Help-seeker satisfaction with diagnosis and treatment of tinnitus

Abstract

Objective

To examine help-seeker satisfaction with the first communication of a tinnitus diagnosis by a healthcare provider, whether help-seekers undertook treatment and how they rated this treatment.

Design

A survey design assessed tinnitus characteristics and distress, health status, help-seeking, diagnosis communication, treatment and patient satisfaction.

Study sample

A self-selected cohort and a population-based cohort.

Results

Satisfaction scores were examined against demographic, clinical factors, and type of healthcare provider. A total of 281 adults participated (median age 61.6, IQR = 10.8 years), 52.3% sought help for tinnitus and 22.4% received treatment. The most frequently seen healthcare providers were general practitioners (34.0%), audiologists (29.3%) and ear, nose and throat specialists (25.9%). About two-thirds (64.1%) of help-seekers were unsatisfied with the first communication of a tinnitus diagnosis they received, and 56.5% rated their first tinnitus treatment as poor. Help-seekers were significantly more satisfied with audiologists than other providers regarding the communication of the first tinnitus diagnosis. Higher tinnitus distress scores were significantly associated with lower patient satisfaction with communication of first tinnitus diagnosis. No other factors were associated with patient satisfaction.

Conclusion

There are significant communication barriers along the tinnitus clinical pathway. Identifying and addressing these barriers could improve patient satisfaction.

Keywords:

• Clinical pathway
• health professionals
• help-seeking
• patient expectations
• tinnitus

Introduction

The prevalence of chronic tinnitus is reported to be approximately 10–15% of the global population and increases to over 20% in older adults (Jarach et al., 2022). Tinnitus may be experienced as a range of internal sounds in the head or the ear(s), from ringing to roaring or clicking (Baguley et al., 2013). The risk factors for tinnitus include hearing loss, increasing age (Møller, 2011) and exposure to loud noise (Shargorodsky et al., 2010). Autoimmune and degenerative neural disorders, diabetes, generalised anxiety disorder and vascular disease have also been associated with prolonged tinnitus (Shargorodsky et al., 2010). Additionally, tinnitus can be a side effect of ototoxic medications and substances (Crummer & Hassan, 2004). Tinnitus can also be described as a neurological condition, whereby certain changes in the brain or auditory system may contribute to producing the tinnitus sound (Eggermont & Roberts, 2012). Tinnitus can affect quality of life (Henry et al., 2005), quality of sleep (Erlandsson, 2000; Lasisi & Gureje, 2011), concentration (Erlandsson & Hallberg, 2000) and mental health in those more severely affected (Stegeman et al., 2021). The number of people who report seeking help for tinnitus is much lower than the prevalence of tinnitus (Adams et al., 1999; Brown et al., 1990; Sindhusake et al., 2003).

Help-seeking can be described as both a part of illness behaviour and health behaviour (Cornally & McCarthy, 2011). A help-seeker can be defined as an individual who has recognised a health issue and believes that external intervention is required, and then actively seeks help (Cornally & McCarthy, 2011). For those seeking help, help-seeking can be considered as a problem-focused, planned behaviour involving an interpersonal interaction with a health professional (Cornally & McCarthy, 2011). Patient satisfaction is an assessment used to measure of the quality of services provided by health professionals (Goldstein et al., 2000; Verbeek, 2004), but currently there is not a universally accepted definition, or standard measurement of patient satisfaction in health research (Batbaatar et al., 2017). A review of patient satisfaction research found that the most significant influences on patient satisfaction were; the quality of health professional’s interpersonal skills, the competence of the health professional, the physical environment of the amenity (clinic or hospital), accessibility for the patient, continuity of care given to the patient, hospital characteristics and care outcomes (Batbaatar et al., 2017). Assessment of patient satisfaction can identify shortcomings (and benefits) and the potential improvements for patients (Goldstein et al., 2000; Verbeek, 2004). Given that the quality of healthcare providers’ interpersonal skills can impact on patient satisfaction, research suggests that using a positive approach when communicating about and diagnosing tinnitus is more likely to assist patients in coping with tinnitus (Beukes et al., 2021). These first or initial interactions with healthcare providers regarding tinnitus may impact on the patient’s healthcare journey (Marks et al., 2019). Tinnitus patients who had positive interactions with general practitioners reported that it helped them access support (45%), increase their understanding of tinnitus (31%) and reduced their anxiety (20%) (Wray, 2021). Patients who were negatively counselled on tinnitus, at either a primary or secondary clinical level, sought help again from another healthcare provider (McFerran et al., 2018). In another study, many participants reported being advised “nothing can be done” (80.3%), a common statement for being negatively counselled, and also reported being uninformed on where to find additional information about tinnitus (81.4%). This was reported after seeing either a general practitioner (43.5%), audiologist (70.4%), ENT specialist (70.0%), nurse (5.2%), having psychological support (11.7%) or not reported (8.0%) (Husain et al., 2018).

Each of these particular healthcare providers provide different services for patients with tinnitus along the tinnitus clinical pathway, and may have different clinical practice guidelines for tinnitus diagnosis and treatment. In primary care, GPs may provide explanations, physical assessments and referrals for secondary care to an ENT specialist or an audiologist (Henry et al., 2019); consultations with an audiologist do not require a referral in the Australian health system. Whereas audiologists can provide hearing assessments, education, counselling and tinnitus management, ENT and other specialists play an important role in considering whether tinnitus is a symptom of a serious medical condition, e.g. Meniere’s disease, acoustic neuroma (Henry et al., 2019). Referrals amongst these clinicians depend on local circumstances, including access to or availability of particular clinicians (Cima et al., 2020).

For those seeking medical help for tinnitus, it is recommended that a thorough medical history and a physical assessment should be performed by the treating healthcare professional to exclude the possibility of serious disorders, examination of potential hearing complications, and any other health conditions (Crummer & Hassan, 2004). In addition, treatment and management of tinnitus ideally should address the sound of, attention to and emotional reaction to the tinnitus (Kaltenbach, 2009).

Research on seeking help for tinnitus was recently reviewed by Carmody et al. (2023). Most research in this area to date has been on self-selected and clinical populations, and shows that the most frequently seen healthcare providers for tinnitus are general practitioners (GPs), ear, nose and throat (ENT) specialists and audiologists. There is also an indication that there is dissatisfaction with the services and treatments provided by these healthcare providers (Carmody et al., 2023). When help-seekers access specialised tinnitus clinics, they tend to be more satisfied and report more positive ratings of healthcare providers, services and treatments (Carmody et al., 2023). However, the majority of these studies did not use validated patient satisfaction surveys for diagnosis, services and treatments. Furthermore, few studies show the complete journey of help-seekers first seeking a diagnosis, whether or not they have treatment and if the treatment was effective (Carmody et al., 2023). For the studies that tested factors with patient satisfaction, the following factors were significantly associated with positive patient satisfaction; the type of clinic (whether audiology or ENT), sex of the patient, group status (whether previous patient or newer patient) and type of treatment provided (Carmody et al., 2023). Group status (whether previous patient or newer patient) was also found to significantly associated with reporting clinical shortcomings (dissatisfaction) with “tinnitus persists” from the previous patient group (Carmody et al., 2023).

The aim of this study is to examine help-seeker satisfaction with the first communication of a tinnitus diagnosis by a healthcare provider, whether help-seekers subsequently undertook treatment and how they rated this treatment.

Methods

Participants and study design

Two cohorts of adults (18 and over) with tinnitus were recruited for the study. The self-selected cohort (Cohort 1) of adults with tinnitus were recruited to capture information from those who are likely to have sought help for their tinnitus. Cohort 1 participants answered the recruitment correspondence to take part in the study and were more motivated to take part. A population-based cohort (Cohort 2) of adults with tinnitus was recruited from an existing population study on health and ageing, the Busselton Healthy Ageing Study (BHAS) to assess aspects of help-seeking and satisfaction at an adult population level.

Adults with tinnitus in the self-selected cohort (Cohort 1) were recruited during February to August 2011, through public advertisements in the metropolitan area of Perth, Western Australia. These advertisements stated the inclusion criteria for participation in the study, which were that the individual had to be over 18 years of age, be in good general health and able to respond affirmatively to the question: Have you experienced any prolonged ringing, buzzing, or other sounds in your ear(s) or head more than once a week lasting for 5 minutes or longer in the past year? (Dauman & Tyler, 1992). Following the advertisement and emails, 187 individuals indicated interest in participating in the study. These individuals were either emailed a website link to the survey or were sent a paper survey they could complete and return in a reply-paid envelope. Of the 187 respondents, 158 returned the surveys (84.4% response rate), eight of which were incomplete and not included in the analysis. A total of 150 completed surveys were used in this study.

The population-based cohort of adults with tinnitus (Cohort 2) was a subset of participants in the Busselton Healthy Ageing Study (BHAS). This study recruited from all residents on the electoral roll in the City of Busselton, Western Australia who were born between 1946 and 1964. They were invited to participate in a random order (James et al., 2013). The BHAS collected demographics, lifestyle, activity and environment, medical history, physical symptoms and quality of life from the participants through a series of surveys and attending the study centre in Busselton for up to four hours to provide a fasting blood sample and undergo comprehensive physical and cognitive assessments; for the full study protocol see James et al., (2013).

This present study utilised data from all the participants in the BHAS at the time of this study (n = 1004). Of these participants, 20.9% (n = 210) had presented with tinnitus. As part of a clinical history questionnaire they were asked: Have you experienced any prolonged ringing, buzzing, or other sounds in your ear(s) or head more than once a week lasting for 5 minutes or longer in the past year? (Dauman & Tyler, 1992). Ten of these 210 declined being invited to follow up survey; 200 participants were invited to participate in the present study. They were posted a letter of invitation to participate in this study, a copy of the study survey and a reply-paid envelope to return a consent form and the completed survey. A total of 131 individuals (65% response rate) completed and returned the survey between March to September 2012.

Ethics approval for the study was obtained from The University of Western Australia’s Human Research Ethics Committee. All participants were allocated unique identification numbers to ensure confidentiality.

Measures

The primary outcome measures for this study assessed satisfaction with the communication of the first tinnitus diagnosis, and satisfaction with first treatment, both using validated surveys the Patient Satisfaction with Communication and the Functional Assessment of Chronic Illness Therapy–Treatment Satisfaction-General. Furthermore, three surveys were used to assess tinnitus characteristics and help-seeking, tinnitus distress, and health status, the Tinnitus Sample Case History Questionnaire, Tinnitus Reaction Questionnaire and the Glasgow Health Status Inventory–all purpose. Only those who reported seeking help for tinnitus completed the Patient Satisfaction with Communication survey, and only those who reported having treatment after seeking help completed the Functional Assessment of Chronic Illness Therapy–Treatment Satisfaction-General survey.

Demographic information

Previous studies have reported higher rates of hearing loss in tinnitus populations (Sindhusake et al., 2003). Factors such as sex, age, number of clinic visits or treatments sought, tinnitus distress or severity, depression, type of specialist seen by patient, using different clinical groups (older versus newer patients) have been tested with patient satisfaction (Carmody et al., 2023). Help-seeking and treatment data was collected from participants including if they sought help, who they sought help from, if they had treatment, if they sought more than one treatment and if the treatment was effective.

The demographic information collected in this study included date of birth and sex. In this study the factors age, sex, cohort, tinnitus distress, help-seeking and healthcare provider seen for diagnosis (GP, ENT specialist or audiologist), treatment and healthcare provider seen (GP, ENT specialist or audiologist), health status, being on medication, self-reported hearing loss, self-reported anxiety and self-reported depression were tested with patient satisfaction of healthcare provider communication of diagnosis. Participants were asked if they sought help, who provided the diagnosis of tinnitus, whether they had treatment for tinnitus and who provided this treatment.

Tinnitus characteristics and clinical factors

The Tinnitus Sample Case History Questionnaire (TSCHQ) (Langguth et al., 2007) was developed and validated for the collection of medical history and tinnitus characteristics of the participants. The survey is not scored. To improve accessibility for participants, require less time to complete and to increase relevance for the study, the original list of 35 questions was reduced to 29, in line with adaptations by others (Kojima et al., 2017; Müller et al., 2016; Rademaker et al., 2021).

Tinnitus distress

The Tinnitus Reaction Questionnaire (TRQ) was used to assess the participant’s level of tinnitus distress. The TRQ contains 26 questions each with a 0 to 4 response scale to indicate the degree of distress of tinnitus in the past week (Wilson et al., 1991). The higher the total TRQ score the higher the distress attributed to the tinnitus. As a clinical guide, a TRQ score ≥17 has been used to indicate ‘clinical tinnitus’ (Vieira et al., 2011; Wilson et al., 1991). This classification of TRQ scores as adopted by this study, with those scoring less than 17 classified as ‘subclinical.’

Health status

The Glasgow Health Status Inventory–all purpose (GHSI) was used to collect information on the participant’s health status (Gatehouse et al., 1998). This inventory assesses self-perceived psychological, social and physical facets of wellbeing. The higher the total GHSI score, the better the participant’s self-rated health status.

Satisfaction with communication of diagnosis

The Patient Satisfaction with Communication (PSC) is a self-reported measure of patient’s satisfaction with the communication of diagnosis and contains three questions that allows a response, each with a rating scale (Gabrijel et al., 2008; Schofield et al., 2003). The Patient Satisfaction with Communication was adapted slightly for this study. A response of ‘not discussed’ was included, and the term ‘tinnitus’ replaced the term ‘cancer’. The third question was adapted slightly to include a measure of expectations: ‘How would you rate the way the aims of treatment were discussed with you?’ was changed to ‘How would you rate the way the aims and expectations of treatment were discussed with you?’

The PSC on the scale was collapsed into one of two responses: ‘high’ (excellent and good, scored 5 and 4 respectively) and ‘mid-to-low’ (satisfactory, inadequate, poor, and not discussed scored, 3, 2, 1, and 0 respectively). The mean of each of the three questions was calculated, and converted into binomial values, unsatisfied (PSC < 3) and satisfied (PSC ≥3) for some of the analyses.

Satisfaction with treatment

The Functional Assessment of Chronic Illness Therapy–Treatment Satisfaction-General (FACIT–TS-G) (Engebretson et al., 2020; Webster et al., 2003) is an 8-item scale used to measure satisfaction with tinnitus treatment, with higher scores indicating higher levels of patient satisfaction with treatment. Each item’s answer is based on a 5-point Likert scale. Scores from each item of the survey can be used individually (Engebretson et al., 2020). Item 8 ‘How do you rate this treatment overall?’ was used in this study for participants to score their satisfaction with their first treatment of tinnitus as ‘Poor’ (scored 0), ‘Fair’ (scored 1), ‘Good’ (scored 2), ‘Very good’ (scored 3) or ‘Excellent’ (scored 4) (Webster et al., 2003).

Statistical analysis

Descriptive statistics of the samples’ sociodemographic information and their scores on the different measures were calculated. All statistical calculations were performed using IBM SPSS v29. The two-sided threshold for statistical significance was set at p < 0.05. As the group numbers were low for those who received treatment for their tinnitus, satisfaction of treatment could not be tested against all factors. The analysis included only the ratings of the most commonly seen healthcare providers, i.e. GPs, ENT specialists and audiologists, and not the ratings for neurologist and other providers. Those who self-diagnosed their tinnitus (n = 8) were also not included in the analysis.

The cohorts were compared by demographic factors, and the following tinnitus characteristics: tinnitus as ringing, tinnitus (≤5 years or > 5 years), tinnitus occurrence (intermittent or permanent), tinnitus onset (gradual or abrupt), tinnitus loudness (1–5, low to high respectively), pitch of tinnitus (low, medium, high), whether loud noise worsens tinnitus, whether concentration affected by tinnitus, a diagnosis of Meniere’s disease, pain or discomfort from sound, difficulty tolerating sound, tinnitus affected by stress and tinnitus affected by tiredness.

For categorical data with more than two groups with continuous data, a one-way ANOVA was performed with effect size given in ω² (effect sizes given as small = 0.01; medium = 0.06; large = 0.14). To estimate how the mean of a variable (continuous data) changes according to the levels of two categorical variables a two-way ANOVA was performed with effect size given in partial η². Pearson’s chi-squared test of association was used to investigate categorical data with effect sizes given by the phi coefficient. For continuous data, the Spearman’s rank correlation coefficient was used as outliers were present in most of the continuous data and if the normality assumption was violated as indicated by the Shapiro–Wilk test (p < 0.05); effect sizes were given as r_s. Effects sizes (d) were calculated according to Cohen’s (1988) conventions: d < 0.2 indicates little to no difference, 0.2 ≤ d < 0.5 small difference, 0.5 ≤ d < 0.8 medium difference and d ≥ 0.8 large difference (Cohen, 1988).

Results

Demographic information, help-seeking, treatment and satisfaction

A total of 281 participants took part in the study, 150 in Cohort 1 (self-selected) and 131 in Cohort 2 (population sample) (Table 1). Participants had a median age of 61.6 (IQR = 10.8) years (Table 1). The median age and ratio of males to females of the participants was similar across the two samples, although approximately two thirds of the participants were males. Approximately half of participants reported seeking help, with about a quarter obtaining treatment, of whom close to 90% went on to seek more than one treatment. Of those who sought help, approximately 60% of participants reported dissatisfaction with their first diagnosis communication from a healthcare provider. Of those that had treatment given to them from the same healthcare provider, over half reported the treatment as poor (Table 1).

Table 1. General demographics, assessment of tinnitus and health, patient satisfaction of communication diagnosis from a healthcare provider and satisfaction of treatment.

Variable	Cohort 1		Cohort 2		Overall
	Median (IQR)		Median (IQR)		Median (IQR)
Age (years) (n = 265, range 23.6-86.9)^a	62.6 (14.8)		61.3 (7.6)		61.6 (10.8)
TRQ total score (range 0-80)	14.0 (22.0)		7.0 (13.0)		10.0 (21.0)
GHSI total score (range 16.67-88.89)	58.3 (19.5)		63.9 (13.9)		61.1 (18.1)
	%	n	%	n	%	n
Male^b	66.7	100	61.8	81	64.4	281
Female	32.0	48	38.2	50	34.8	98
Sought help	60.0	90	43.5	57	52.3	147
TRQ score classification
TRQ <17 (subclinical)	56.7	85	77.9	102	66.5	187
TRQ ≥17 (clinical)	43.3	65	22.1	29	33.5	94
Had treatment (of those that sought help)	30.0	27	10.5	6	22.4	33
Sought more than one treatment (of those that had reported having treatment)	92.6	25	66.7	4	87.8	29
Satisfied with first diagnosis^c (average rating ≥3)	33.8	27	39.2	20	35.9	47
Unsatisfied with first diagnosis^c (average rating <3)	66.3	53	60.8	31	64.1	84
Rated treatment as poor^c	60.0	12	33.3	1	56.5	13

Notes: ^aAge is at time of investigation; sixteen respondents in Cohort 1 did not provide date of birth. ^bThe sex of two participants in Cohort 1 was unknown. ^cSatisfaction rating based on general practitioners, ear, nose and throat specialists and audiologists only, neurologists, other and self-diagnoses excluded. Abbreviations: TRQ: tinnitus reaction questionnaire, GHSI: glasgow health status inventory–all purpose.

When comparing the two cohorts, the median Tinnitus Reaction Questionnaire (TRQ) total score for cohort 1 (median = 14.0, IQR = 22.0) was significantly higher than that for cohort 2 (median = 7.0, IQR = 13.0). The median Glasgow Health Status Inventory (GHSI) total score for cohort 1 (median = 58.3, IQR19.5) was significantly lower than that for cohort 2 (median = 63.9, IQR13.9) (see Supplementary Tables 1 and 2).

Table 2. Healthcare Providers seen by help-seekers for first diagnosis of tinnitus (counts and percentages) and Patient Satisfaction with Communication (PSC) scores (mean and standard deviation).

Healthcare Provider seen	Cohort 1		Cohort 2		Overall
	n (%)	PSC mean (SD)	n (%)	PSC mean (SD)	n (%)	PSC mean (SD)
GP	25 (27.8)	2.0 (1.2)	25 (43.9)	2.1 (1.5)	50 (34.0)	2.1 (1.4)
ENT specialist	30 (33.3)	1.9 (1.3)	8 (14.0)	2.0 (0.7)	38 (25.9)	1.9 (1.3)
Audiologist	25 (27.8)	2.8 (1.0)	18 (31.6)	2.6 (1.6)	43 (29.3)	2.7 (1.3)
Total^a	80 (100.0)	2.3 (1.5)	51 (100.0)	2.4 (1.5)	131 (100.0)	2.2 (1.3)

Notes: ^aNeurologists, Other and Self-diagnoses excluded: Neurologist cohort 1 n = 1, cohort 2 n = 2 (total n = 3), Other healthcare providers cohort 1 n = 3, cohort 2 n = 6 (total n = 8), Self-diagnosed cohort 1 n = 6, cohort 2 n = 2 (total n = 8).

Abbreviations: GP: General practitioner; ENT, Ear, nose and throat specialist; PSC: Patient satisfaction with communication.

The following factors were found to be significantly different between the cohorts: help-seeking, type of healthcare provider, had treatment, tinnitus occurrence (intermittent or permanent), TRQ score classification (subclinical or clinical), tinnitus onset (gradual or abrupt), pitch of tinnitus (low, medium, high), concentration affected by tinnitus, Meniere’s disease, tinnitus affected by stress and tinnitus affected by tiredness (see Supplementary Tables 2 and 3).

Table 3. Factors and their associations with Patient Satisfaction with Communication (unsatisfied or satisfied), analysed by the χ² test. The row percentages are shown to compare satisfaction by factor.

Variable	PSC Unsatisfied		PSC Satisfied		Chi square
	n	%	n	%	χ^2[1], p value, effect size
Type of healthcare provider
GP	35	70.0	15	30.0	6.628, 0.04, 0.23
ENT specialist	28	73.7	10	26.3
Audiologist	21	48.8	22	51.2
Cohort 1	53	66.3	27	33.8	0.404, 0.53, 0.06
Cohort 2	31	60.8	20	39.2
Sex – Male	56	66.7	28	33.3	1.00, 032, 0.09
Sex – Female	26	57.8	19	42.2
Hearing loss (self-reported)	56	64.4	31	35.6	0.07, 0.93, 0.00
No hearing loss (self-reported)	28	63.6	16	36.4
On medication (for a health issue)	42	68.1	26	38.2	0.342, 0.56, −0.05
Not on medication	42	66.7	21	33.3
Anxiety (self-reported)	30	68.2	14	31.8	0.360, 0.55, 0.05
No anxiety (self-reported)	54	62.1	33	37.9
Depression (self-reported)	32	69.6	14	30.4	0.758, 0.38, 0.08
No depression (self-reported)	52	61.2	33	38.8
TRQ score classification
TRQ <17 (subclinical)	44	57.1	33	42.9	3.955, 0.05, −0.17
TRQ ≥17 (clinical)	40	74.1	14	25.9

Note: The sex of two participants were missing. Satisfaction rating based on general practitioners, ear, nose and throat specialists and audiologists only. Abbreviations: GP: General practitioner; ENT: Ear, nose and throat specialist; TRQ: Tinnitus reaction questionnaire; PSC: Patient satisfaction with communication

Healthcare providers seen who provided first diagnosis of tinnitus

Participants who sought help were asked who they saw for their first diagnosis of tinnitus (Table 2). The most seen healthcare providers for first diagnosis of tinnitus were general practitioners (GPs), followed by audiologists and then ear, nose and throat (ENT) specialists. The mean score for satisfaction with diagnosis communication from GPs, ENT specialists and audiologists was 2.2 (SD 1.3) with the highest satisfaction scores for audiologists and lowest for ENT specialists (Table 2).

Satisfaction with communication of diagnosis for tinnitus

To determine if the Patient Satisfaction with Communication scores were significantly associated with the type of healthcare provider seen (either a GP, ENT specialist or audiologist), a one-way ANOVA was conducted using the average Patient Satisfaction with Communication scores. The Patient Satisfaction with Communication scores for GPs, ENT specialists and audiologists were significantly different (F[2, 128] = 4.267, p < .016, ω² = 0.05). A Tukey’s post-hoc analysis revealed that the satisfaction with audiologists was statistically greater (0.78, 95% CI [0.09, 1.48] p = .023) than with ENT specialists; no other group differences were statistically significant.

There were significant associations between Patient Satisfaction with Communication (unsatisfied or satisfied) and (i) the type of healthcare provider seen (χ²=6.628, p = 0.04), and (ii) TRQ score classification (subclinical or clinical) (χ²=3.955, p = 0.05) (Table 3). No significant associations were found between Patient Satisfaction with Communication (unsatisfied or satisfied) with the following variables: cohort, the participant’s sex, self-reported hearing loss, being on medication, self-reported anxiety and self-reported depression (Table 3).

A two-way ANOVA was performed to examine the effect of the type of healthcare provider (GP, ENT specialist or audiologist) and TRQ score classification (subclinical or clinical) with Patient Satisfaction with Communication scores. Residual analysis was performed to test for the assumptions of the two-way ANOVA. Outliers were assessed by inspection of a boxplot, normality was assessed using Shapiro-Wilk’s normality test for each cell of the design, and homogeneity of variances was assessed by Levene’s test. Residuals for ENT specialists TRQ score classification TRQ ≥17 (clinical), were not normally distributed according to Shapiro-Wilk’s normality test (p < 0.05), there were two outliers, and there was homogeneity of variances as assessed by Levene’s test was p = 0.527. As the results were the same for with and without outliers it was decided that the two-way ANOVA is robust enough and outliers would be included in the analysis.

There was no statistically significant interaction between type of healthcare provider (GP, ENT specialist or audiologist) and TRQ score classification (subclinical or clinical) for Patient Satisfaction with Communication scores F(2125) = 0.841, p = 0.434, partial η² = 0.013. Therefore, an analysis of the main effect for type of healthcare provider (GP, ENT specialist or audiologist) and TRQ score classification (subclinical or clinical) was performed. There was a statistically significant main effect of type of healthcare provider (GP, ENT specialist or audiologist), F(2125) = 4.299, p = 0.016, partial η² = 0.064. All pairwise comparisons were run where reported 95% confidence intervals and p-values are Bonferroni-adjusted. The unweighted marginal means for Patient Satisfaction with Communication scores were GP 1.99 ± 0.20, ENT specialist 1.93 ± 0.21 and audiologist 2.69 ± 0.20. The mean score for seeing an audiologist was significantly higher than the mean score for seeing a GP (mean difference Patient Satisfaction with Communication score 0.697, 95% CI [0.01-1.38], p = 0.009). The mean for score for seeing an audiologist was also significantly higher than the mean score for seeing an ENT specialist (mean difference Patient Satisfaction with Communication score 0.760, 95% CI [0.048-1.47], p = 0.046). The mean difference between seeing a GP and seeing an ENT specialist was not significant. There was no statistically significant main effect of TRQ score classification (subclinical or clinical) on Patient Satisfaction with Communication scores (F(1125) = 1.114, p = 0.293, partial η² = 0.009).

Patient Satisfaction with Communication average scores were tested with age, tinnitus distress (TRQ total score) and health status (GHSI total score) using Spearman’s rank correlation coefficient. No significant associations were found for Patient Satisfaction with Communication scores with age (r_s[125] = 0.05, p > 0.05), tinnitus distress (TRQ total score) (r_s[131] = −0.102, p > 0.05), and health status (GHSI total score) (r_s[131] = 0.096, p > 0.05).

Satisfaction rating of first treatment

The mean score for FACIT-TS-G Item 8, which measured mean satisfaction with treatment that was provided by the healthcare provider (separate from the diagnosis rating), was 0.78 (SD 1.1, range 0-4, n = 23); for Cohort 1 the mean satisfaction was 0.8 (SD 1.1, n = 20) and for Cohort 2 it was 1.0 (SD 1.0, n = 3) Table 4. (See Supplementary Table 4 for the types of treatments). Many of those who had treatment sought more than one treatment (87.8%, n = 29, see Table 1). As only a few help-seekers went on to have treatment, no further analysis was conducted on help-seekers’ satisfaction rating of treatment.

Table 4. FACIT-TS-G Item 8: overall satisfaction of treatment by healthcare provider and by cohort.

	Item 8 rating categories of treatment, n (%)
	Poor	Fair	Good	Very Good	Excellent	Total
Treatment rating by healthcare provider
GP	2 (100)	0	0	0	0	2
ENT specialist	2 (50)	0	1 (25)	0	1 (25)	4
Audiologist	9 (52.9)	4 (23.5)	4 (23.5)	0	0	17
Treatment rating by cohort
Cohort 1	12 (60)	3 (15)	4 (20)	0	1 (5)	20
Cohort 2	1 (33.3)	1 (33.3)	1 (33.3)	0	1 (33.3)	3
Total	13 (56.5)	4 (17.4)	5 (21.7)	0	1 (4.3)	23

Abbreviations: FACIT–TS-G: Functional assessment of chronic illness therapy–treatment satisfaction-general; GP: general practitioner; ENT: specialist, ear, nose and throat specialist.

Discussion

The purpose of this study was to examine the help-seeker satisfaction with healthcare provider’s first communication of a diagnosis of tinnitus, whether help-seekers undertook treatment and how they rated this treatment. The study found that the most frequently seen healthcare providers were general practitioners, ENT specialists, and audiologists, which agrees with previous reports (George & Kemp, 1991; Husain et al., 2018; McFerran et al., 2018; Naughton, 2004; Redmond, 2010; RNID, 2019; Sindhusake et al., 2003).

Specifically, the main findings of this study were that, (i) most help-seekers were unsatisfied with the first communication of a tinnitus diagnosis from a healthcare provider, (ii) the type of healthcare provider seen by the help-seeker may influence their satisfaction with the first communication of a tinnitus diagnosis, with the greatest satisfaction reported with audiologists, (iii) that those with clinically significant tinnitus were less likely to be satisfied with their diagnosis communication, (iv) only a small proportion of help-seekers had treatment, (v) that satisfaction with treatment is relatively poor, and (vi) most help-seekers who had treatment sought treatment again. None of the other factors examined were found to influence satisfaction with the communication related to the diagnosis. As noted, the sample size for those who had treatment was too small to analyse for factors that influenced this.

In this study, audiologists had significantly higher satisfaction ratings than GPs and ENT specialists. This supports previous findings that tinnitus patients’ generally have positive experiences with audiologists (Carmody et al., 2023; Goldstein et al., 2015; West, 1999). This may be related to the fact that tinnitus is strongly related to hearing, and that tinnitus plays a significantly greater role in the clinical activities of audiologists than it does for GPs and ENT specialists (Lee et al., 2022; Searchfield & Baguley, 2011; West, 1999). Those with tinnitus should be encouraged to consider seeking help from audiologists early in the help-seeking search; in many settings referrals from a GP are not needed to access an audiologist. Audiologists’ scope of practice for tinnitus includes assessing whether there are any indications that the tinnitus is related to another issue that needs the attention of a GP or an ENT specialist (Gander et al., 2011; McFerran et al., 2018; Sheppard et al., 2022).

The findings of the study indicate that help-seekers were generally unsatisfied with the first communication of a tinnitus diagnosis from healthcare providers, but they were more satisfied with the communication from audiologists compared to other providers. This finding supports previous research of patients reporting dissatisfaction when first seeking help for tinnitus (Carmody et al., 2023). Counselling plays a large role in the management of tinnitus, which may influence the satisfaction of help-seekers. Previous research has shown that help-seekers have reported negative counselling regarding their tinnitus from their healthcare provider in both primary and secondary care settings, for example being told that nothing can be done or that they had to learn to live with it (McFerran et al., 2018; Naughton, 2004; Redmond, 2010; Sanchez & Stephens, 2000).

Overall, by using two types of cohorts, this study adds to findings of previous research that the experience for help-seekers is predominately unsatisfying, with difficulties along the clinical pathway such as lack of access to information, referrals or treatment, with few help-seekers having treatment or treatment being ineffective (George & Kemp, 1991; Husain et al., 2018; McFerran et al., 2018; Naughton, 2004; Redmond, 2010; Sindhusake et al., 2003; Wray et al., 2017). Many help-seekers revert to repeating the process of seeking help, which is a common occurrence for help-seekers with tinnitus (George & Kemp, 1991; McFerran et al., 2018). Even though GPs and ENT specialists play an important role in tinnitus to rule out medical complications, a referral to an audiologist at some point on the tinnitus healthcare journey is recommended. Further education of GPs on tinnitus and referral pathways to audiologists is recommended (Gander et al., 2011), especially as tinnitus is most commonly associated with hearing loss (Crummer & Hassan, 2004).

Limitations

As the study was retrospective, there is an increased likelihood of recall bias from a reliance on past experiences (Khare & Vedel, 2019). An online survey was primarily used for this study, which may have excluded some people who are not connected to the internet or are not computer literate (Archer, 2003); paper surveys were accepted as an option by some participants in cohort 1, and all of those in cohort 2. As the sample size treatment was small, we were unable to do any meaningful testing of satisfaction with factors; however, this showed that few help-seekers went on to have treatment. Additionally, cohort 2 were taking part in a population study and this may have been the first time their attention was drawn to their hearing or tinnitus (James et al., 2013).

Clinical implications

These findings demonstrate the importance of effective communication between healthcare providers and patients highlighting patient-centred care in addressing the needs and expectations of each patient. Another aspect is the need for training and education for healthcare providers to better understand tinnitus and the associated distress. In addition, the study shows that acknowledging the psychological impact would mean more referrals to counselling or mental health support as a part of a comprehensive tinnitus treatment plan. More importantly is the improvement of treatment options for tinnitus and the need for ongoing research and development of effective tinnitus treatment modalities. This research may include exploring new therapeutic techniques or improving existing ones, and improving access for patient and healthcare providers to the latest updates in these areas of information and treatment. Finally, enhancing collaboration among tinnitus specialists and allied healthcare providers could lead to more holistic and coordinated treatment approaches for patients.

Conclusion

This study identified that help-seekers with tinnitus are likely to be dissatisfied with the first interactions with healthcare providers and results from first treatments. Overall, most help-seekers do not undertake treatment either by choice or they are not offered treatment, and may choose to seek treatment again. The study emphasises the importance of effective communication, patient-centred approaches and comprehensive and improved treatment plans in the diagnosis and treatment of tinnitus.

Acknowledgements

The authors would like to acknowledge all the participants for their contributions to the study, the Ear Science Institute Australia, the Ear Sciences Centre (UWA), the Australian Postgraduate Award and the Busselton Population Medical Research Institute (BPMRI).

Disclosure statement

No potential conflict of interest was reported by the author(s).

Correction Statement

This article has been corrected with minor changes. These changes do not impact the academic content of the article.