PONE-D-24-13714Tinnitus; a growing public health problem, but what is the impact on Dutch general practices? A retrospective study using routine healthcare dataPLOS ONE

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Reviewer #1: PLOS ONE Tinnitus; a growing public health problem, but what is the impact on Dutch general practices? A retrospective study using routine healthcare data

In this manuscript the authors describe an interesting retrospective study to report the morbidity trends and healthcare utilization among patients with tinnitus at Dutch general practices (GP), and comparing overall healthcare utilization before and after tinnitus to similar patients without tinnitus using health care databases. It is a topic of high interest, with clear methods, high quality data and adequate description of results and its discussion. I strongly recommend studies on this for providing knowledge on health care consumption and its potential impact on applying health care resources to those in need. However, the manuscript misses quality based on flaws in details on tinnitus and rationale for statements quoted throughout the manuscript. I strongly advise to revise the manuscript on this which at this moment strongly limit the quality of the report and could easily be adjusted.

Introduction

Line 45; this is the definition of subjective tinnitus; please add this to the sentence.

Line 48: ‘ranging from 5% and 43%’; details are missing about these percentages, for example ‘of people from the adult general population’?. Besides this, it’s incorrect to state that with respect to these numbers they all ‘suffer from tinnitus’. About at least 25% of the people with tinnitus do not have any complaints from their tinnitus. Please be cautious with this phrasing on suffering (e.g. also in line 228)

Line 51; ‘by occupation and mobile technology usage, its prevalence is expected to rise (1.4% in each 5-year birth cohort). ‘ � this statement is speculative. So far there is no robust evidence on the rise of the prevalence nor on the etiology of this ‘expected rise’. So please refrain from speculations and describe this as an hypothesis, knowledge gap or topic of interest for future health care purposes. This is the same reason that also the title of the manuscript is somewhat misleading: ‘Tinnitus; a growing health problem….’. As the evidence base for this statement is absent and the current manuscript is on GP diagnosis we can’t make firm conclusions on this. Therefore I would suggest to rephrase this title slightly

Line 55: ‘For example, drug therapies used to treat tinnitus, like antihistamines, 56 antidepressants, or antiepileptics, may provide symptom relief but do not offer a complete cure for tinnitus. � this statement is not according to national treatment guidelines nor according to the current evidence base on the effectivity of the mentioned therapies.

Line 65; ‘cross-sectional study by Rademaker et al. indicated that healthcare use is higher in 66 patients with tinnitus.’� please indicate the comparison which was made (in this case compared to those without a diagnosis of tinnitus).

Line 96: ‘patients with tinnitus’; Although in the text it is mentioned that ICPC-diagnosis were obtained, from this, the reader can’t understand that if you refer to ‘patients with tinnitus’ you are pointing out to those patients who visited the GP and were having a (first) ICPC-diagnosis of tinnitus. For example, if the patient would have visited the GP with a list of complaints in which tinnitus was not the most important and not scored by the GP, the patient will be classified as ‘patient without tinnitus’. This is very important to get clear throughout the text, including the abstract!

Line 134: ‘The presence of chronic diseases was dichotomized into two categories (zero and one or more). � from this it is unclear at which time this was assessed; at baseline of each patient or at the end of follow-up of each patient. Secondly, which domains of chronic diseases were considered? Mental diseases?

Results section;

Line 174; ‘prescription for tinnitus’; it is unclear to me how the authors can conclude on the disease related to the prescribed drugs and whether this is really related to the tinnitus (or to any other disease for which the patient was visiting the GP at the same time). If this is based on having a tinnitus diagnosis and having a prescription at the same data, then it is still to be debated if the prescription is to treat the tinnitus.

Line 199; ‘during tinnitus’; this is an assumption that people were (still) having tinnitus after setting the diagnosis (although logically, this is not clear )

Discussion:

Line 215: Our findings reveal that the number of patients contacting their GP for 215 tinnitus is low � this conclusion is false as the database does not contain data on people with tinnitus who didn’t attend the GP. At the same time I would mention the actual years of observation in this sentence so that the reader does understand in which time the ‘increase’ was observed.

Line 235-250: In the discussion the prevalence and incidence of tinnitus is discussed with explanations for higher numbers in older people and assumptions that this can be related to ‘mobile technology usage’ amongst others. However I do miss a more critical assessment of the rationale for the findings. For example, also ‘changes over years in behaviour of patients to seek help’ can attribute to increasing records of a tinnitus diagnosis. Then this should also appear for other diseases. As the authors are health care registration specialists I have no doubts that they are able to improve the quality of this manuscripts by elaborating on this before drawing conclusions that it is only a higher disease prevalence or incidence by itself as the only explanation for the presented findings. Apart from this, in current literature there is a lack of knowledge about which leisure context do contribute the most to noise induced hearing loss (including tinnitus). Now the authors state only mobile technology usage as main focus in the abstract, introduction and discussion, but also other leisure contexts can be the ‘main cause’ (e.g. bars, dancings, festivals).

Line 252: ‘Since guidelines for tinnitus are not widely implemented across Europe, management and treatment can vary widely across countries and GPs.’ � With a reference on the paper of Cima et al, which is a summery of European guidelines without any original quality assessment of guidelines and individual made recommendations, how can the authors conclude on ‘not widely implemented’? I do agree that treatment vary widely and for sure following guidelines is far from perfect in health care settings, but the first part of the sentence does not hold any basis.

Line 260: ‘Nasal corticosteroids are the initial therapy for sudden sensorineural hearing loss’ � Ok, this is a mistake. I will help you out; nasal corticosteroids are used for different diseases mostly rhinosinusitis (related) problems. The authors have a mix-up with ‘oral or intratympanic corticosteroids in which the first is the initial therapy for sudden hearing loss with intratympanic considered as salvage therapy. Please correct this and the rationale around the nasal corticosteroids findings in the manuscript.

Line 263-265: ‘. Although this is not the first line of treatment for tinnitus and evidence is 264 inconclusive, review studies widely describe that these may positively influence the subjective experience of tinnitus.31,37’ � this statement is not in line with the current evidence nor the opinion on its effectiveness. Please read Cochrane Reviews on these treatments or nationale guidelines on this; these drugs are not considered effective and are not part of any clinical guideline on tinnitus treatment. So, not a first line, but not any line treatment and suggesting ‘may a positive influence’ is misleading readers. Off course, I do agree that a guideline for tinnitus for GPs could be an important step to improve treatments standards and uniformization, and could limit referrals to second line of care such as discussed in the next paragraph, but the rationale for this should be correct.

Line 331; This could indicate that a large proportion of these 332 patients require medical attention other than their GP. � There are several reasons for the referral which are also mentioned in the discussion by the authors. It is not sure if the patient required medical attention as reason for referral. Maybe the GP was limited by facility or knowledge to provide care needed by the patient, or because they were just following guidelines (and as the authors stated; there are no GP guidelines..)

Reviewer #2: In general: well written article about the development of tinnitus in the Dutch General practice. The discussion session is very strong and I like the suggestions for future studies.

Some suggestions:

Title: This is a little bit long. Can you trim this?

r 45: tinnitus is not always chronic. I would prefer that you remove the word chronic in the sentence.

r 53 – 55: “Various treatments and care for tinnitus can be provided mainly to reduce 55 or cope with the complaints. For example, drug therapies used to treat tinnitus, like antihistamines, 56 antidepressants, or antiepileptics, may provide symptom relief but do not offer a complete cure for tinnitus”

Like you also mention in the discussion: there is no guideline of tinnitus that recommends drug therapy. I would recommend giving cognitive behavior therapy as an example. This is far more accepted.

R 69: “Due to the preventable nature of tinnitus” What do you mean? I think you refer to the hearing loss and noise exposure? However, hearing loss is just one of the influencing factors. There are much more influencing factors like stress, anxiety, depression, temporomandibular disorders.

Table 1:

No chronic disease: 5442, should that be 5,442?

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Reviewer #1: Yes: A.L. (Diane) Smit

Reviewer #2: Yes: Annemarie van der Wal

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The impact of tinnitus on Dutch general practices: a retrospective study using routine healthcare data

PONE-D-24-13714R1

Dear Dr. Bes,

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