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Discipline of Speech Pathology, Sydney School of Health Sciences, The University of Sydney, Susan Wakil Health Building, D18 Western Avenue, Camperdown, NSW, Australia
Discipline of Speech Pathology, Sydney School of Health Sciences, The University of Sydney, Susan Wakil Health Building, D18 Western Avenue, Camperdown, NSW, Australia
Address correspondence and reprint requests to Catherine Madill, Discipline of Speech Pathology, Sydney School of Health Sciences, The University of Sydney, Susan Wakil Health Building, D18 Western Avenue, Camperdown NSW, Australia, 2006.
Discipline of Speech Pathology, Sydney School of Health Sciences, The University of Sydney, Susan Wakil Health Building, D18 Western Avenue, Camperdown, NSW, Australia
Case history assessments are ubiquitously performed across various health professions for diagnostic purposes. Questionnaires are considered a valuable tool within this process. There is currently no standardized tool available to collect such information in the assessment of voice disorders. Conflicting advice from peak bodies and research evidence makes the process heterogenous, haphazard and difficult to compare findings.
Objective
To systematically identify existing case history questionnaires available for general clinical practice and provide synthesis and analysis of the questions within.
Methods
A scoping review was conducted across published and unpublished literature using the PRISMA Extension for Scoping Reviews framework. The broad search included research papers within six electronic databases, textbooks, online publishing sites, voice clinic websites and peak body websites. Search criteria were uniformly applied. Descriptive analysis and content analysis was conducted. At each stage, transparency and replicability was achieved through an independent review process.
Results
Identified voice case history questionnaires were few (n = 23) with 80% from unpublished sources. A total of 581 unique questions were identified. No single question was common across all 23 questionnaires. The most frequently asked questions, excluding demographics, included medicines taken (n = 21), smoking (n = 20) and alcohol (n = 19). These questions were not reflected in the highest frequency categories: Health Status/Medical Conditions/Reports (n = 200), Vocal Symptoms (n = 88), Voice Use (n = 51) despite these categories representing 58% of all questions asked. Within the highest frequency category, the subcategory of Systemic Diseases was the highest, representing 19% of all questions within the category.
Conclusions
This study illuminates the similarities yet many differences that exist across identified voice case history questionnaires in terms of number of questions, number of categories, preference for question-type and structure. It demonstrates the need for standardization of a voice case history questionnaire which would potentially enable more accurate diagnosis and data comparison between voice clinics to aid future research.
for example, voice disorders including spasmodic dysphonia, muscle tension dysphonia, mild vocal paresis, functional neurological and intracordal lesion require information provided by the patient for accurate differential diagnosis.
Case history assessments often include a case history questionnaire followed by a face-to-face interview. In this scenario, the use of a case history questionnaire allows for a more patient focused, individualized and nuanced case history interview,
where aspects not explored in the questionnaire can be revealed and investigated using open questions to gather more information. Capturing patient information through questionnaire is arguably preferable as it allows the patient unlimited opportunity to record responses in their own time, providing greater accuracy of information, increased efficiency for clinicians and removal of the risk of interviewer bias.
Standardization of case history assessment questionnaires in other health disciplines has been achieved and adopted. For example, in the assessment of tinnitus, the development of a self-reported standardized questionnaire is preferred by audiologists to a structured case history interview.
There appears to be however, little consensus across voice related peak bodies regarding the importance of case history assessment information in the diagnosis of voice disorder and little guidance is provided to clinicians as to which case history questionnaire to use and what questions should be asked. For example, while the American Speech-Language-Hearing Association recommends the use of case history assessment and provides a template to collect such information,
the European Laryngological Society and other voice evaluation medical protocols omit the case history assessment entirely from their ‘List of Basic Requirements for Assessment’.
A basic protocol for functional assessment of voice pathology, especially for investigating the efficacy of (phonosurgical) treatments and evaluating new assessment techniques.
Interestingly, the American Laryngologists Society has updated it is ‘Comprehensive Laryngology Curriculum’ to include patient (case) history with the rationale that such information is important for the purposes of treatment but gives no mention of the value of such information to diagnosis.
Across the literature there is a paucity of high level and at times conflicting evidence regarding the value of case history information to voice disorder diagnosis. A study of functional voice disorders showed a positive association with selected case history assessment information, namely teaching activity and gender.
In contrast, a study of the organic voice disorder, mucosal bridge, showed that diagnosis did not correlate with some case history measures (smoking, alcohol intake, sino-nasal symptoms) and was inconsistent with others.
Whilst these examples highlight the differences between voice disorder types and the complexity of diagnostic assessment, a systematic review investigating a range of clinical diagnostic voice assessments concluded that few studies examined the contribution of the case history assessment.
It was noted that the paucity of information should not be interpreted to mean there is no clinical merit in the case history assessment, but rather that this should be a focus for future studies.
Despite the conflicting advice from peak bodies and lack of high level evidence regarding the value of this information to diagnosis, a study of the assessments used to evaluate voice disorders in teachers, found case history questionnaires were used 80% of the time compared to the next most frequently used assessments, perceptual measures (40%) and videostroboscopy (40%).
Such high frequency use suggests case history questionnaires are both commonly used and considered by voice clinicians to provide some clinical, if not diagnostic, value. Additionally, case history information has been found to impact the interpretation of other, more objective voice assessment measures. For example, knowledge of case history assessment information was found to have an effect on how clinicians interpreted the videolaryngostroboscopic (visual) assessment and ultimately the accuracy of the voice disorder diagnosis.
Recommended protocols for instrumental assessment of voice: American speech-language-hearing association expert panel to develop a protocol for instrumental assessment of vocal function.
Recommended protocols for instrumental assessment of voice: American speech-language-hearing association expert panel to develop a protocol for instrumental assessment of vocal function.
It is hard to establish why this might be the case. Historically it may be that because these tools have not been widely reported in the literature a circular absence was created with no research on the topic because the topic is not present in the existing literature. Alternately, each clinical setting has built their own questionnaires through iterative processes based on clinical experience and received wisdom and the local utility of questions, without need to reference a standardized format. Whichever it is, there is no ‘gold standard’ case history questionnaire for voice clinicians to use in the general assessment of voice disorder. Without standardization between voice clinics, the process remains heterogenous making the comparison of data across settings difficult.
Specific recommendations for the development of case history questionnaires used for data collection and health care-research include clear identification of what will be measured, use of an appropriate response style, consideration of item generation, wording and order, pilot testing, reliability and validity assessment, and a range of factor analysis and extraction processes.
The need to diagnose, triage, or supplement other assessment data with questionnaire responses needs also to be considered in the design of the questionnaire.
The purpose of the current study is to identify, through broad and systematic searching and review, the case history questionnaires available to voice clinicians for general assessment purposes. This research attempts to identify the questions and question-categories most frequently asked across the identified case history questionnaires to begin the process toward standardization.
A standardized voice case history questionnaire would ultimately provide for better evaluation of results, potentially more accurate diagnosis, and allow for comparisons across voice clinics. Standardization of data collection will enable higher quality treatment and research into the future.
Material and methods
A scoping review was identified as the most suitable review type to systematically map the broad landscape of existing case history questionnaires.
Key search terms were identified in consultation with a librarian from The University of Sydney Health Sciences. The relevant electronic databases, library catalogues, web-based search engines, online voice publishing sites and peak body organizations were identified by the authors as places to search; and search criteria were established. The content of the records identified for final inclusion was then analyzed using descriptive statistics and content analysis.
The review was guided by the following questions: (1) What case history questionnaires are available to voice clinicians for the use of general clinical assessment of voice disorder? (2) What similarities and differences exist across them? (3) What are the most frequently asked questions and question-categories across the identified questionnaires?
Data sources
To enable a thorough search of relevant sources both the peer reviewed and gray literature were searched and the following five sources were included: (1) published for purposes of research and found within electronic databases, (2) published in voice disorder textbooks (most recent editions) and accessible via library database, internet search engines and voice publishing websites, (3) used currently or previously in clinical practices and freely available via internet search engines (4) unpublished theses found within the electronic database Proquest Dissertations & Theses Global, or (5) recommended by peak bodies via their websites (American Speech-Language-Hearing Association (ASHA), European Laryngological Society (ELS), American Laryngological Society (ALS), British Voice Association (BVA), Royal College of Speech and Language Therapists (RCSLT), and The Voice Foundation (TVF)).
Search strategy
Each of the five sources listed above required a different search strategy as follows:
1)
Published for the purposes of research: The first author conducted a literature search systematically in March 2020 using five electronic databases: MEDLINE via Ovid (biomedical sciences, 1946-present), EMBASE via Ovid (biomedical sciences, 1947-present), CINAHL (nursing and allied health, 1981-present), Scopus (multidisciplinary, 1823-present) and Web of Science Core Collection (multidisciplinary, 1900-present). The search strategy included the key terms ‘case history questionnaire’, ‘patient history questionnaire’, ‘voice questionnaire’, ‘voice disorder’, ‘vocal disorder’ and ‘adult’. The key search terms were used consistently across all databases, however with MEDLINE the MeSH term ‘surveys and questionnaires’ was used in addition to allow for as broad searching as possible. Refer to Appendix 11.1 for the MEDLINE search strategy. A replication of the MEDLINE search was undertaken by a health sciences librarian with 100% of the search results matched.
2)
Published in voice disorder textbooks (most recent editions): The first author conducted a literature search in March 2020 using The University of Sydney library database, a broad internet search via Google search engine's ‘shopping’ tab, and three specific voice textbook publishers: Plural Publishing, Compton Publishing and Blue Tree Publishing. The search strategy included the term ‘voice disorder textbook’. For the library search, limiters included ‘book’, ‘held in health sciences library’, ‘publication date 2000-2019’. The Health Sciences library was chosen as it is the primary custodian of all allied health resources at the university. All searches were repeated by a health sciences librarian with 100% of the search results matched.
3)
Voice clinic websites via internet search engines: A review of case history questionnaires found online that were once used or currently being used in clinical practice was undertaken. The first author conducted a search in March 2020 of freely available, case history questionnaires using the search engines Google, Bing and Yahoo. Data from 2020 showed that Google was the most popular search engine worldwide with a market share of 86%, followed by Bing (4%) and Yahoo (<1%).
The search terms ‘voice case history questionnaire’ and ‘voice patient history questionnaire’ were used across all search engines.
4)
Unpublished theses: The first author conducted a search of unpublished theses in April 2020 using the electronic database Proquest Dissertations & Theses Global (1997-present). The search strategy included the terms ‘case history questionnaire’, ‘patient history questionnaire’, ‘voice questionnaire’, ‘voice disorder’, ‘vocal disorder’ and ‘adult’. The ‘abstract’ search function was applied. A replication of the search was independently undertaken by a health sciences librarian with 100% of the search results matched.
5)
International professional bodies: A review of any case history questionnaires recommended by the internationally recognized peak bodies across the profession was undertaken. Six organizations (ASHA, ELS, ALS, BVA, RCSLT, TVF) were contacted via email and followed up with a second email where no response was received. The relevant websites were also searched for case history questionnaires/templates available for download.
Citation management
All citations from electronic databases were imported into EndNote8 software which was used to identify and remove duplicates as well as preview titles and abstracts. From the 2343 articles imported from MEDLINE, EMBASE, CINAHL, Scopus, and Web of Science, 1086 duplicates were removed. From the 22 articles imported from Proquest Dissertations & Theses Global, no duplicates were found.
Eligibility criteria
The specific inclusion and exclusion criteria were applied to all potential case history questionnaires irrespective of their origin.
Inclusion criteria
Included in the review were case history questionnaires: (1) accessible to voice clinicians, (2) replicable for general clinical use, (3) able to be used in the current form, (4) relating to human adults (+18 years), (5) originally written or translated into English.
Exclusion criteria
Excluded from the review were those case history questionnaires: (1) published only in part, (2) described in narrative form but available as a tool for clinical use, (3) designed for a specific sub-population or to answer a specific research question, (4) designed to be completed by an experienced voice clinician rather than the patient themselves, (5) not exclusively designed for the purposes of voice assessment but including other speech pathology or laryngology practice areas (eg swallowing and upper airway difficulty).
Screening
A two-stage screening process was used to assess the inclusion of case history questionnaires identified by the search. The title and abstract of each citation were screened by the first author. The remaining titles were then subject to full text review using the following questions: (1) Does a case history questionnaire exist? (2) If so, does it meet the defined search criteria? A randomly selected 20% of records were reviewed by an independent reviewer to ensure inter-rater reliability. The first author and the independent reviewer met through the screening process to discuss any uncertainties and resolve any conflicts related to study selection. The flow of records from identification to final inclusion is represented in Fig. 1.
The screening process occurred across the five sources as follows:
1)
Published in research papers: The first author screened the titles and abstracts of 1257 records. 967 records were excluded based on the inclusion criteria. A randomly selected 20% of articles were independently reviewed with 100% agreement. One research paper29 made reference to a patient questionnaire used within the study. However the questionnaire was missing from the published appendix. The author was contacted and the questionnaire was obtained. This questionnaire was then subject to full text review.
2)
Published in voice disorder textbooks: A total of 33 records were identified in The University of XX Health Sciences library including both hardcopy and online books. Records were screened by title and description. For example, where titles included terms as ‘children’, ‘paediatrics’, ‘treatment’, ‘visual examination’ they were excluded. A total of 19 records were excluded. A randomly selected 20% of articles were independently reviewed with 100% agreement. The search engine ‘Google’ yielded 11 results from a total of 50, after a similar screening process was conducted through consecutive pages until redundancy (no new items emerged). Searches within the online publishing sites yielded 11 results after screening until redundancy and included Plural Publishing (n = 10), Compton Publishing (n = 1) and Blue Tree Publishing (n = 0). Some records appeared across multiple sites.
3)
Voice clinic websites via internet search engines: The search results from the search engines: Google (n = 633M), Yahoo (n = 6.84M) and Bing (n = 311,000) were screened by title and description until redundancy was achieved as evidenced by consistently irrelevant search results. For all search engines this was achieved within 20 pages of the respective search results. Hand searches of each identified website were conducted to confirm whether an adult voice case history questionnaire was available for download. A total of 24 records resulted: Google (n = 13), Yahoo (n = 8), Bing (n = 17) with some records appearing across multiple search engines.
4)
Unpublished Theses: The first author screened the titles and abstracts of the 22 search results and excluded 21 records. On a randomly selected 20% of articles an independent reviewer achieved 100% agreement.
5)
International professional bodies: Only two professional bodies, ASHA and BVA responded to an email request, despite follow up requests. ASHA suggested the Princeton University Case History Questionnaire, Louisiana University's Voice Patient Case History and Boston University's Aphasia Centre form. The first two were previously identified and subject to full review. The latter did not meet the inclusion criteria. BVA suggested the personal voice history form of one of their voice specialists. This did not meet the inclusion criteria as it was designed to be completed by a clinician during patient interview. The search of peak body websites yielded only two results: (1) ASHA ‘voice evaluation’ template and (2) ALS ‘voice specific patient history’. Both were subject to full text review.
Data summary and synthesis
Data was compiled separately for each source using excel spreadsheets and word tables. Identical record forms were created for the independent reviewer to enable comparison of findings.
Coding
Across all questionnaires, the questions were individually extracted and documented in an excel spreadsheet. Questions were recorded verbatim until redundancy, that is until no new questions emerged. Where questions had the same intended meaning but used slightly different wording, they were recorded as the same question. Questions were recorded as being either open or closed (refer to Appendix 11.3). The number of sections within each questionnaire was also recorded. An independent review of a 20% randomly selected sample was conducted with 100% agreement reached.
Questions were initially inductively coded into 13 mutually exclusive, clearly defined categories by the first author (refer to Appendix 11.2 for category definitions). Inductive coding creates categories without reference to a pre-existing set of codes. Once the codes or categories are created, the resultant list can be used to deductively code by allocating the data to the created codes. In this case, the first author analyzed the questions into themes and used the themes to create categories. The second author, then independently and blindly coded the questions into the initial defined categories. Comparisons were made and disagreements discussed. To ensure replicability, the third author, independently and blindly coded the questions into the defined subcategories. Overall inter-rater reliability was 78% (Health Status/Medical Conditions/Reports (64%), Vocal Symptoms (92%), Vocal Use (78%).
Due to the low level of agreement in the initial coding, several changes were made to the coding procedure including (1) the adoption of International Statistical Classification of Diseases and Health Related Problems ICD
as the agreed standard for disease description to categorise items which were related to disease and disease processes and (2) discussion of the remaining superordinate categories to ensure a joint understanding of the coding. Following this revision to the procedure, both the first and second author coded the questions again with the third author conducting an independent, blind coding prcedure for replicability. Overall inter-rater reliability was 85% - Vocal Symptoms (92%), Vocal Use (78%). and consensus was achieved through discussion.
Results
From the systematic search process conducted across March-June 2020, a total of 23 case history questionnaires were included. Sources were as follows: 20% originated from published sources: research papers (n = 2) and textbooks (n = 3); 80% originated from unpublished sources (not searchable across academic databases nor peer reviewed): clinic websites (n = 18), unpublished theses (n = 0), peak body websites (n = 0). These records were analyzed using descriptive statistics and content analysis.
Published research papers: Of the 290 articles subject to full text review, 288 articles were excluded for multiple reasons including: (1) the authors reported on the findings of a questionnaire used but did not include it in full within the body of the report or as an appendix (n = 240), (2) the questionnaire was included but was not a case history questionnaire eg VHI, VRQL, The Health Omnibus Survey, Voice Related Survey (n = 12), and/or (3) the questionnaire was designed for a specific population or to answer a specific research question (n = 36). One retrospective study used patient history forms from a specified clinic, the Massachusetts Voice and Speech Laboratory, however the form was not included in the research paper or as an appendix and was thus excluded. One questionnaire
was included, despite being designed for the specific population of teachers, as it made provision for the inclusion of the general population with “question modifications for the general population” as part of the questionnaire.
An independent reviewer conducted a review of a randomly selected 20% of records using a separate excel spreadsheet. When results were compared there were no disagreements regarding the number of papers to be excluded, however there were minor uncertainties regarding the specific exclusion criteria that applied. These uncertainties were resolved with discussion and 100% consensus achieved.
2)
Published in textbooks: 23 records were subject to a full text review. Twenty records were excluded based on the exclusionary criteria of: (1) no questionnaire was included (n = 11), (2) the included questionnaire was identical to a previous questionnaire in a different voice textbook by the same author (n = 2), (3) questionnaire was intended to be filled out by a clinician during interview rather than the patient (n = 6), (4) questionnaire was described in narrative form but not for clinical use in its current form (n = 1). On a 20% randomly selected sample reviewed by an independent reviewer, there was disagreement regarding the inclusion of one questionnaire
because it was designed for ‘professional voice users’. It was agreed this term referred to many voice populations rather than one specific population as defined by the search criteria, and thus should be included.
3)
Voice clinic websites via internet search engines: 24 records were subject to a full text review. Six records were excluded with the following reasons: (1) not exclusively designed for the purposes of voice assessment but included language, speech, hearing and/or swallowing assessment questions (n = 4), (2) questionnaire designed to be filled out by clinician during interview rather than patient (n = 2).
4)
Unpublished Theses: Only one thesis was subject to a full review. After discussion between reviewers it was resolved that the case history questionnaire did not meet the search criteria on the basis that it was designed for a specific population and to answer a specific research question.
5)
International professional bodies: Two records were subject to full text review but excluded by both reviewers; ASHA's template was excluded as it is designed to be filled out by a clinician. ALS's form was excluded as it is described in narrative form only and related to treatment rather than assessment.
Content analysis
The 23 identified case history questionnaires were analyzed using descriptive statistics and content analysis.
A total of 581 unique questions were recorded. The frequency of each question was calculated. No individual question was common across all 23 questionnaires. The highest frequency questions, excluding demographics (name/date), included the consumption of medicines taken (n = 21), smoking (n = 20), alcohol (n = 19), history of allergies (n = 18), caffeinated beverages (n = 16) and describing the voice problem (n = 16). The number of questions, including open questions and closed questions, as well as number of sections per questionnaire was determined and the mean for each was calculated. The results are shown in Fig. 2.
FIGURE 2Mean value of total questions, open questions, closed question and sections per questionnaire.
The mean number of questions was 77.61 (range 27–151). The mean number of open questions was 27.57 (range of 1–62) and closed questions was 50.04 (range 12–133). The mean number of sections was 4.13 (range 0-17). There were eight questionnaires with no sections at all.
Secondary analysis – analysis of question categories
The question categories are represented in Fig. 3 which shows the total number of questions per category. The highest category represented one third of all questions asked. The highest three categories represented 58% of all questions asked: (1) Health Status/Medical Conditions/Reports (n = 200, 34%), (2) Vocal Symptoms (n = 88, 15%), (3) Voice Use (n = 51, 9%). Seven questionnaires (30%) had questions across all categories (refer to Table 1) however these questionnaires varied considerably in terms of total number of questions asked. The Patient History: Professional Voice Users
Of the three highest frequency categories, representing 58% of all questions asked: The Health Status/ Medical Conditions/ Reports category was represented across all 23 questionnaires (range 2–72 questions). The Vocal Symptoms category was represented across all 23 questionnaires (range 1–33 questions). The Voice Use category was represented across 21 questionnaires, with two questionnaires having no questions in this category (range 0-14 questions) (refer to Appendix 11.3).
Secondary analysis – analysis of open questions per category
The number of open questions per category was calculated (refer to Table 2). Some categories favored the use of open questions more than others. These included Identifying information, Onset, Perception of the Problem, Treatment, and Medicines Taken. By contrast, categories including Health Status/Medical Conditions/Reports, Vocal Use, Psychological Factors, Lifestyle Factors and Environmental Factors favored the use of closed questions.
TABLE 2Total Number of Questions, Number of Open Questions and Percentage of Open Questions Per Category Across Analyzed Case History Questionnaires
Tertiary analysis – Subcategory analysis of three highest categories
The three highest frequency categories, representing 58% of all questions, were further analyzed. These included Health Status/Medical Conditions/Reports (n = 200), Vocal Symptoms (n = 88), and Vocal Use (n = 51). Questions within the highest category ‘Health Status/Medical Conditions/Reports’ were deductively coded by the first author using the categories defined in the International Statistical Classification of Diseases and Health Related Problems ICD (10)
which was chosen as the agreed standard for disease description. The other two categories, ‘Vocal Symptoms’ and ‘Vocal Use’ were inductively coded into mutually exclusive, clearly defined categories as defined by the first author (refer to Appendix 11.2 for subcategory definitions). The second author independently and blindly coded all questions into the defined subcategories. Comparisons were made and consensus was achieved through discussion. To ensure replicability, the third author, independently and blindly coded the questions into the defined subcategories. Overall inter-rater reliability was 85% - Vocal Symptoms (92%), Vocal Use (78%).
Subcategory analysis - Health status/ medical conditions/ Reports
The subcategories for the category of Health Status/ Medical Conditions/ Reports are represented below in Fig. 4 and show the number of questions per subcategory. The highest subcategory, ‘Symptoms/ Signs/ Abnormal Clinical Findings’, represented 14% of all questions asked within this category (n = 28).
FIGURE 4Subcategory analysis of the health/medical conditions/reports category.
The subcategories for the category of Vocal Symptoms are represented below in Fig. 5, and show the number of questions per subcategory. The highest subcategory, Physical Descriptors of Voice, represented 47% of all questions asked within this category (n = 41).
FIGURE 5Subcategory analysis of the vocal symptoms category.
The subcategories for the category of Vocal Use are represented below in Fig. 6 and show the number of questions per subcategory. The highest subcategory, Daily Use of Voice, represented 61% of all questions asked within this category (n = 31).
FIGURE 6Subcategory analysis of the vocal use category.
There were surprisingly few case history questionnaires identified for analysis (n = 23) from the broad, systematic search process. Those included were 80% from unpublished sources (voice clinic websites) and 20% from published sources (research papers, textbooks). Although the three most popular search engines were used in the search for unpublished voice case history questionnaires, 100% of records came from voice clinics within the US, with 60% of these from university voice clinics. By contrast, the electronic databases used to search for published research articles yielded a much more representative selection of global research. This suggests that other voice clinics around the world either do not have websites searchable via these search engines or do not have case history questionnaires available for download. An alternate explanation could be a systematic bias due to the search engines algorithms which are designed to preference the most visited websites.
Similarities and differences across analyzed questionnaires
There were similarities across the 23 case history questionnaires analyzed but also differences in terms of number of questions, number of categories, number of open versus closed questions, and number of sections. For example, the majority of questionnaires (56%) included questions from all categories or were only missing one category; and the highest two frequency categories of Health Status/ Medical Conditions/ Reports, and Vocal Symptoms were included across all questionnaires. There was a general preference for the use of closed questions and for the use of sections. There was however a marked difference in the number of questions asked by the questionnaires, ranging from 27 to 151 questions (refer to Appendix 11.3). No single question was common across all 23 questionnaires. The number of questions within categories was also variable. For example, in the highest frequency category of Health Status/ Medical Conditions/ Reports the range was 2 to 72 questions.
Analysis of categories and the questions within each category
Following the synthesis and analysis of the questionnaires, the highest frequency questions and the highest frequency categories were identified. Interestingly the three highest frequency questions were not reflected in the three highest frequency categories of Health Status/ Medical Conditions/ Reports (n=200), Vocal Symptoms (n = 88), Voice Use (n = 51), despite these categories representing 58% of all questions asked (refer to Table 3).
The explanation may lie in the clinical value of the question. Questions with well documented, diagnostic evidence for voice disorder may be regarded by clinicians as high value questions, thus explaining their frequency. Questions with little or no diagnostic evidence may be regarded as low value questions and less frequently asked. Despite not having high level evidence of the overall value of case history assessment information to diagnosis of voice disorder, there is substantial evidence of the many risk factors for voice disorders. for example, the most commonly asked question of ‘Medications Taken’ may be justified by the evidence linking the potential side effects and unique interactions of medications when taken in combination, to voice problems.
Antibiotics, steroids, and anti-reflux medication in particular have been linked to oropharyngeal dryness, voice changes, mood disturbances and perceptual disturbances in the voice.
This suggests, not only the questions of smoking and alcohol will be frequently asked, but the question of ‘History of Reflux/ Heartburn’ (currently only seen across 14 questionnaires) might also be included as a frequently asked question.
Analysis of question-type (open versus closed)
Questionnaire effectiveness demands comprehensive patient information be obtained while questionnaire efficiency demands a minimum number of questions to be answered by the patient.
The solution to this contrast in requirements may lie in how the questions are asked, that is, open versus closed. Open questions allow provision of indepth information
In this study, there was an overall preference for the use of closed questions across the voice case history questionnaires analyzed. However, within entire categories there was a preference for questions to be either mostly open or mostly closed. for example, the most frequently asked question ‘(list all the) medications taken?’ was an open question from the category of Medicines, where the mean number of questions was only 1.4 and 70% of all questions within this category were open questions. By contrast, the category of Health Status/ Medical Conditions/ Reports used open questions only 26% of the time and the category of Environmental Factors used open questions only 18% of the time, which suggests these categories are better served by closed questions. In fact, the three highest frequency categories demonstrated a strong preference for the use of closed questions. The reason may be explained by the clinicians’ need to acquire a lot of specific patient information in these categories, best achieved by prompting the response with closed questions.
Analysis of highest frequency category
The largest number of questions, despite their closed type, was in the highest frequency category Health Status/ Medical Conditions/ Reports. This category represented 34% of all questions asked. At such a large number, the notion of questionnaire efficiency is certainly challenged. However, there is well documented evidence of the innumerable health conditions and diseases that adversely affect the voice. In fact, changes in the voice often signal the first manifestation of a wide variety of systemic, neurological, and structural disorders.
As such, the need for accuracy of information in this category would seem to justify the large number of questions asked, especially where the voice disorder is considered holistically rather than in isolation of the rest of the body. This need must be balanced however with efficiency and our understanding of questionnaire fatigue; being the longer the questionnaire the higher the risk of patients’ not answering questions reliably, if at all.
Analysis of question content and grammatical structure
The question content and grammatical structure determines how the respondent interprets the question and the response they subsequently provide. Without specificity, questions may be misinterpreted and incorrect responses may result.
allows for misinterpretation by the respondent due to the ambiguity of the word mucosa to a general population. Other issues in good questionnaire design include avoiding jargon, long questions, and double questions.
If a question asks for more than one piece of information, it may be unclear what the answer means. for example, the question in the Patient History: Professional Voice Users
questionnaire: ‘Have you noticed confusion or loss of consciousness? is a double question demanding a yes/no answer. Similarly, the complex wording in the Questionnaire for the General Population Group
question: ‘How many years do you have to load your voice during practizing your profession?’ is difficult to interpret and suggests a possible grammatical error.
Analysis of overall questionnaire structure
The structure of the questionnaire as a whole should be considered.
To avoid questionnaire fatigue and improve the chances of completion, it is recommended that questionnaires begin with the easier-to-answer questions (open) and the more sensitive questions (financial situation, health status) sequenced toward the end.
The use of sections by the questionnaires analyzed in this study was mixed. The mean number of sections was 4.13 (range 0–17) and 8 questionnaires (34%) had no sections at all.
Limitations
A number of limitations were noted in the research. All searches were conducted in English. It is acknowledged there is an inherent bias toward research from English speaking countries as a result. Strict inclusion and exclusion criteria were applied which posed necessary limitations on search results given the timeframe and resources available. It is acknowledged that different search criteria would have yielded different outcomes. In the online searching of unpublished voice case history questionnaires, 100% of records identified were from voice clinics within the US, with 60% of these from voice clinics attached to universities. This may mean that these results are specific to the US. Different results may be achieved from analyzing questionnaires from other geographical areas if they could be obtained.
Future directions
It is clear from this scoping review that more work is needed to move the field from the current state of individual, and highly varied case history questionnaires to standardized questionnaires that facilitate wide-spread data harmonization thus allowing for greater collaboration in interpretation of clinically acquired data. Research is needed to (1) establish firm categories and classifications of questions, (2) establish an evidence base for the clinical utility of those categories and (3) discover what information clinicians believe is worth collecting and for what purpose. This would facilitate the development of a standard minimum data set to which clinicians and researchers can add additional, context specific questions but which will provide a consistent underpinning across studies and clinics.
Once established, this standard minimum questionnaire derived dataset can be collected from all voice patients and will enable the development of shared databanks and repositories containing both the newly standardized questionnaire data and the well-established standard visual, acoustic, perceptual, aerodynamic, and patient reported outcome measures.
Recommended protocols for instrumental assessment of voice: American speech-language-hearing association expert panel to develop a protocol for instrumental assessment of vocal function.
This scoping review highlights that not only is there is no standardized approach to gathering voice history information via patient-completed questionnaire but that few voice case history questionnaires are available to clinicians for general clinical assessment of voice disorder. Whilst clinicians may perceive case history questionnaires to be a commonly used and an essential part of the diagnostic process, there is little guidance from the field at large as to what questions to ask, how and why to ask them. This scoping review also examines the commonalities and differences that exist between the identified voice case history questionnaires with the purpose of beginning a process toward standardization. It highlights the need for a standardized voice case history assessment questionnaire to enable consistency of assessment content and wording of questions. Standardization would also enable comparison between voice clinics worldwide, permitting future voice diagnostic research and ultimately better patient outcomes. This research contributes to the process of standardizing voice case history questionnaires. The next steps include a Delphi consensus process between experienced voice clinicians and researchers to determine both the content and structure of a standardized voice assessment questionnaire as well as a determination of the specific diagnostic value of each question category, and the questions within, to the assessment of voice disorder.
Author contributions
All authors were involved in the design of the study and analysis of data. All authors were involved in the interpretation and revision of the manuscript critically for its intellectual content. All authors have agreed to investigate and resolve any questions relating to the work.
Declaration of Competing Interest
The authors declare that no financial support has been received in conducting the research nor in the development of this manuscript.
Acknowledgments
The first author would like to acknowledge the support and expertise of Elaine Tam, Academic Liaison Librarian at The University of Sydney, who provided advice regarding the design of the research.
The authors would like to acknowledge the support of the Dr Liang Voice Program at The University of Sydney.
Appendix
Search Strategy for Ovid MEDLINE
Database: Ovid MEDLINE(R) ALL <1946 to March 20, 2020>
Search Strategy:
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case history question*.mp. (28)
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patient history question*.mp. (12)
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(voice adj2 question*).mp. [mp = title, abstract, original title, name of substance word, subject heading word, floating sub-heading word, keyword heading word, organism supplementary concept word, protocol supplementary concept word, rare disease supplementary concept word, unique identifier, synonyms] (183)
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questionnaire.mp. or “Surveys and Questionnaires”/ (666468)
Definitions of Question Categories and Subcategories
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Category
Definition
Identifying information
The identifying characteristics used to broadly define a population for the purposes of understanding their health status and/or the means by which to contact them. Includes demographic information, contact information, socio-economic information, education information, genetic/family history
Perception of the Voice Problem
How the patient describes, understands or rates the voice problem. Includes what other people say about the voice problem or how they react to it as well as the impact of the voice problem on Quality of Life beyond the structural/functional impairment itself (as understood by the ICF framework)
Onset
Any details surrounding how and when the voice problem first began
Vocal Symptoms
Perceptual descriptors of the voice as well as changes in the voice (both positive and negative) experienced from hour to hour or day to day. Includes variability, duration and frequency of problem
Associated Symptoms
Non-voice factors, experiences or feelings the patient perceives to be linked to the voice problem
Health Status/Medical Conditions/Reports
Physical health descriptors of the patient, diagnosed conditions or disorders reported on by a health professional, with current or previous. Includes previous surgeries, previous voice problems, and any medical report findings
Medicines
Any medically prescribed or over the counter pharmaceutical (non-prescription) currently being taken by the patient
Lifestyle Factors
The adaptable behaviors and life choices that influence the patient's health and wellbeing. Includes smoking, alcohol, caffeine, sleep, social and family factors
Environmental Factors
Environmental influences on the voice
Vocal Use
Use of voice for work or recreational purposes, including singing.
Psychological Factors
Emotional influences on the voice and wellbeing
Treatment
Prognostic variables affecting whether a patient would be capable of engaging in and benefiting from treatment for their voice problem. Includes goals, patient motivation, suitability to treatment, previous treatment
Other
Questions that do not fit into any other category and cannot of themselves form a distinct category
*Based on the International Statistical Classification of Diseases and Related Health Problems 10th Revision (ICD-10) Version; 2019
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Health Status/Medical Conditions/Reports
Sub-Category
Definition
Diseases of the ear
Disorders of the external, middle and inner ear
Diseases of the eye
Disorders of conjunctiva, glaucoma, visual disturbances and blindness
Diseases of the skin
Disorders of the skin and subcutaneous tissue
Diseases of the respiratory system
Upper and lower respiratory infections, diseases of upper or lower respiratory tract, lung diseases
Diseases of the digestive system
Diseases of oral cavity, oesophagus and stomach, appendix, liver, gall bladder and intestines.
Endocrine, nutritional and metabolic diseases
Disorders of hormone producing glands. Includes obesity, metabolic disorders, nutritional deficiency
Diseases of the nervous system
CNS inflammatory diseases, degenerative disorders of nervous system, Extrapyramidal and movement disorders eg cerebral palsy, PNS disorders
Diseases of the circulatory system
Heart disease, rheumatic fever, hypertension, diseases of veins, lymph nodes/vessels
Diseases of the musculoskeletal system and connective tissue
Soft tissue, joint or muscle disorders, disorders of bone density and structure
Certain infectious and parasitic diseases
Diseases generally recognized as communicable or transmissible including viral and bacterial diseases eg tuberculosis and infections with a predominantly sexual mode of transmission ie chlamydiae, human immunodeficiency virus [HIV] disease
Injuries and external causes of morbidity/mortality
Accidents or injuries to head, neck or body, including falls and transport accidents
Pregnancy, childbirth
Maternal disorders predominantly related to pregnancy and labor
Symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified
Includes clinical symptoms and signs involving cognition, perception, emotional state and behavior (excluding voice)
Symptoms and signs of Voice
Symptoms and signs specific to voice
Mental and behavioral disorders
Includes mental and behavioral disorders due to psychoactive substance use, mood disorders, behavioral syndromes associated with physiological disturbances and physical factors, behavioral and emotional disorders with onset usually occurring in childhood and adolescence
Contact with health services/medical reports or diagnosis
Encounters with health services for examination and investigation eg hospitalization, including reports prepared by a medical practitioner
Other
Questions that do not fit into any other category and cannot of themselves form a distinct category
A basic protocol for functional assessment of voice pathology, especially for investigating the efficacy of (phonosurgical) treatments and evaluating new assessment techniques.
Recommended protocols for instrumental assessment of voice: American speech-language-hearing association expert panel to develop a protocol for instrumental assessment of vocal function.
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