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RRP 13-440 – HSR&D Study

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RRP 13-440
Progressive Tinnitus Management: An Assessment of Readiness
James A. Henry PhD
VA Portland Health Care System, Portland, OR
Portland, OR
Funding Period: October 2014 - September 2015

BACKGROUND/RATIONALE:
Military personnel are exposed to numerous hazards that are associated with tinnitus and hearing loss, including but not limited to blasts/explosions and sustained high levels of noise. In spite of the awareness about these potential exposures and increased efforts to use hearing protection in the field, a substantial number of military personnel still experience these auditory problems, which become significantly greater following military discharge. Tinnitus has been the most prevalent service-connected disability since fiscal year (FY) 2007. In FY 2015, 1,450,462 Veterans were service-connected for tinnitus. Despite the obvious need, our work has shown that VA clinical services for tinnitus are inconsistent across VA medical centers (VAMCs).

Over the last 20+ years, we have conducted research leading to the development and testing of a program called Progressive Tinnitus Management (PTM). PTM is a cross-disciplinary (Mental Health and Audiology) counseling/self-management program that has been shown in randomized, controlled studies to reduce symptoms and improve life satisfaction for tinnitus sufferers. Furthermore, we have shown that PTM can be successfully delivered using in-home telehealth technology, which greatly expands Veterans' access to effective tinnitus management services. VA Central Office has endorsed PTM as an effective intervention for tinnitus and has recommended its use at VAMCs. We have provided PTM training to hundreds of VA audiologists. Based on feedback from those audiologists, it is evident that PTM has been fully or partially implemented in some clinics but otherwise is not routinely offered. Consequently, most Veterans suffering from tinnitus do not have access to evidence-based tinnitus services. In partnership with the VA Offices of Audiology and Speech Pathology and Mental Health Services, and the former Polytrauma/Blast-related Injuries Quality Enhancement Research Initiative (QUERI), and in preparation for VA-wide dissemination of PTM, we conducted this study to examine current tinnitus practices, and provider- and systems-level contributors to this gap between evidence-based VA recommendations and actual practices.

OBJECTIVE(S):
The objectives of this study were to: (1) describe current tinnitus-management practices in VA Audiology and Mental Health (MH) programs across the country; (2) identify barriers and facilitators to PTM program implementation based on the experience of VA Audiology and MH clinics that have fully, partially, or not implemented PTM; and (3) determine readiness of VA Audiology and MH clinics, within VISN 20, to implement PTM. With this information, it is intended that a full implementation study (using a Hybrid III implementation/effectiveness design) of PTM will be designed and tested within VISN 20.

METHODS:
This mixed-methods study used a three-phased design to obtain information from VA audiologists and psychologists (those most aware of tinnitus practices at their site). Specifically, we: (Phase 1) surveyed clinicians at VAMCs nationwide regarding current provision of tinnitus clinical services, and implementation and sustainability of new programs such as PTM; (Phase 2) interviewed clinicians at VAMCs with full PTM, partial PTM, and no-PTM (based on survey results) regarding barriers and facilitators for full implementation of PTM; and (Phase 3) interviewed clinicians at most of the VISN 20 sites having an audiology clinic regarding site-specific barriers and facilitators to implementing and providing PTM, readiness to adopt PTM, and strategies for full PTM implementation.

FINDINGS/RESULTS:
Data collection is complete: Phase 1. We sent requests to each of 142 Audiology programs and 142 MH programs with instructions to complete the online survey, and received 87 responses from audiologists and 66 responses from MH providers. Results showed that: available tinnitus services vary widely from site to site; audiologists show higher levels of readiness to provide tinnitus services than MH providers; and 90% of audiologists and 66% of MH providers responding would be interested in receiving training in tinnitus management. Phase 2. Interviews were completed with five audiologists (3 of 5 were Audiology chiefs) and two MH providers (1 was a MH chief), to determine barriers and facilitators to providing PTM in selected VA clinics nationwide. Phase 3. We conducted interviews with 15 audiologists and six MH providers within VISN 20 to determine readiness of clinics to implement PTM. Phase 2 and 3 interviews showed that PTM implementation barriers include audio-visual technology and room scheduling issues, as well as lack of: collaboration and co-location between MH and Audiology, administrative time/support, group facilitator skills, available PTM materials, and empirical data supporting the need for, and interest in, PTM among Veterans. Sites with comprehensive TBI/polytrauma services endorsed greater awareness of tinnitus and readiness to implement PTM.

IMPACT:
This research will contribute to the advancement of science improving access and self-management of chronic conditions, such as tinnitus, among Veterans. The short-term goal is to identify barriers to implementation of PTM in VA clinics. The long-term goal is to implement PTM in a way that will increase and ensure patient access and ultimately reduce the burden of tinnitus among Veterans. Our Vision is to Provide Access to Tinnitus Services for every Veteran in need. PTM can be administered via multiple modalities, enabling access to effective tinnitus services for Veterans everywhere. PTM is normally implemented in the clinic, and all patients initially receive an audiologic assessment. For patients who require tinnitus-specific intervention, that intervention can be provided via telehealth. We have in fact completed two studies demonstrating the efficacy of telephone-based PTM. We have also become aware of some VA clinicians implementing PTM using Clinical Video Telehealth at VA sites of care. Future implementation efforts must address the barriers identified in this pre-implementation study, particularly the need for empirical data, updated PTM materials, and awareness of tinnitus and the interdisciplinary nature of PTM among MH providers. The use of telehealth options may help overcome location challenges such as shortages of meeting space or lack of co-location between MH and Audiology.

PUBLICATIONS:

Journal Articles

  1. Henry JA, Thielman EJ, Zaugg TL, Kaelin C, McMillan GP, Schmidt CJ, Myers PJ, Carlson KF. Telephone-Based Progressive Tinnitus Management for Persons With and Without Traumatic Brain Injury: A Randomized Controlled Trial. Ear and Hearing. 2019 Mar 1; 40(2):227-242.
  2. Tuepker A, Elnitsky C, Newell S, Zaugg T, Henry JA. A qualitative study of implementation and adaptations to Progressive Tinnitus Management (PTM) delivery. PLoS ONE. 2018 May 16; 13(5):e0196105.
  3. Henry JA. "Measurement" of Tinnitus. Otology & neurotology : official publication of the American Otological Society, American Neurotology Society [and] European Academy of Otology and Neurotology. 2016 Sep 1; 37(8):e276-85.
  4. Henry JA, Griest S, Austin D, Helt W, Gordon J, Thielman E, Theodoroff SM, Lewis MS, Blankenship C, Zaugg TL, Carlson K. Tinnitus Screener: Results From the First 100 Participants in an Epidemiology Study. American Journal of Audiology. 2016 Jun 1; 25(2):153-60.
  5. Alamgir H, Turner CA, Wong NJ, Cooper SP, Betancourt JA, Henry J, Senchak AJ, Hammill TL, Packer MD. The impact of hearing impairment and noise-induced hearing injury on quality of life in the active-duty military population: challenges to the study of this issue. Mil Med Res. 2016 Apr 12; 3:11.
  6. Henry JA, Griest S, Thielman E, McMillan G, Kaelin C, Carlson KF. Tinnitus Functional Index: Development, validation, outcomes research, and clinical application. Hearing Research. 2016 Apr 1; 334:58-64.
Center Products

  1. Henry JA, Carlson KF, Elnitsky C, Kaelin C, Thielman E, Tuepker A, Zaugg T. Implementation of Progressive Tinnitus Management – An Assessment of Readiness: Summary of Audiology and Mental Health Clinician Survey Results. Telephone presentation to DoD Hearing Center of Excellence. 2015 Jul 7.
Conference Presentations

  1. Henry JA. Evidence-Based Methods of Tinnitus Management. Paper presented at: America-China Tinnitus Advanced Seminar; 2016 Sep 30; Sichuan, China.
  2. Blankenship C, Carlson KF, Henry JA. Revised 'Tinnitus Screener': Results from First 200 Participants in Epidemiology Study. Paper presented at: Military Health System Research Symposium; 2016 Aug 15; Orlando, FL.
  3. Carlson KF, Henry JA, Reavis K, Griest S, Blankenship C, Theodoroff SM, Lewis MS, Helt W, Gordon J, Austin D, Thielman E. Differential Characteristics of Tinnitus among Recent Veterans by Traumatic Brain Injury and Blast Exposure History. Paper presented at: Military Health System Research Symposium; 2016 Aug 15; Orlando, FL.
  4. Carlson KF, Thielman E, Zaugg T, Elnitsky C, Tuepker A, Kaelin C, Henry JA. Factors Affecting the Provision of Evidence-based Progressive Tinnitus Management in Department of Veterans Affairs Medical Centers. Presented at: AcademyHealth Annual Research Meeting; 2016 Jun 27; Boston, MA.
  5. Henry JA, Esquivel C, Moring J, Hecht Q. Tinnitus Updates - Published and Ongoing Research, Remaining Gaps. Presented at: Department of Defense Hearing Center of Excellence Collaborative Auditory and Vestibular Research Network Meeting; 2016 May 18; Fort Rucker, AL.
  6. Henry JA, Esquivel C, Moring J, Hecht Q. Tinnitus Updates - Published and Ongoing Research, Remaining Gaps. Paper presented at: Collaborative Auditory and Vestibular Research Network Annual Meeting; 2016 May 18; Ft. Rucker, AL.
  7. Henry JA. VA Tinnitus Research: Helping Veterans. Poster session presented at: VA Portland Health Care System Annual Research Day; 2016 May 6; Portland, OR.
  8. Henry JA. VA Tinnitus Research: Helping Veterans. Paper presented at: VA Portland Health Care System Annual Research Day; 2016 May 5; Portland, OR.
  9. Henry JA. Scientific Evidence Regarding Tinnitus Treatment Using Multiple Hearing Devices. Paper presented at: Phonak Government Services Training Academy Training Session; 2016 Feb 25; St Louis, MO.
  10. Henry JA, Schmidt C, Edmonds K, Stidley JL. How to Implement Progressive Tinnitus Management in the Clinic. Paper presented at: Joint Defense / Veteran Audiology Annual Conference; 2016 Feb 24; St Louis, MO.
  11. Boudin A, Carlson KC, Elnitsky C, Esquivel C, Camou E, Thielman E, Henry JA. Online Surveys of Tinnitus Management Practices in VA and DoD: Results and Clinical Implications. Paper presented at: Joint Defense / Veteran Audiology Annual Conference; 2016 Feb 23; St Louis, MO.
  12. Boudin A, Carlson KF, Elnitsky C, Esquivel C, Camou E, Thielman E, Henry JA. Online Surveys of Tinnitus Management Practices in VA and DoD: Results and Clinical Implications. Presented at: Joint Defense / Veteran Audiology Annual Conference; 2016 Feb 23; St Louis, MO.
  13. Carlson KF, Thielman E, Zaugg TL, Elnitsky C, Tuepker A, Kaelin C, Henry JA. VA Clinician Surveys and Interviews Reveal Need for Increased Mental Health Involvement in Tinnitus Management. Presented at: Joint Defense / Veteran Audiology Annual Conference; 2016 Feb 23; St Louis, MO.
  14. Carlson KF, Tuepker A, Henry JA, Thielman E, Zaugg TL, Elnitsky C, Kaelin C. VA Clinician Surveys and Interviews Reveal Need for Increased Mental Health Involvement in Tinnitus Management. Paper presented at: Joint Defense / Veteran Audiology Annual Conference; 2016 Feb 23; St Louis, MO.
  15. Henry JA. Evidence-Based Tinnitus Management. Paper presented at: Starkey Hearing Innovation Expo; 2015 Dec 8; Las Vegas, NV.


DRA: Sensory Loss, Brain and Spinal Cord Injuries and Disorders
DRE: Treatment - Implementation
Keywords: QUERI Implementation
MeSH Terms: none