A qualitative study of implementation and adaptations to Progressive Tinnitus Management (PTM) delivery

History of Tinnitus Research at the VA National Center for Rehabilitative Auditory Research (NCRAR), 1997-2021: Studies and Key Findings

The Veterans Affairs (VA) Rehabilitation Research & Development (RR&D) National Center for Rehabilitative Auditory Research (NCRAR) was first funded by the RR&D Service in 1997 and has been funded continuously since that time. The overall purpose of the NCRAR is to "improve the quality of life of Veterans and others with hearing and balance problems through clinical research, technology development, and education that leads to better patient care" ( www.ncrar.research.va.gov ). An important component of the research conducted at the NCRAR has been a focus on clinical and rehabilitative aspects of tinnitus. Multiple investigators have received grants to conduct tinnitus research and the present article provides an overview of this research from the NCRAR's inception through 2021.

A Qualitative Study of Veterans' Perspectives on Tinnitus: An Invisible Wound

PURPOSE

Tinnitus is highly prevalent among U.S. military Veterans, yet referral to, and use of, tinnitus rehabilitation services to improve quality of life and functional status with tinnitus is low. Veterans with tinnitus often have other health issues that overlap or exacerbate the impact of tinnitus, potentially complicating referral and rehabilitative pathways. This qualitative study explores views on the daily impacts of tinnitus and experiences with tinnitus-related health care among Veterans. The goal of this research is to amplify the voices of Veterans regarding their experiences with tinnitus to illuminate the physiological and socioemotional sequelae associated with the condition and to increase clinician awareness of the complex, interdisciplinary rehabilitative needs among Veterans with bothersome tinnitus.

METHOD

This qualitative study was part of a larger study about tinnitus and traumatic brain injury (TBI). Veterans were sampled to represent national Department of Veterans Affairs (VA) users with and without comorbid TBI, and who were or were not interested in tinnitus rehabilitation services. Forty Veterans with tinnitus were interviewed (32 men, eight women). Data were analyzed using a modified grounded theory approach.

RESULTS

Major themes across the Veteran interviews included (a) functional effects of tinnitus on daily life, (b) tinnitus and other health conditions, (c) reactions to the lack of a cure for tinnitus, (d) strategies to improve quality of life and function, and (e) use of VA services for tinnitus.

CONCLUSIONS

Our findings highlight that bothersome tinnitus negatively impacted various aspects of daily functioning, including communication, sleep, concentration, and mood, suggesting a need for audiologists to work closely with mental health services to improve quality of life and functional status for those negatively impacted by the condition. Future work is needed to obtain the viewpoints of clinicians and other health care partners to better understand the barriers and facilitators to providing evidence-based tinnitus treatment in VA and non-VA settings.

A scoping review of applications of the Consolidated Framework for Implementation Research (CFIR) to telehealth service implementation initiatives

BACKGROUND

The Consolidated Framework for Implementation Research (CFIR), introduced in 2009, has the potential to provide a comprehensive understanding of the determinants of implementation-effectiveness of health service innovations. Although the CFIR has been increasingly used in recent years to examine factors influencing telehealth implementation, no comprehensive reviews currently exist on the scope of knowledge gained exclusively from applications of the CFIR to telehealth implementation initiatives. This review sought to address this gap.

METHODS

PRISMA-ScR criteria were used to inform a scoping review of the literature. Five academic databases (PUBMED, PROQUEST, SCIDIRECT, CINAHL, and WoS) were searched for eligible sources of evidence from 01.01.2010 through 12.31.2021. The initial search yielded a total of 18,388 records, of which, 64 peer-reviewed articles met the inclusion criteria for the review. Included articles were reviewed in full to extract data, and data collected were synthesized to address the review questions.

RESULTS

Most included articles were published during or after 2020 (64%), and a majority (77%) were qualitative or mixed-method studies seeking to understand barriers or facilitators to telehealth implementation using the CFIR. There were few comparative- or implementation-effectiveness studies containing outcome measures (5%). The database search however, revealed a growing number of protocols for implementation-effectiveness studies published since 2020. Most articles (91%) reported the CFIR Inner Setting domain (e.g., leadership engagement) to have a predominant influence over telehealth implementation success. By comparison, few articles (14%) reported the CFIR Outer Setting domain (e.g., telehealth policies) to have notable influence. While more (63%) telehealth initiatives were focused on specialty (vs primary) care, a vast majority (78%) were focused on clinical practice over medical education, healthcare administration, or population health.

CONCLUSIONS

Organized provider groups have historically paid considerable attention to advocating for telehealth policy (Outer Setting) reform. However, results suggest that for effective telehealth implementation, provider groups need to refocus their efforts on educating individual providers on the complex inter-relationships between Inner Setting constructs and telehealth implementation-effectiveness. On a separate note, the growth in implementation-effectiveness study protocols since 2020, suggests that additional outcome measures may soon be available, to provide a more nuanced understanding of the determinants of effective telehealth implementation based on the CFIR domains and constructs.

Implementation Science: Increasing the Public Health Impact of Audiology Research

PURPOSE

Implementation science aims to facilitate the use of evidence-based programs, practices, and policies in routine care settings. In audiology, as in other health disciplines, there is a persistent research-to-practice gap. Improving the adoption, reach, implementation, and sustainment of effective interventions in audiology would increase their public health impact, ensuring that all individuals needing hearing health care services could benefit from innovations and evidence-based best practices. This tutorial provides an introductory overview of implementation science relevant to the field of audiology, including Internet-based practices and interventions.

METHOD

Major concepts and themes of implementation science are presented, including implementation outcomes, implementation science frameworks, implementation strategies, current topics in implementation science, and study design considerations. Recent publications in audiology are highlighted to illustrate implementation science concepts and themes. The relevance of each topic to the use of evidence-based programs, practices, and policies in audiology is highlighted with reference to recent research in the field.

CONCLUSIONS

Challenges in the widespread delivery of evidence-based audiological practices and interventions limit their public health impact. The application of implementation science principles and methods in audiology research, as demonstrated in other areas of health research, can increase our focus on ensuring that effective practices are widely available, accessible, equitable, and sustainable to improve the lives of those who need them.

Implementation Science Research in Communication Sciences and Disorders: A Scoping Review

PURPOSE

The purpose of this study was to complete a scoping review of implementation science (IS) research in communication sciences and disorders (CSD) over time and to determine characteristics of IS research in CSD.

METHOD

A scoping review was conducted of PubMed and Education Resources Information Center for sources published in English that (a) included CSD practitioners, (b) addressed IS research, and (c) identified a specific evidence-based practice. Resulting sources were systematically examined for study aim, patient populations, implementation framework utilized, setting of the study, implementation strategy examined, and implementation outcome measured.

RESULTS

The majority of the 82 studies that underwent a full-text review (80.5%) were published in 2014 or later. One fourth of the studies were concept papers, and another one fourth focused on context assessment (25.6% of studies, each), 11% focused on designing implementation strategies, and 36.6% focused on testing implementation strategies. The patient population most frequently represented aphasia (21.3%), and most studies (34.4%) were conducted in inpatient medical settings. Nearly half (42.6%) of the nonconcept studies lacked an IS framework. Among implementation strategies identified, approximately one third of studies focused on education and/or training plus another strategy and one fourth focused on education and/or training alone. Implementation outcomes measured typically represented early stages of implementation.

CONCLUSIONS

This scoping review of IS research in CSD described the landscape of IS studies in CSD. IS is intersecting with CSD at a rapid rate, especially since 2014. Future IS research in CSD should adopt an implementation framework a priori and consider the broad range of implementation strategies and outcomes to support the uptake of research into typical practice settings.

Cognitive Behavioral Therapy for Tinnitus: Addressing the Controversy of Its Clinical Delivery by Audiologists

Audiologists' role in providing care for tinnitus typically includes conducting an audiologic evaluation, fitting hearing aids when appropriate, assessing the impact of tinnitus, and facilitating use of sound to improve quality of life with tinnitus when appropriate. Cognitive behavioral therapy (CBT) is consistently judged by systematic reviews as having the strongest evidence relative to other therapies for improving quality of life with tinnitus. Because audiologists are already playing an active role in providing care for tinnitus, and the relative paucity of behavioral health providers who are experienced in implementing CBT for tinnitus, a logical question is whether audiologists can provide CBT and whether it is within their scope of practice. In this article, we present both sides of the argument as to whether audiologists can provide CBT and we make recommendations for appropriate administration of CBT for tinnitus management.

Mental Health Symptoms Among Veteran VA Users by Tinnitus Severity:A Population-based Survey

INTRODUCTION

Tinnitus is prevalent among Service members and Veterans and is often comorbid with mental health disorders. Associations between the severity of individuals' tinnitus and mental health symptoms are not well described.

MATERIALS AND METHODS

We conducted a population-based survey of a stratified random sample of 1,800 Veterans diagnosed with tinnitus. We used the Tinnitus Functional Index to measure tinnitus severity and the Primary Care-Posttraumatic Stress Disorder (PTSD) screen and the Hospital Anxiety and Depression Scale to assess PTSD, depression, and anxiety. Descriptive statistics and bivariable and multivariable regression models were used to estimate associations between Veterans' tinnitus severity and mental health symptoms. Inverse probability weights were used to account for sample stratification and survey non-response. Multivariable odds ratios (ORs) and 95% confidence intervals (CIs) controlled for Veterans' demographics, military history, and health diagnoses.

RESULTS

A total of 891 Veterans completed surveys (adjusted response rate = 53%). Large proportions rated their tinnitus as severe (29.4%; 95% CI: 27.2-31.6) or very severe (18.7%; 95% CI: 16.8-20.5). In multivariable regression models, and compared with Veterans with none/mild tinnitus, the likelihood of screening positive for PTSD was increased for those who reported moderate (OR = 4.0; 95% CI: 1.6-10.3), severe (OR = 7.5; 95% CI: 3.1-18.5), or very severe (OR = 17.5; 95% CI: 4.4-70.0) tinnitus. Similarly, Veterans' likelihood of positive depression screens were elevated for those with moderate (OR = 2.6; 95% CI: 1.1-5.9), severe (OR = 3.0; 95% CI: 1.4-6.5), or very severe (OR = 15.5; 95% CI: 4.3-55.5) tinnitus, as was the likelihood of positive anxiety screens for those with severe (OR = 2.6; 95% CI: 1.1-6.3) or very severe (OR = 13.4; 95% CI: 4.0-44.3) tinnitus.

CONCLUSIONS

Mental health symptoms are strongly associated with Veterans' tinnitus severity. A better understanding of the interplay between these conditions may help improve the provision of interdisciplinary (Audiology and Mental Health) care for Service members and Veterans.

Factors affecting the implementation of evidence-based Progressive Tinnitus Management in Department of Veterans Affairs Medical Centers

PURPOSE

Progressive Tinnitus Management (PTM) is an evidence-based interdisciplinary stepped-care approach to improving quality of life for patients with tinnitus. PTM was endorsed by Department of Veterans Affairs (VA) Audiology leadership in 2009. Factors affecting implementation of PTM are unknown. We conducted a study to: 1) estimate levels of PTM program implementation in VA Audiology and Mental Health clinics across the country; and 2) identify barriers and facilitators to PTM implementation based on the experiences of VA audiologists and mental health providers.

METHOD

We conducted an anonymous, web-based survey targeting Audiology and Mental Health leaders at 144 major VA facilities. Quantitative analyses summarized respondents' facility characteristics and levels of program implementation (full PTM, partial PTM, or no PTM). Qualitative analyses identified themes in factors influencing the implementation of PTM across VA sites.

RESULTS

Surveys from 87 audiologists and 66 mental health clinicians revealed that few facilities offered full PTM; the majority offered partial or no PTM. Inductive analysis of the open-ended survey responses identified seven factors influencing implementation of PTM: 1) available resources, 2) service collaboration, 3) prioritization, 4) Veterans' preferences and needs, 5) clinician training, 6) awareness of (evidence-based) options, and 7) perceptions of scope of practice.

CONCLUSION

Results suggest wide variation in services provided, a need for greater engagement of mental health providers in tinnitus care, and an interest among both audiologists and mental health providers in receiving tinnitus-related training. Future research should address barriers to PTM implementation, including methods to: 1) improve understanding among mental health providers of their potential role in tinnitus management; 2) enhance coordination of tinnitus-related care between health care disciplines; and 3) collect empirical data on Veterans' need for and interest in PTM, including delivery by telehealth modalities.

Sense and Sensibility: A Review of the Behavioral Neuroscience of Tinnitus Sound Therapy and a New Typology

Tinnitus Sound Therapy is not a single strategy. It consists of many different sound types, targeting many different mechanisms. Therapies that use sound to cover, reduce attention to, or facilitate habituation of tinnitus are among the most common tinnitus treatment paradigms. Recent history has seen a proliferation of sound therapies, but they have each been criticized for having limited empirical support. In this review, Sound Therapy's modern history will be described, and a typology will be introduced and discussed in light of current behavioral neuroscience research. It will be argued that contributing factors to the limited evidence for the efficacy of Sound Therapy are its diversity, plural modes of action, and absence of a clear typology. Despite gaps in understanding the efficacy of sound's effects on tinnitus, there is compelling evidence for its multiple, but related, neurophysiological mechanisms. Evidence suggests that sound may reduce tinnitus through its presence, context, reaction, and potentially adaptation. This review provides insights into the neurocognitive basis of these tinnitus Sound Therapy modes. It concludes that a unifying classification is needed to secure and advance arguments in favor of Sound Therapy.

An Evaluation of a Continuing Education Workshop for Audiologists on the Assessment and Management of Tinnitus

INTRODUCTION

Tinnitus assessment and management is an important component of audiology. The benefits of continuing education (CE) workshops in the field of tinnitus have not been published. This study evaluated the outcomes of a workshop centered around a Sound Therapy and Aural Rehabilitation for Tinnitus (START) framework. Our hypotheses were that a CE workshop would (1) be useful, (2) improve clinician's knowledge and willingness to undertake tinnitus practice, and (3) result in learners using knowledge gained in their practice.

METHODS

Twenty-five participants attending a 3-day tinnitus workshop were invited to complete an evaluation immediately and 3 months after the workshop's completion. The workshop consisted of seminars and practical sessions. The pedagogical approaches employed were experiential (theory building, reflection, and testing) and community of practice (shared experiences).

RESULTS

Participants reported on a 5-point Likert scale (1 = not useful-5 = excellent) a high level of satisfaction both immediately after the workshop (ratings of usefulness: mean, 4.8; SD, 0.4; willingness to practice: 4.6; SD. 0.6; ability to manage: 4.6; SD, 0.5; all "excellent" ratings) and 3 months later (ratings of usefulness: mean, 4.2; SD, 0.9, "very useful;" willingness to practice: 4.6; SD, 0.6, "excellent;" ability to manage: 4.1; SD. 0.5, "very useful"). Open-ended questions indicated participants made changes in their practice that reflected material provided in the CE.

CONCLUSION

The workshop was successful in improving knowledge and confidence of audiologists in undertaking tinnitus assessment and management, but the need for ongoing support and supervision was a common theme.

Audiologists and Tinnitus

Purpose Although tinnitus is highly prevalent among patients receiving audiology services, audiologists are generally untrained in tinnitus management. Audiology graduate programs, as a rule, do not provide comprehensive instruction in tinnitus clinical care. Training programs that do exist are inconsistent in their recommendations. Furthermore, no standards exist to prevent the delivery of unvetted audiologic services, which can be expensive for patients. Patients seeking professional services by an audiologist, therefore, have no basis upon which to be assured they will receive research-based care. The purpose of this article is to describe the current status of tinnitus management services that exist within the general field of audiology and to suggest specific approaches for improving those services. Conclusion Audiologists may be in the best position to serve as the primary health care providers for patients experiencing tinnitus. Tinnitus care services by audiologists, however, must achieve a level of evidence-based standardization.

Soldiering on: a survey on the lived experience of tinnitus in aged military veterans in the UK

Tinnitus has long been interrogated as a medical conundrum, with little discourse between medicine and other disciplines. It involves the perception of sound in the ears or head without any external sound source, most likely a natural consequence of some form of hearing loss. For many people, tinnitus is bothersome and associated with various problems such as insomnia, difficulty concentrating and impaired listening ability. Nevertheless, with little attention from humanities or the social sciences, our understanding of the wider perspectives and psychosocial context of adults with tinnitus is limited, especially among UK military veterans. The aim of this study was to explore the impact of tinnitus on aged UK veterans, and to consider the support they receive and require to live well with tinnitus. In all, 120 aged UK veterans took part in this study. Data revealed similarities and differences between UK veteran and other study populations. For example, tinnitus symptom severity was higher in aged veterans than a general (younger) research population, particularly so on measures of intrusiveness and the effect of tinnitus on listening ability. Veterans had mixed views on social support. Many did not want to talk about tinnitus with others and/or did not want to burden their family, preferring to deal with their tinnitus 'backstage'. Others appreciated empathy or sympathy; many implied a desire that their family and/or friends could better understand their experience of living with tinnitus and the problems it caused them. These complexities support a need for cross-disciplinary work to understand and respond to tinnitus-related problems in veterans.

Lifeworld interpretation of tinnitus

Lifeworld-led care provides a route through which research and practice can navigate the 'biopsychosocial' allowing us to overcome the shortfalls of the medical model and enabling us to prioritise humanity in the care of people living with tinnitus. In this article, we sought to explore qualitative descriptions of life with tinnitus. We aimed to address the question 'what it is like to live with tinnitus?' In doing so we examined qualitative studies and provide suggestions about key themes that seem consistent. This is a narrative, thematic overview of the way lifeworld has been conceptualised and explored in tinnitus research.