG were associated with higher circulating levels of COVID ab in patients receiving IVIG, particularly in patients concomitantly receiving RTX. Our findings suggest that IIM patients, especially those at increased risk of COVID infection and worse COVID outcomes due to RTX therapy may have protective benefits when on concurrent IVIG treatment.

Temporal Trends in the Standing Broad Jump Performance of 10,940,801 Children and Adolescents Between 1960 and 2017.

BACKGROUND: The standing broad jump (SBJ) is an excellent functional measure of explosive lower-body strength that is significantly related to health among children and adolescents. OBJECTIVES: The aim of this study was to estimate national (country-level) and international (pooled global data) temporal trends in SBJ performance for children and adolescents, and to examine the relationships between national trends in SBJ performance and national trends in health-related and socioeconomic/demographic indicators. METHODS: Data were obtained from a systematic search of studies reporting temporal trends in SBJ performance for 9- to 17-year-olds, and by examining national fitness datasets. Sample-weighted regression models estimated trends at the study/dataset-country-sex-age level, with national and international trends estimated by a post-stratified population-weighting procedure. Pearson's correlations quantified relationships between national trends in SBJ performance and national trends in health-related and socioeconomic/demographic indicators. RESULTS: Data from 34 studies/datasets were extracted to estimate trends for 10,940,801 children and adolescents from 24 high-, 4 upper-middle-, and 1 low-income countries between 1960 and 2017. Collectively, there was a negligible (per decade) improvement in SBJ performance of 1.73 cm (95% CI 1.71-1.75), 0.99% (95% CI 0.97-1.01) or a standardized effect size of 0.07 (0.07-0.07) over the entire period, with the rate of improvement steady from the 1960s to the 1980s, slowing in the 1990s, before declining. Sex- and age-related temporal differences were negligible. Trends differed between countries, with most countries experiencing declines. National trends in SBJ performance were not significantly related to national trends in health-related and socioeconomic/demographic indicators. CONCLUSIONS: SBJ performance of children and adolescents has declined since 2000 (at least among most of the countries in this analysis) and is suggestive of a modern decline in functional explosive lower-body strength. Growing recognition of the importance of muscular fitness as a marker of population health highlights the need for continued tracking of temporal trends in SBJ, especially among low- and lower-middle-income countries for which temporal data are lacking. PROSPERO REGISTRATION NUMBER: CRD42013003657.

Temporal Trends in the Handgrip Strength of 2,592,714 Adults from 14 Countries Between 1960 and 2017: A Systematic Analysis.

BACKGROUND: Handgrip strength (HGS) is an excellent marker of functional capability and health in adults, although little is known about temporal trends in adult HGS. OBJECTIVES: The aim of this study was to systematically analyze national (country-level) temporal trends in adult HGS, and to examine the relationships between national trends in adult HGS and national trends in health-related and socioeconomic/demographic indicators. METHODS: Data were obtained from a systematic search of studies reporting temporal trends in HGS for adults (aged ≥ 20 years) and by examining national fitness datasets. Trends in mean HGS were estimated at the country-sex-age group level by best-fitting sample-weighted linear/polynomial regression models, with national and sub-regional (pooled data across geographically similar countries) trends estimated by a post-stratified population-weighting procedure. Pearson's correlations quantified relationships between national trends in adult HGS and national trends in health-related and socioeconomic/demographic indicators. RESULTS: Data from ten studies/datasets were extracted to estimate trends in mean HGS for 2,592,714 adults from 12 high- and 2 upper-middle-income countries (from Asia, Europe and North America) between 1960 and 2017. National trends were few, mixed and generally negligible pre-2000, whereas most countries (75% or 9/12) experienced negligible-to-small declines ranging from an effect size of 0.05 to 0.27, or 0.6 to 6.3%, per decade post-2000. Sex- and age-related temporal differences were negligible. National trends in adult HGS were not significantly related to national trends in health and socioeconomic/demographic indicators. CONCLUSIONS: While trends in adult HGS are currently limited to 14 high- and upper-middle-income countries from three continents, adult HGS appears to have declined since 2000 (at least among most of the countries in this analysis), which is suggestive of corresponding declines in functional capability and health. PROSPERO REGISTRATION NUMBER: CRD42013003678.

The distributional impact of a green payment policy for organic fruit.

Consumer spending on organic food products has grown rapidly. Some claim that organics have ecological, equity, and health advantages over conventional food and therefore should be subsidized. Here we explore the distributive impacts of an organic fruit subsidy that reduces the retail price of organic fruit in the US by 10 percent. We estimate the impact of the subsidy on organic fruit demand in a representative poor, middle income, and rich US household using three analytical methods; including two econometric and one machine learning. We do not find strong evidence of regressive redistribution due to our simulated organic fruit subsidy; the poor household's relative reaction to the subsidy is not much different than the reaction at the other two households. However, the infra-marginal savings from the subsidy tend to be larger in richer households.

2015 American College of Rheumatology Workforce Study: Supply and Demand Projections of Adult Rheumatology Workforce, 2015-2030.

OBJECTIVE: To describe the character and composition of the 2015 US adult rheumatology workforce, evaluate workforce trends, and project supply and demand for clinical rheumatology care for 2015-2030. METHODS: The 2015 Workforce Study of Rheumatology Specialists in the US used primary and secondary data sources to estimate the baseline adult rheumatology workforce and determine demographic and geographic factors relevant to workforce modeling. Supply and demand was projected through 2030, utilizing data-driven estimations regarding the proportion and clinical full-time equivalent (FTE) of academic versus nonacademic practitioners. RESULTS: The 2015 adult workforce (physicians, nurse practitioners, and physician assistants) was estimated to be 6,013 providers (5,415 clinical FTE). At baseline, the estimated demand exceeded the supply of clinical FTE by 700 (12.9%). By 2030, the supply of rheumatology clinical providers is projected to fall to 4,882 providers, or 4,051 clinical FTE (a 25.2% decrease in supply from 2015 baseline levels). Demand in 2030 is projected to exceed supply by 4,133 clinical FTE (102%). CONCLUSION: The adult rheumatology workforce projections reflect a major demographic and geographic shift that will significantly impact the supply of the future workforce by 2030. These shifts include baby-boomer retirements, a millennial predominance, and an increase of female and part-time providers, in parallel with an increased demand for adult rheumatology care due to the growing and aging US population. Regional and innovative strategies will be necessary to manage access to care and reduce barriers to care for rheumatology patients.

Relationship Between Skating Economy and Performance During a Repeated-Shift Test in Elite and Subelite Ice Hockey Players.

Lamoureux, NR, Tomkinson, GR, Peterson, BJ, and Fitzgerald, JS. Relationship between skating economy and performance during a repeated-shift test in elite and subelite ice hockey players. J Strength Cond Res 32(4): 1109-1113, 2018-The purpose of this study was to determine the importance of skating economy to fatigue during repeated high-intensity efforts of a simulated ice hockey shift. Forty-five collegiate and Junior A male ice hockey players (aged 18-24 years) performed a continuous graded exercise test using a skate treadmill. Breath-by-breath data for oxygen consumption (V[Combining Dot Above]O2) and respiratory exchange ratio were collected and used to derive energy expenditure (EE) averaged over the final 10 seconds of each stage. Economy was determined as the slope of the regression line relating V[Combining Dot Above]O2 and EE against skating speed separately. Participants also completed 8 bouts of maximal ice skating through a course designed to simulate typical shift, with timing gates determining first half, second half, and total fatigue decrement, calculated by a percent decrement score. Partial correlation was used to determine the association between economy measures and decrement during the repeated-shift test. Twenty-six participants met inclusion criteria and were included in data analysis. Skating economy measures (both relative V[Combining Dot Above]O2 and EE) were very likely moderate positive correlates of total fatigue decrement (r [95% confidence interval]: V[Combining Dot Above]O2, 0.46 [0.09, 0.72] and EE, 0.44, [0.06, 0.71]) but not with first or second gate decrement. Our results indicate that skating economy plays an important role in fatigue resistance over repeated on-ice sprints designed to simulate a typical shift. This supports the use of technical skating coaching and training techniques to enhance skating economy as a means of improving ice hockey performance.

Joint-specific assessment of swelling and power Doppler in obese rheumatoid arthritis patients.

BACKGROUND: Clinical swollen joint examination of the obese rheumatoid arthritis (RA) patient can be difficult. Musculoskeletal Ultrasound (MSUS) has higher sensitivity than physical examination for swollen joints (SJ). The purpose of this study was to determine the joint-specific association between power Doppler (PDUS) and clinical SJ in RA across body mass index (BMI) categories. METHODS: Cross-sectional clinical and laboratory data were collected on 43 RA patients. PDUS was performed on 9 joints (wrist, metacarpalphalangeal 2-5, proximal interphalgeal 2/3 and metatarsalphalangeal 2/5). DAS28 and clinical disease activity index (CDAI) were calculated. Patients were categorized by BMI: <25, 25-30, and >30. Demographic and clinical characteristics were compared across BMI groups with Kruskal-Wallis test and chi-square tests. Joint-level associations between PDUS and clinically SJ were evaluated with mixed effects logistic regression models. RESULTS: While demographics and clinically-determined disease activity were similar among BMI groups, PDUS scores significantly differed (p = 0.02). Using PDUS activity as the reference standard for synovitis and clinically SJ as the test, the positive predictive value of SJ was significantly lower in higher BMI groups (0.71 in BMI < 25, 0.58 in BMI 25-30 and 0.44 in BMI < 30) (p = 0.02). The logistic model demonstrated that increased BMI category resulted in decreased likelihood of PDUS positivity (OR 0.52, p = 0.03). CONCLUSIONS: This study suggests that in an obese RA patient, a clinically assessed SJ is less likely to represent true synovitis (as measured by PDUS). Disease activity in obese RA patients may be overestimated by CDAI/DAS28 calculations and clinicians when considering change in therapy.

Regional distribution of adult rheumatologists.

OBJECTIVE: To analyze the distribution of rheumatology practices in the US and factors associated with that distribution, in order to better understand the supply of the rheumatology workforce. METHODS: Using the American College of Rheumatology membership database, all practicing adult rheumatologist office addresses were mapped with ArcView software. The number of rheumatologists per Core Based Statistical Area (CBSA) was calculated. To investigate whether sociodemographic factors correlated with clustering of rheumatologists, covariates from the 2010 US Census for each CBSA, including age, sex, race/ethnicity, and median household income, were modeled. RESULTS: Many CBSAs, predominantly smaller micropolitan areas, did not have a practicing rheumatologist. For some of these smaller micropolitan areas (with populations of at least 40,000), the closest practicing rheumatologist was more than 200 miles away. However, we also identified several more-populous areas (populations of 200,000 or more) without a practicing rheumatologist. Greater numbers of rheumatologists were more likely to practice in areas with higher population densities and higher median incomes. More rheumatologists were also found in CBSAs in which there were rheumatology training programs. CONCLUSION: These findings demonstrate that many smaller regions of the country have no or few practicing adult rheumatologists. Patients with chronic rheumatic conditions in these areas likely have limited access to rheumatology care. Policy changes could address potential regional rheumatology workforce shortages, but limitations of the current data would need to be addressed prior to implementation of such changes.

Social impact bonds and their application to preventive health.

Although preventive health in Australia has been acknowledged as central to national health and wellbeing, efforts to reform the delivery of preventive health have to date produced limited results. The financing of preventive health at a national level is based on outcome- or performance-based funding mechanisms; however, delivery of interventions and activities at a state level have not been subjected to outcome-based funding processes. A new financing tool being applied in the area of social services (social impact bonds) has emerged as a possible model for application in the prevention arena. This paper explores key issues in the consideration of this funding model in the prevention arena. When preventive health is conceptualised as a merit good, the role of government is clarified and outcome measures fully articulated, social impact bonds may be a viable funding option to supplement core public health activities. WHAT IS KNOWN ABOUT THE TOPIC? The complexities of outcome monitoring in preventive health are well understood.Likewise, the problem of linking funding to outcomes from preventive health practice has also been debated at length in health policy. However, not much is known about the application of social impact bonds into the preventive health arena.WHAT DOES THIS PAPER ADD? This paper discusses the limitations and opportunities facing the application of the social impact bond financing model in the preventive health arena. This has not been undertaken previously.WHAT ARE THE IMPLICATIONS FOR PRACTITIONERS? Social impact bonds have received significant recent attention from federal and state government treasury departments as potential financing tools for government. Health policy practitioners are watching this space very closely to see the outcomes of a New South Wales trial. Health promotion practitioners and primary care practitioners who deliver preventive services will need to keep abreast of this issue as it will have significant impact on their practice if states and territories introduce outcome-based funding processes.

Potential impact on patient residence to hospital travel distance and access to care under a policy of preferential referral to high-volume knee replacement hospitals.

OBJECTIVE: To examine the potential impact of a policy of selective referral to high-volume knee replacement hospitals on patients' travel distance to hospitals and access to care for patients seeking total knee replacement (TKR) in urban and rural settings. METHODS: The travel distance required for patients to reach their hospital of service and the additional travel distance required to reach the nearest high-volume hospital were analyzed using a 100% sample of Medicare fee-for-service patients undergoing TKR in 2001. RESULTS: Of the 183,174 TKRs performed in the US during 2001, 95% of the patients selected underwent TKR at a hospital that was located within 50 miles of their residence. There were 11,550 patients who had their TKR performed at a low-volume hospital (LVH) where there was no nearer high-volume hospital. The impact of a policy that would direct patients to high-volume hospitals varied by region. In urban areas, the nearest high-volume hospital was a median of 3.8 miles further than the LVH of service. The patient factors race and poverty were associated with selection of LVHs in urban areas. In rural areas and urban clusters, 1,506 patients would have had to travel >50 miles and 259 patients would have had to travel >100 miles to reach a high-volume hospital. CONCLUSION: A policy to direct patients away from LVHs could increase patients' travel time to hospitals in rural areas and restrict access for minority and low-income patients in urban areas. Any implementation of selective referral to high-volume centers should address access to hospitals for rural patients and urban minority and low-income patients.

Quality improvement in action. Direct general practitioner referrals to audiology for the provision of hearing aids: a single centre review.

Direct referral audiology clinics (DRACs) for the assessment and provision of hearing aids in those over 60 years of age were initially introduced in the National Health Service (NHS) as a method to decrease outpatient waiting times and reduce demand on ear, nose and throat (ENT) appointments. We retrospectively reviewed the electronic records of 353 patients referred to the DRACs at our hospital over a four-month period to determine the continued benefits of a DRAC service, in terms of impact upon ENT appointments, and appropriate general practitioner (GP) use of the clinics. Of the 353 patients seen within the DRAC clinics, 320 were ultimately provided with a hearing aid. Fifty five patients required review by an otolaryngologist, either being referred directly by the audiology department or referred back to their GP for re-referral. The greatest lack of adherence to the referral criteria for DRAC appointments related to appropriate treatment of wax within the community, with two patients declining an aid when their perceived improvement in hearing was significant following microsuctioning. DRACs appear to continue to provide a cost-benefit to the NHS, reducing demand on ENT appointments, but further improvements could be made within primary care to further utilise this service.

Changes in regional variation of Medicare home health care utilization and service mix for patients undergoing major orthopedic procedures in response to changes in reimbursement policy.

BACKGROUND: Significant variation in regional utilization of home health (HH) services has been documented. Under Medicare's Home Health Interim and Prospective Payment Systems, reimbursement policies designed to curb expenditure growth and reduce regional variation were instituted. OBJECTIVE: To examine the impact of Medicare reimbursement policy on regional variation in HH care utilization and type of HH services delivered. RESEARCH DESIGN: We postulated that the reimbursement changes would reduce regional variation in HH services and that HH agencies would respond by reducing less skilled HH aide visits disproportionately compared with physical therapy or nursing visits. An interrupted time-series analysis was conducted to examine regional variation in the month-to-month probability of HH selection, and the number of and type of visits among HH users. SUBJECTS: A 100 percent sample of all Medicare recipients undergoing either elective joint replacement (1.6 million hospital discharges) or surgical management of hip fracture (1.2 million hospital discharges) between January 1996 and December 2001 was selected. RESULTS: Before the reimbursement changes, there was great variability in the probability of HH selection and the number of HH visits provided across regions. In response to the reimbursement changes, though there was little change in the variation of probability of HH utilization, there were marked reductions in the number and variation of HH visits, with greatest reductions in regions with highest baseline utilization. HH aide visits were the source of the baseline variation and accounted for the majority of the reductions in utilization after implementation. CONCLUSIONS: The HH interim and prospective payment policies were effective in reducing regional variation in HH utilization.

Mapping the experience of drug dealing risk environments: an ethnographic case study.

BACKGROUND: The traditional approach to understanding the economic dimensions of risk environments is to examine the forces that determine the activities of social actors. Drug dealing poses a particular problem for risk environments as dealing and drug dealers are often thought to be out of the scope of harm reduction interventions. However, local level drug dealing can be an important feature of local economies in marginalized communities, and the sharp distinctions between users and dealers may not always hold. METHODS: Ethnographic evidence is used to describe how two drug dealers experience risk. Two domestic spaces, the house of a heroin and amphetamine dealer respectively, are used to illustrate the relationships between structural forces, experience and physical space. RESULTS: One key mechanism through which risk environments mediate the relations between structural forces and individuals is through the modification of every day space. Rather than simply being a container for action, space is made through experience. This case study illustrates how two drug dealers orient themselves in space in relation to a complex amalgam of sensations, memories, inscriptions and intentions. Rather than simply being effects of structural oppression, these drug dealers are active participants in the local drug economy. The risk environment and associated economic processes become embodied into the dealers' and their physical environments. CONCLUSION: Drug dealers shape, and are shaped by, their risk environments. A 'determinants' approach to understanding the economic dimension to drug use risk environments needs to be refined. Community resilience policies such "neighbourhood renewal" need to take into account the embodied aspects of economic structures in the experience of drug use and drug dealing. The economic relations, the processes that disable the transformation of different forms of capital, the memories and the practices that make drug users, are embodied. Community resilience policies need to bring into focus the embodiment of the economic dimensions of risk environments if they are to successfully reduce harm.

Impact of the Medicare Short Stay Transfer Policy on patients undergoing major orthopedic surgery.

OBJECTIVE: To examine the impact of the Short Stay Transfer Policy (SSTP) on practice patterns. DATA SOURCES: This study uses data from the Centers for Medicare and Medicaid Services Medicare Provider Analysis and Review (MEDPAR) file, Home Health Standard Analytical File, 1999 Provider of Service file, and data from the 2000 United States Census. STUDY DESIGN: An interrupted time-series analysis was used to examine the length of stay (LOS) and probability of "early" discharge to post acute care (PAC). DATA COLLECTION: Separate 100 percent samples of all fee-for-service Medicare recipients undergoing either elective joint replacement (JR) surgery or surgical management of hip fracture (FX) between January 1, 1996 and December 31, 2000 were selected. PRINCIPAL FINDINGS: Prior to implementation of the SSTP. LOS had been falling by 0.37 and 0.30 days per year for JR and FX patients respectively. After implementation of the SSTP, there was an immediate increase in LOS by 0.20 and 0.17 days, respectively. Thereafter, LOS remained flat. The proportion of patients discharged "early" to PAC had been rising by 4.4 and 2.6 percentage points per year for JR and FX patients respectively, to a peak of 28.8 percent and 20.4 percent early PAC utilization in September 1998. Immediately after implementation of the SSTP, there was a 4.3 and 3.0 percentage point drop in utilization of "early" PAC. Thereafter utilization of early PAC increased at a much slower rate (for JR) or remained flat (for FX). There was significant regional variation in the magnitude of response to the policy. CONCLUSION: Implementation of the SSTP reduced the financial incentive to discharge patients early to PAC. This was accomplished primarily through longer LOS without meaningful change in PAC utilization. With the recent expansion of the SSTP to 29 DRGs (representing 34 percent of all discharges), these findings have important implications regarding patient care.

Impact of changes in Medicare Home Health care reimbursement on month-to-month Home Health utilization between 1996 and 2001 for a national sample of patients undergoing orthopedic procedures.

BACKGROUND: Beginning October 1, 1997, Medicare implemented a series of major changes to the Home Health (HH) reimbursement system. Reimbursements were first significantly reduced under the Interim Payment System (IPS) and then relaxed slightly until implementation of the HH Prospective Payment System (PPS) on October 1, 2000. OBJECTIVE: The objective of this study was to examine the impact of reimbursement policy on HH care utilization. RESEARCH DESIGN: We postulated that in response to the initial changes, there would be reductions in both the probability of any HH use and the number of HH visits per HH user. Under PPS, we postulated there would be further reduction in number of HH visits. We tested whether the policy response differed by HH agency structure and whether subgroups of patients were differentially affected. An interrupted time-series analysis was conducted to examine month-to-month probability of HH selection and the number of HH visits among users. SUBJECTS: A 100% sample of all Medicare recipients undergoing either elective joint replacement (1.6 million hospital discharges) or surgical management of hip fracture (1.2 million hospital discharges) between January 1996 and December 2001 was selected. RESULTS: Under the IPS, the probability of any HH use and number of visits per episode of HH care fell until the IPS was refined in October 1998. With implementation of the PPS, HH visits fell commensurately. Differentially larger reductions in care were noted at for-profit HH agencies, for the elderly, women, patients receiving state assistance, and patients first discharged to skilled nursing facility or rehabilitation hospitals. CONCLUSIONS: Changes in month-to-month utilization of HH services were sharp and well correlated with policy implementation dates, strengthening the evidence for a causal association between policy and patient care in the midst of a sea of concurrent policy changes. Greater reductions in HH visits were noted for vulnerable groups.

Do patients with benign paroxysmal positional vertigo receive prompt treatment? Analysis of waiting times and human and financial costs associated with current practice.

This study retrospectively analysed how 20 patients with posterior canal benign paroxysmal positional vertigo (BPPV) were managed from primary care, to treatment in tertiary care. The average time from first referral to treatment was 93 weeks, with an average of 58 weeks within primary care and 40 weeks within hospital care. At least 85% of cases had classical symptoms of BPPV and could have been easily identified by Primary Care Physicians at first referral, had they been trained to recognise and diagnose the condition. It was concluded that patients could be treated more efficiently and at less cost if the condition was identified at first referral in primary care, and treated in either primary care or dedicated BPPV clinics receiving referrals from primary care. A dedicated clinic for BPPV is recommended, which will substantially reduce waiting time for treatment and save primary care and hospitals time and money by avoiding unnecessary appointments and medication.