Cost effectiveness of multidisciplinary management of Tinnitus at a specialized Tinnitus centre
From: BMC Health Serv Res. 2009 Feb 11;9(1):29. [Epub ahead of print]
Subjective tinnitus is the involuntary perception of the concept of a sound without the presence of an external source. It is a chronic condition that is highly prevalent, especially among hearing impaired individuals. Studies show a prevalence of 10% to 20% in the general population and among hearing impaired individuals prevalence has been estimated at 75% to 80%. Of the Dutch population at least 2 million individuals suffer from some form of tinnitus, 340,000 individuals indicate to hear the tinnitus continuously and 60,000 individuals claim to be severely impaired in their daily activities. Among severe sufferers it causes disability associated with severe affective problems, major declines in concentration, sleeping difficulties, hypersensitivity to sounds and problems in re-directing attention. The combination of these complaints makes them feel exhausted and frustrated resulting in diminished quality of life. Tinnitus is known to occur as a concomitant of almost all the dysfunctions that involve the human auditory system and it is postulated that the aetiology of tinnitus is diverse and that different activation circumstances can be present. Little is known about the pathophysiology and there is no known drug or curative therapy at present though considerable research effort has been expended in this regard.
In many cases tinnitus sufferers are referred to different caregivers in a nonstandardized way, and often receive insufficient and sometimes inappropriate treatment. This may comprise prescribing a drug that is not proven to be effective, or informing the patients that not much can be done to improve the situation. Especially in those individuals suffering from a moderate to severe tinnitus, incorrect information and delay of appropriate treatment is expected to increase psychological strain, aggravation of tinnitus severity and prolongation of the referral trajectory. Since tinnitus sufferers seek help in various areas of health care without receiving appropriate treatment, they are financially burdening the system superfluously. In absence of a proven cure or uniformly effective treatment, tinnitus are is often fragmentised and costly.
As for most health problems in the Dutch population, the general practitioner is the initial professional to consult for patients with tinnitus. In most cases, within six months after onset of subjective tinnitus the individual consults his general practitioner, but one quarter of the respondents wait several years until they seek help. In the official Dutch general practitioner patient information letter on tinnitus, it is stated that there is not much that can be done to alleviate complaints. Another frequently consulted specialist is the ENT physician. Treatment possibilities include removal of cerumen, medication, and audiological rehabilitation. Generally, the effects of these treatments are disappointing.
A recent study by El Refaie et al (2004) shows that functional and social handicap in tinnitus sufferers is significantly reduced, and quality of life improves significantly, as a result of attendance at a specialised tinnitus clinic. Specialised clinics for chronic disorders such as tinnitus and chronic pain have been proven to be most effective in treatment. Similarities between tinnitus and chronic pain in terms of cognitive and behavioural mechanisms have been suggested recently and a similar treatment could be effective for the tinnitus population. As in chronic pain, multidisciplinary specialised treatment is more effective in ameliorating severe tinnitus complaints than monodisciplinary treatments. A retrospective pilot study, by the applicants of this proposal, in the Tinnitus Centre Limburg (TCL) shows significant improvements in 71% of the patients. Intrusiveness of the tinnitus ameliorates in 85% of the subjects and 78% experiences improvement in emotional distress caused by the tinnitus.
The objective of this study is to examine the effectiveness, costs and cost effectiveness of a comprehensive multidisciplinary treatment provided by a specialised tinnitus centre. Treatment is based on a stepped care approach, tailored to individual needs, with key elements from cognitive behavioural therapy, education, relaxation techniques, attention diversion, exposure in daily live situations, and tinnitus retraining therapy.
The following research questions were formulated:
1. What are the effects on generic quality of life of comprehensive specialized tinnitus care as provided by a specialised tinnitus centre, as compared to usual care?
2. What are the effects on health, in terms of negative affect, tinnitus beliefs, fear of the tinnitus, and tinnitus annoyance, of comprehensive specialized tinnitus care as provided by a specialised tinnitus centre, as compared to usual care?
3. What are the costs to health care and to society of treatment provided by a specialised tinnitus centre in the Dutch health care system as compared to usual care?
4. What is the cost effectiveness of treatment provided by a specialised tinnitus centre in the Dutch health care system as compared to usual care?
This study will provide information on whether a comprehensive, multidisciplinary treatment is more effective and efficient care for tinnitus patients. The results will also show whether the specialised treatment improves quality of life and patient satisfaction. If the intervention is proven to be effective, implementation of the intervention is considered and anticipated. First results are not expected before the beginning of 2010.
Trial Registration The trial has been registered at ClinicalTrial.gov. The trial registration number is NCT00733044.
