Tinnitus referral pathways within the National Health Service in England: a survey of their perceived effectiveness among audiology staff

<p>Abstract</p> <p>Background</p> <p>In the UK, audiology services deliver the majority of tinnitus patient care, but not all patients experience the same level of service. In 2009, the Department of Health released a Good Practice Guide to inform commissioners about key aspects of a quality tinnitus service in order to promote equity of tinnitus patient care in UK primary care, audiology, and in specialist multi-disciplinary centres. The purpose of the present research was to evaluate utilisation and opinions on pathways for the referral of tinnitus patients to and from English Audiology Departments.</p> <p>Methods</p> <p>We surveyed all audiology staff engaged in providing tinnitus services across England. A 36-item questionnaire was mailed to 351 clinicians in all 163 National Health Service (NHS) Trusts identified as having a tinnitus service. 138 clinicians responded. The results presented here describe experiences and opinions of the current patient pathways to and from the audiology tinnitus service.</p> <p>Results</p> <p>The most common referral pathway was from general practice to a hospital-based Ear, Nose & Throat department and from there to a hospital-based audiology department (64%). Respondents considered the NHS tinnitus referral process to be generally effective (67%), but expressed needs for improving GP referral and patients' access to services. 'Open access' to the audiology clinic was rarely an option for patients (9%), nor was the opportunity to access specialist counselling provided by clinical psychology (35%). To decrease the number of inappropriate referrals, 40% of respondents called for greater awareness by referrers about the audiology tinnitus service.</p> <p>Conclusions</p> <p>Respondents in the present survey were generally satisfied with the tinnitus referral system. However, they highlighted some potential targets for service improvement including 1] faster and more appropriate referral from GPs, to be achieved through education on tinnitus referral criteria, 2] improved access to psychological services through audiologist training, and 3] ongoing support from tinnitus support groups, national charities, or open access to the tinnitus clinic for existing patients.</p

Beeinflussen Patientenmerkmale den Erfolg einer ambulanten Behandlung des chronischen Tinnitus?

Various patient characteristics were assessed before offering a treatment to reduce tinnitus related distress to 57 individuals suffering from chronic idiopathic tinnitus. Patients were randomly assigned to a cognitive-behavioral tinnitus coping training (TCT) and a habituation-based training (HT) modelled after Tinnitus Retraining Therapy (TRT) as conceived by Jastreboff. Both trainings were conducted in groups. It was hypothesized that comorbidity regarding mental disorders or psychopathological symptoms (DSM-IV diagnoses, SCL-90R score) and a high level of dysfunctional cognitions relating to tinnitus would have a negative effect on therapy outcome while both trainings proved to be highly efficacious for the average patient. Also further patient features (assessed at baseline) were explored as potential predictors of outcome. None of the hypotheses was corroborated by the data. On the contrary, a higher number of diagnoses was associated with better outcome (statistical trend) and a higher extent of annoyance and interference led to a larger positive change in patients if treated by TCT. No predictor could be identified for long-term success (follow-up >=18 months) except regarding education. The higher the educational level, the larger was the improvement in HT patients. It is concluded that therapy outcome of TCT and HT can not reliably be predicted by patient characteristics and that early variables of the therapeutic process should be analysed as potentially predicting subsequent therapeutic outcome.Es ist bisher noch nicht untersucht worden, ob der Erfolg einer ambulanten Behandlung von idiopathischem Tinnitus durch das Vorliegen einer psychopathologischen Belastung beeinträchtigt wird oder andere Tinnitus-relevante Patientenvariablen die Wirksamkeit moderieren.In einem randomisierten Kontrollgruppendesign wurde die Wirksamkeit eines kognitiv-behavioralen Tinnitusbewältigungs-Trainings (TBT) und eines habituationsbasierten Trainings (HT), angelehnt an die Konzeption der Tinnitus Retraining Therapie nach Jastreboff, verglichen (N=57). Als Outcomekriterium fungierte der Beeinträchtigungsscore aus dem Tinnitusfragebogen von Goebel u. Hiller . Mittels des MiniDIPS-Interviews wurden wesentliche psychopathologische Diagnosen abgeklärt. Aus der SCL-90R wurde der Globale Belastungsscore (GSI) als eine weitere unabhängige Variable genutzt. Ein Fragebogen zu dysfunktionalen Kognitionen zu Tinnitus lieferte die dritte Prädiktorvariable, zu der die Hypothese eines negativen Zusammenhangs zum Therapieerfolg formuliert wurde. Als potentielle Prädiktorvariablen wurden zusätzlich Dauer und Lautstärke des Tinnitus sowie andere Tinnitus-relevante Parameter ausgewählt. Die Hypothesen konnten nicht bestätigt werden. Es ergaben sich keine signifikanten Korrelationen weder in der Gesamtgruppe noch innerhalb der einzelnen Trainingsgruppen. Tendenziell zeigten sich bei der TBT Gruppe einige positive Zusammenhänge zwischen Ausgangsbelastung und Ausmaß des Erfolgs. Der Erfolg des HT (im follow-up) hing mit der Schulbildung der Patienten zusammen. Beide Verfahren, die bezogen auf die Reduzierung der Tinnitusbelastung nahezu gleich wirksam sind, zeigen keine differentielle Effektivität in Abhängigkeit von der Psychopathologie des Patienten. Diese stellt also keine Kontraindikation für ambulante Therapien der verwendeten Art dar. Einige Daten sprechen dafür, dass bei mit TBT behandelten Patienten eine höhere psychopathologische Ausgangsbelastung und ein höheres Level an Tinnitus-bezogener Beeinträchtigung sogar eine größere Verbesserung erwarten lässt