Hearing case studies

Systematic reviews represent the highest level of evidence for the effectiveness of clinical interventions and are critical in informing health policy and evidence-based practice.

One of the foremost organisations producing systematic reviews is Cochrane. This is a UK based charity that supervises a global independent network of clinicians, researchers, patient advocates and others.

In collaboration with Cochrane ENT, our Hearing Theme developed an innovative prioritisation process and successfully identified priority topics for Cochrane systematic reviews of interventions for subjective tinnitus. Those reviews address interventions where there are gaps in clinical knowledge and clinical practice is variable.

This means that resources needed for producing Cochrane systematic reviews are invested in work that is important for funders, guideline developers, clinicians and people with tinnitus. This work focused on UK clinical practice for tinnitus and therefore the relevant priority criteria were applied; such as availability of the intervention within the NHS and inclusion in the scope of the NICE tinnitus guideline.

The outcomes

• Topics for priority Cochrane reviews were identified. Three high priority reviews were recommended: sound therapy using amplification devices and/or sound generators; betahistine; Cognitive Behaviour Therapy (CBT). Further priorities were: Gingko biloba; anxiolytics; hypnotics; antiepileptics and neuromodulation.

• The scoping exercise has already resulted in the expedited production of two Cochrane systematic reviews: sound therapy and betahistine for tinnitus which directly informed the NICE guideline on tinnitus assessment and management, published in March 2020. A further priority review on CBT for tinnitus has been published.

• Two further reviews on neuromodulation and Gingko biloba for tinnitus are in progress.

• The lack of high quality research evidence for the effectiveness of sound therapy for tinnitus concluded by the Cochrane review resulted in development of consensus-based guidelines for fitting of combination hearing aids (combined amplification and sound generation) for subjects with tinnitus (https://www.thebsa.org.uk/wp-content/uploads/2020/03/OD104-88-BSA-Combination-aids-practice-guidance.pdf). Work that led to development of the guideline included UK-wide service evaluation, establishing clinical consensus among UK hearing professionals, patients’ survey and focus group.

The impact

• Priority Cochrane reviews directly informed tinnitus guidelines including NICE Tinnitus: Assessment and management guideline (https://www.nice.org.uk/guidance/ng155) and the British Society of Audiology Tinnitus Practice Guidance (Under review). The reviews influenced recommendations and future research directions.

• The prioritisation process can easily be adapted to a range of international, national or local settings and priorities and can be transferred to other conditions and types of systematic reviews. For example, regional or country-specific clinical practice can be taken into consideration as well as the national, regional or international guidelines (e.g. European or country-specific) when formulating the priority criteria.

• Cochrane reviews drive future research directions that would lead to providing high quality evidence for treatment options for tinnitus and improve current clinical practice. Two examples of research projects that aim to address those research priorities are: HUSH feasibility trial, exploring feasibility of conducting a multicentre randomised controlled trial of effectiveness of digital hearing aids for tinnitus, and optimisation of transcranial direct current stimulation for the treatment of tinnitus (a PhD project).

Priority setting

The hearing theme led on two of the three James Lind Alliance Priority Setting Partnerships (PSP) in ENT and Audiology, which cover two of the most prevalent and burdensome conditions affecting adults in the UK: Tinnitus (2013) and Mild-to-moderate Sensorineural Hearing Loss (2015).

By identifying the ‘top 10’ list of unanswered treatment and research priorities, these JLA PSPs have influenced:

• Prioritisation of new systematic reviews of amplification for tinnitus and for hearing loss by the Cochrane ENT group
• The NIHR Horizon Scanning Research and Intelligence Centre is to run a global search to identify emerging technologies to benefit people with mild-moderate hearing loss
• BSA Practice Guidance for Tinnitus in Children and Teenagers and for Rehabilitation of adults with hearing loss
• A pan- European working group (Core Outcome Measures in Tinnitus, COMiT, initiative) supported by an EU COST Action and chaired by Derek Hoare is producing a Core Outcome Set to create standards for selecting patient-reported outcome measures (PROMs) in a range of clinical trials of treatment efficacy
• Validation of a US-developed patient-reported outcome measure for tinnitus with recommendations to UK audiologists for modifications of its use.