Cost-effectiveness of multidisciplinary management of Tinnitus at a specialized Tinnitus centre.

RIGHTS : This article is licensed under the BioMed Central licence at http://www.biomedcentral.com/about/license which is similar to the 'Creative Commons Attribution Licence'. In brief you may : copy, distribute, and display the work; make derivative works; or make commercial use of the work - under the following conditions: the original author must be given credit; for any reuse or distribution, it must be made clear to others what the license terms of this work are.BACKGROUND: Tinnitus is a common chronic health condition that affects 10% to 20% of the general population. Among severe sufferers it causes disability in various areas. As a result of the tinnitus, quality of life is often impaired. At present there is no cure or uniformly effective treatment, leading to fragmentized and costly tinnitus care. Evidence suggests that a comprehensive multidisciplinary approach in treating tinnitus is effective. The main objective of this study is to examine the effectiveness, costs, and cost-effectiveness of a comprehensive treatment provided by a specialized tinnitus center versus usual care. This paper describes the study protocol. METHODS/DESIGN: In a randomized controlled clinical trial 198 tinnitus patients will be randomly assigned to a specialized tinnitus care group or a usual care group. Adult tinnitus sufferers referred to the audiological centre are eligible. Included patients will be followed for 12 months. Primary outcome measure is generic quality of life (measured with the Health Utilities Index Mark III). Secondary outcomes are severity of tinnitus, general distress, tinnitus cognitions, tinnitus specific fear, and costs. Based on health state utility outcome data the number of patients to include is 198. Economic evaluation will be performed from a societal perspective. DISCUSSION: This is, to our knowledge, the first randomized controlled trial that evaluates a comprehensive treatment of tinnitus and includes a full economic evaluation from a societal perspective. If this intervention proves to be effective and cost-effective, implementation of this intervention is considered and anticipated. TRIAL REGISTRATION: The trial has been registered at ClinicalTrial.gov. The trial registration number is NCT00733044

Tinnitus:Pathophysiology, diagnosis and treatment

Tinnitus is a common and heterogeneous condition, characterised by experiencing sound in the absence of an external source. Various treatment options are available in the Netherlands for patients with tinnitus, but these have limited support from methodologically sound studies. Diagnosis and treatment of tinnitus demands a standardized and multidisciplinary approach. Ideally, there should be a stepwise approach to diagnosis and treatment of tinnitus, with a gradual increase in intensity of treatment. This increase should depend upon the patient's requirements and degree of distress. Current scientific evidence suggests that intensive treatment of tinnitus based on cognitive behavioural therapy (CBT) is indicated for patients with severe tinnitus.</p

Potential barriers and facilitators for implementation of an integrated care pathway for hearing-impaired persons: an exploratory survey among patients and professionals

BACKGROUND: Because of the increasing costs and anticipated shortage of Ear Nose and Throat (ENT) specialists in the care for hearing-impaired persons, an integrated care pathway that includes direct hearing aid provision was developed. While this direct pathway is still under investigation, in a survey we examined expectations and potential barriers and facilitators towards this direct pathway, of patients and professionals involved in the pathway. METHODS: Two study populations were assessed: members of the health professions involved in the care pathway for hearing-impaired persons (general practitioners (GPs), hearing aid dispensers, ENT-specialists and clinical audiologists) and persons with hearing complaints. We developed a comprehensive semi-structured questionnaire for the professionals, regarding expectations, barriers, facilitators and conditions for implementation. We developed two questionnaires for persons with hearing complaints, both regarding evaluations and preferences, and administered them after they had experienced two key elements of the direct pathway: the triage and the hearing aid fitting. RESULTS: On average GPs and hearing aid dispensers had positive expectations towards the direct pathway, while ENT-specialists and clinical audiologists had negative expectations. Professionals stated both barriers and facilitators towards the direct pathway. Most professionals either supported implementation of the direct pathway, provided that a number of conditions were satisfied, or did not support implementation, unless roughly the same conditions were satisfied. Professionals generally agreed on which conditions need to be satisfied. Persons with hearing complaints evaluated the present referral pathway and the new direct pathway equally. Many, especially older, participants stated however that they would still visit the GP and ENT-specialist, even when this would not be necessary for reimbursement of the hearing aid, and found it important that the ENT-specialist or Audiological Centre evaluated their hearing aid. CONCLUSION: This study identified professional concerns about the direct pathway for hearing-impaired persons. Gaps exist in expectations amongst professions. Also gaps exist between users of the pathway, especially between age groups and regions. Professionals are united in the conditions that need to be fulfilled for a successful implementation of the direct pathway. Implementation on a regional level is recommended to best satisfy these conditions

Choosing between measures: comparison of EQ-5D, HUI2 and HUI3 in persons with hearing complaints

OBJECTIVES: To generate insight into the differences between utility measures EuroQol 5D (EQ-5D), Health Utilities Index Mark II (HUI2) and Mark III (HUI3) and their impact on the incremental cost-effectiveness ratio (ICER) for hearing aid fitting METHODS: Persons with hearing complaints completed EQ-5D, HUI2 and HUI3 at baseline and, when applicable, after hearing aid fitting. Practicality, construct validity, agreement, responsiveness and impact on the ICER were examined. RESULTS: All measures had high completion rates. HUI3 was capable of discriminating between clinically distinctive groups. Utility scores (n = 315) for EQ-5D UK and Dutch tariff (0.83; 0.86), HUI2 (0.77) and HUI3 (0.61) were significantly different, agreement was low to moderate. Change after hearing aid fitting (n = 70) for HUI2 (0.07) and HUI3 (0.12) was statistically significant, unlike the EQ-5D UK (0.01) and Dutch (0.00) tariff. ICERs varied from 647,209 euros/QALY for the EQ-5D Dutch tariff to 15,811 euros/QALY for HUI3. CONCLUSION: Utility scores, utility gain and ICERs heavily depend on the measure that is used to elicit them. This study indicates HUI3 as the instrument of first choice when measuring utility in a population with hearing complaints, but emphasizes the importance of a clear notion of what constitutes utility with regard to economic analyse

Item Response Theory Applied to Factors Affecting the Patient Journey Towards Hearing Rehabilitation

To develop a tool for use in hearing screening and to evaluate the patient journey towards hearing rehabilitation, responses to the hearing aid rehabilitation questionnaire scales aid stigma, pressure, and aid unwanted addressing respectively hearing aid stigma, experienced pressure from others; perceived hearing aid benefit were evaluated with item response theory. The sample was comprised of 212 persons aged 55 years or more; 63 were hearing aid users, 64 with and 85 persons without hearing impairment according to guidelines for hearing aid reimbursement in the Netherlands. Bias was investigated relative to hearing aid use and hearing impairment within the differential test functioning framework. Items compromising model fit or demonstrating differential item functioning were dropped. The aid stigma scale was reduced from 6 to 4, the pressure scale from 7 to 4, and the aid unwanted scale from 5 to 4 items. This procedure resulted in bias-free scales ready for screening purposes and application to further understand the help-seeking process of the hearing impaired