The decision aid for tinnitus – reviewing its use

Dr Helen Pryce, Audiology Department, Aston University assesses whether the decision aid for tinnitus is helping patients. 

Two people have tinnitus. It sounds like a high-pitched whistle to both of them. They are both disturbed at night and find it difficult when they come home after a long day to a quiet house. These two people seek help from their GPs and are referred to their local audiology clinics. Their audiologist assesses the loudness and sound of their tinnitus and checks them out for other hearing problems. All else is well and now it’s time to decide what to do next.  

One of our two people is a busy mother of four. She works and is dependent on childcare as her partner is frequently away working. The other is a young man who lives alone. He works a busy job and enjoys socialising in the evening.  

Our audiologist has read all the correct guidelines and prescribes them both a course of Cognitive Behavioural Therapy (CBT) to improve their coping with the tinnitus. The young man is delighted by the suggestion of a CBT group. He attends every session and finds it very helpful. The busy mother attends reluctantly, having made copious arrangements. She is often late arriving and has to shoot off swiftly at the end to get back to her family. Eventually she stops attending and concludes that there is nothing that can help her.   

This is the risk when audiologists prescribe care without involving their patients fully in deciding what will be best for them. What is best depends on more than average efficacy of treatment. It depends on what fits someone’s values, preferences and life. The truth is that there is always more than one thing that can be done, including doing nothing.  

To help with this, we developed a decision aid for tinnitus.  

Decision aids help clinicians and patients to work together to decide what will suit someone best. They comprise summaries of evidence-based treatment options with pros and cons described through the frequently asked questions that people have. They can prompt a discussion about the potential for treatments, alongside a targeted discussion on the way these services are accessed locally. Through these conversations, clinicians and patients can be clear about the relative burdens and advantages of each treatment, or, indeed, of doing nothing.   

But does it work? 

We wanted to see whether the introduction of the tinnitus decision aid would improve decision-making in tinnitus care.  We recruited a number of clinical sites across England and Wales to introduce the decision aid and record changes in the level of decisional satisfaction that their patients experienced.  

The clinical sites that agreed to be involved in individual evaluations of their service both with and without using the decision aid as part of their shared decision-making process. We did not ask the sites to alter their usual care in any way other than to use the decision aid with their patients.  

The sites involved represented rural, urban and suburban communities in both affluent and less affluent communities in England and Wales. Each site introduced the decisional conflict scale. This is a well-validated measure of the components of the decisions we make, including how informed we feel, how the decision matches our values, how supported we are in our decision, how effective we see the decision as being and how confident we are in our decision. 

Four sites have completed a service evaluation. They completed the decisional conflict scales with between 10-30 consecutive patients as a baseline and then introduced the decision aid and repeated with a further consecutive 10-30 patients. We analysed their results and looked at the comparison between no decisional conflict (however low the score) and any decisional conflict. Here are the results: 

The risks of tinnitus patients experiencing decisional conflict were calculated. Patients using the decision aid showed a lower risk of experiencing decisional conflict.  

This decrease in risk means that for around every seven people who are given the decision aid as part of their decision-making, one additional person will have no decisional conflict as a result. Given that this is a low-cost intervention (it’s a piece of paper) this suggests that there is huge potential to improve tinnitus services through introducing the decision aid for tinnitus across further services. In addition, there are further reductions in decisional conflict across the various component parts of the aid.  

Conclusion

Our decision aid appears to impact the decisional conflict experienced by patients. These service evaluations are a great starting point for examining the potential of the decision aid to improve communication between audiologists and patients. It is important to acknowledge that these are results of service evaluation not research. Patients were seen as usual in their clinics and not randomised or blinded to receiving the decision aid or not. Nonetheless, early adopter services such as these are likely to be those with more motivation to improving shared decision-making and so we might have expected a smaller effect of introducing the decision aid in addition.  

We continue to work with further services in assessing the impact of the introduction of the decision aid. Why not check whether your local service has introduced the decision aid and has measured the impact of this?