Willingness to Accept and Pay for Implantable Tinnitus Treatments: A Survey

State of the art: non-invasive electrical stimulation for the treatment of chronic tinnitus

Subjective tinnitus is the perception of sound in the absence of external stimulation. Neuromodulation is a novel method with promising properties for application in tinnitus management. This study sought to review the types of non-invasive electrical stimulation in tinnitus to provide the foothold for further research. PubMed, EMBASE, and Cochrane databases were searched for studies on the modulation of tinnitus by non-invasive electrical stimulation. Among the four forms of non-invasive electrical modulation, transcranial direct current stimulation, transcranial random noise stimulation, and transauricular vagus nerve stimulation yielded promising results, whereas the effect of transcranial alternating current stimulation in the treatment of tinnitus has not been confirmed. Non-invasive electrical stimulation can effectively suppress tinnitus perception in some patients. However, the heterogeneity in parameter settings leads to scattered and poorly replicated findings. Further high-quality studies are needed to identify optimal parameters to develop more acceptable protocols for tinnitus modulation.

Electrical stimulation of the cochlea for treatment of chronic disabling tinnitus: an open-label trial towards the development of an implantable device

Background

Chronic tinnitus affects millions of people globally and constitutes the most commonly compensated disability among military service members in the United States. Existing treatment options largely surround helping patients cope with their disease as opposed to directly suppressing tinnitus perception. The current study investigated the efficacy of electrical stimulation of the cochlea on chronic disabling tinnitus.

Methods

In this single-arm, open-label clinical trial, 22 adult subjects with severe-range asymmetric or unilateral non-pulsatile tinnitus underwent electrical stimulation of the cochlea through use of an extra-cochlear electrode positioned on the cochlear promontory. Each subject underwent 3 stimulation treatments over 3 weeks at 7-day intervals. Tinnitus severity was determined by Tinnitus Handicap Inventory (THI), Tinnitus Functional Index (TFI), and Tinnitus Visual Analog Scale (VAS). Inclusion criteria required subjects have no worse than moderate sensorineural hearing loss determined by pre-enrollment audiometric testing. The primary outcome was nadir post-treatment THI scores, obtained at seven timepoints following electrical stimulation, with clinically significant improvement defined as a decrease of  ≥ 7.

Results

All 22 (100%) subjects experienced clinically significant improvement in the THI during the study period with a mean decrease in scores of − 31 (95% CI − 38 to − 25) from a baseline of 48. Twenty (91%) experienced clinically significant improvement detectable on at least two of the three tinnitus survey instruments and 17 (77%) experienced clinically significant improvement detectable on all three survey instruments (i.e., THI, TFI, and VAS). Eight (36%) subjects reported either complete (THI of 0; n  = 3) or near-complete (THI 1–4; n  = 5) suppression of their tinnitus following a stimulation session. Thirteen (59%) subjects reported a nadir following stimulation at or below the threshold for “no or slight handicap” on the THI (≤ 16). No adverse events were observed.

Conclusions

These findings establish the foundation for the development of an extra-cochlear implantable device that delivers electrical stimulation to the cochlea for the treatment of disabling tinnitus. For patients considering device implantation, trans-tympanic cochlear promontory stimulation can facilitate patient selection.

Trial Registration ClinicalTrials.gov Identifier: NCT03759834. URL: https://clinicaltrials.gov/ct2/show/NCT03759834

Supplementary Information

The online version contains supplementary material available at 10.1186/s12967-022-03271-4.

The Utility of Economic Measures to Quantify the Burden of Tinnitus in Affected Individuals: A Scoping Review

BACKGROUND AND OBJECTIVES

Tinnitus is a chronic subjective condition that impacts patients' health-related quality of life (HRQoL) and requires multidisciplinary interventions. In health economics, quality-adjusted life years (QALYs) and willingness to pay (WTP) are essential for evaluating treatment effectiveness in cost-effectiveness, cost-utility, or cost-benefit analysis. The extent to which these economic measures have been used in tinnitus research has not been investigated. The objectives of this scoping review were to explore findings and limitations of existing studies and provide an insight into how these economic measures could be used to quantify the burden of tinnitus in affected individuals.

METHODS

A scoping review was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) methodological framework. The search strategy involved four electronic databases. Records were included when QALYs or WTP were measured in individuals whose primary or secondary complaint was tinnitus.

RESULTS

A total of 15 studies were identified: three WTP assessment studies and 12 QALY assessment studies using direct preference-based measures (PBMs) (n = 4), indirect PBMs (n = 7), and a disease-specific psychometric instrument (n = 1). The limited use to date of PBMs to assess HRQoL in tinnitus patients is an important finding.

CONCLUSIONS

Further studies using reliable economic methods and focusing on patients' WTP for treatment or their preference for their current health state are needed. Applying PBMs in tinnitus research is crucial not only for the healthcare decision-making process but also to improve patient-centred care.

Survey of tinnitus patients' acceptance of high-definition transcranial direct current stimulation as a management option

OBJECTIVES

To investigate acceptance of high-definition transcranial direct current stimulation (HD-tDCS) as a management option for tinnitus.

DESIGN

Participants completed an online version of the Tinnitus Functional Index (TFI), after which they recorded their satisfaction ratings with different hypothetical intervention outcomes on a 10-point rating scale using Opinio survey software.

STUDY SAMPLE

Data from 272 tinnitus sufferers from English-speaking regions worldwide were collected, of which the majority had moderate to severe tinnitus as per TFI.

RESULTS

The survey showed that HD-tDCS was considered an acceptable form of tinnitus management, and that the satisfaction rating depended significantly on a number of factors: (1) the strength of the tinnitus reduction following the intervention (p < 0.001); 2) the duration of the intervention (p < 0.001); and (3) the effects of the intervention on either tinnitus loudness or tinnitus-related distress (p < 0.001). Respondents rated their satisfaction with the intervention 10/10 only if it completely eliminated tinnitus loudness, although reductions of 50-80% were also rated highly acceptable. No association was found between tinnitus severity and acceptability ratings.

CONCLUSIONS

These findings are important for future HD-tDCS trials for tinnitus, as they demonstrate the need to optimise stimulation protocols to increase effect sizes and decrease time spent on the treatment.

Sauver JL. Impact of Pharmacogenomic Information on Values of Care and Quality of Life Associated with Codeine and Tramadol-Related Adverse Drug Events

Objective

To assess the potential impact of Pharmacogenomic (PGx) variation in cytochrome P450 2D6 (CYP2D6) enzyme function, using loss in quality-adjusted life years (QALYs) associated with treatment problems, and the willingness to pay to avoid treatment problems from patients’ and payers’ perspectives.

Patients and Methods

The study included patients prescribed tramadol or codeine, or both, between January 1, 2005, and December 31, 2017. Demographic information and adverse drug events, including adverse drug events and poor pain control, were collected from the electronic health records using natural language processing techniques and review by trained abstractors. Patients’ willingness to pay and QALY estimates were based on comprehensive literature review. The CYP2D6 phenotypes were divided into 4 groups: ultra-rapid metabolizers, normal metabolizers, intermediate metabolizers, and poor metabolizers.

Results

Among the 2860 identified patients, 63 (2%) were ultrarapid metabolizers, 1449 (50%) were normal metabolizers, 1155 (40%) were intermediate metabolizers, and 193 (7%) were poor metabolizers. The patients’ average estimated willingness-to-pay value to avoid treatment problems was $23 per month; poor metabolizers developed problems with the highest estimated willingness-to-pay value ($32 per month). The mean QALY loss among all patients was 0.024 QALYs (8.8 healthy days); poor metabolizers had the highest loss (0.027 QALYs, 9.9 healthy days).

Conclusion

Patients with various phenotypes developed different treatment problem profiles. Poor CYP2D6 metabolizers developed problems with highest willingness to pay, and they might potentially benefit most from PGx-guided treatment and problem prevention.

The Cortisol Awakening Response: A Feasibility Study Investigating the Use of the Area Under the Curve With Respect to Increase as an Effective Objective Measure of Tinnitus Distress

Purpose Tinnitus is a chronic medical condition that can result in distress, concentration difficulties, and clinical depression. An effective, objective measure of tinnitus distress does not currently exist. Endocrinal studies into the condition have been few, with those investigating the cortisol awakening response limited in scope. It was hypothesized that distressed individuals with tinnitus would awaken and be unable to effectively prepare for the day ahead due to a blunted cortisol response. Method Twenty individuals with varying tinnitus distress were compared with a control group (n = 10) in a pilot study, which measured salivary cortisol concentrations on awakening. Multiple exclusion variables were applied. Results In line with previous studies, total cortisol volume (as measured by area under the curve) was not found to be significantly different in the most distressed individuals with tinnitus, F(2, 26) = 0.254, p = .777ns. However, a separate measure of changing cortisol levels-the area under the curve with respect to increase (or AUC_i)-was found to be significantly less robust in those individuals reporting the most severe tinnitus distress, F(2, 26) = 7.671, p = .002. This indicates that fewer resources would be available to cope with the demands of the day ahead. Additionally, the AUC_i correlated negatively with tinnitus distress later the same day. Conclusions Relationships between proposed objective and self-reported components of self-reported tinnitus distress are considered, with some aspects of tinnitus distress more closely related to physiological mechanisms than others. It is suggested that, with further research, the cortisol awakening response (AUC_i) may be put forward as a credible objective biomarker of tinnitus distress.

Patient Acceptance of Invasive Treatments for Tinnitus

PURPOSE

The field of neuromodulation is currently seeking to treat a wide range of disorders with various types of invasive devices. In recent years, several preclinical trials and case reports in humans have been published on their potential for chronic tinnitus. However, studies to obtain insight into patients' willingness to undergo these treatments are scarce. The aim of this survey study was to find out whether tinnitus patients are willing to undergo invasive neuromodulation when taking its risks, costs, and potential benefits into account.

METHOD

A Visual Analog Scale (VAS, 0-10) was used to measure the outcome. Spearman's rank-order correlation coefficients were computed to determine the correlation between patient characteristics and acceptance rates.

RESULTS

Around one fifth of the patients were reasonably willing to undergo invasive treatment (VAS 5-7), and around one fifth were fully willing to do so (VAS 8-10). Hearing aids, used as a control, were accepted most, followed by cochlear implantation, deep brain stimulation, and cortical stimulation. Acceptance rates were slightly higher when the chance of cure was higher. Patients with a history of attempted treatments were more eager than others to find a new treatment for tinnitus.

CONCLUSIONS

A considerable proportion of patients with tinnitus would accept a variety of invasive treatments despite the associated risks or costs. When clinical neuromodulatory studies for tinnitus are to be performed, particular attention should be given to obtaining informed consent, including explaining the potential risks and providing a realistic outcome expectation.

Evidence and evidence gaps in tinnitus therapy

A nearly endless number of procedures has been tried and in particular sold for the treatment of tinnitus, unfortunately they have not been evaluated appropriately in an evidence-based way. A causal therapy, omitting the tinnitus still does not exist, actually it cannot exist because of the various mechanisms of its origin. However or perhaps because of that, medical interventions appear and reappear like fashion trends that can never be proven by stable and reliable treatment success. This contribution will discuss and acknowledge all current therapeutic procedures and the existing or non-existing evidence will be assessed. Beside external evidence, the term of evidence also encompasses the internal evidence, i.e. the experience of the treating physician and the patient's needs shall be included. While there is no evidence for nearly all direct procedures that intend modulating or stimulating either the cochlea or specific cervical regions such as the auditory cortex, there are therapeutic procedures that are acknowledged in clinical practice and have achieved at least a certain degree of evidence and generate measurable effect sizes. Those are in particular habituation therapy and psychotherapeutic measures, especially if they are combined with concrete measures for improved audio perception (hearing aids, CI, hearing therapies).

Cost-Benefit Analysis of an Otolaryngology Emergency Room Using a Contingent Valuation Approach

OBJECTIVES

Dedicated otolaryngology emergency rooms (ERs) provide a unique mechanism of health care delivery. Relative costs and willingness to pay (WTP) for these services have not been studied. This study aims to provide a cost-benefit analysis of otolaryngology-specific ER care.

STUDY DESIGN

Cost-benefit analysis based on contingent valuation surveys.

SETTING

An otolaryngology-specific ER in a tertiary care academic medical center.

SUBJECTS AND METHODS

Adult English-speaking patients presenting to an otolaryngology ER were included. WTP questions were used to assess patient valuations of specialty emergency care. Sociodemographic data, income, and self-reported levels of distress were assessed. State-level and institution-specific historical cost data were merged with WTP data within a cost-benefit analysis framework.

RESULTS

The response rate was 75.6%, and 199 patients were included in the final analysis. Average WTP for otolaryngology ER services was $319 greater than for a general ER (95% CI: $261 to $377), with a median value of $200. The historical mean cost per visit at a general ER was $575, and mean cost at the specialty ER was $551 (95% CI: $529 to $574). Subtracting incremental cost from incremental WTP yielded a net benefit of $343.

CONCLUSION

Dedicated otolaryngology ER services are valued by patients for acute otolaryngologic problems and have a net benefit of $343 per patient visit. They appear to be a cost-beneficial method for addressing acute otolaryngologic conditions. This study has implications for ER-based otolaryngologic care and direct-to-specialist services.

Acupuncture as a Treatment Option in Treating Posttraumatic Stress Disorder-Related Tinnitus in War Veterans: A Case Presentation

Although close associations between tinnitus and posttraumatic stress disorder (PTSD) among war veterans has been documented, there is limited research that explores evidence-based, efficacious interventions to treat the condition in this particular population. This article presents a case of three war veterans with PTSD symptoms who received a series of acupuncture treatments for tinnitus with positive outcomes. Even though the article presents cases of only three veterans and was based on self-reports, there were very clear trends on how veterans with tinnitus symptoms responded to acupuncture treatments. Information generated from this case presentation is a good starting place in exploring evidence-based approaches in treating tinnitus symptoms in war veterans with PTSD.

Cost of care for subjective tinnitus in relation to patient satisfaction

OBJECTIVE

A consistent management algorithm for subjective tinnitus remains to be elucidated. Chronic tinnitus yields approximately US$2110 in annual health care costs per patient. However, it is unclear whether spending more in the management of tinnitus equates with greater patient satisfaction. Thus, the aim of this study is to correlate patient satisfaction with patient demographics, provider recommendations, and total health care-related expenditures.

STUDY DESIGN

A retrospective chart review and a patient satisfaction questionnaire.

SETTING

All data were collected from a large Midwestern hospital.

SUBJECTS AND METHODS

Patients were included who presented to the tinnitus clinic during the year 2011 and were between the ages of 18 and 89 years. They were excluded with diagnoses of Ménière's disease, pulsatile tinnitus, acoustic neuromas, or autoimmune inner ear diseases. The retrospective data and satisfaction surveys were entered by 3 of the authors. Responses were based on Likert scales.

RESULTS

Of the 692 patients included, 230 completed and returned the satisfaction questionnaire (33.2% response rate), yielding an overall mean of $662.60 charges. The frequency of intervention recommendations per patients ranged from 0 to 13, with a median of 4. Spearman's correlations did not result in significant correlations between patient satisfaction and number of clinic visits (P=.499) or associated charges (P=.453).

CONCLUSION

Given that the variability among provider recommendations, the high overall mean of tinnitus-related charges, and patient satisfaction was not related to costs, further research is needed examining patient preference in the treatment of tinnitus.