3

Hearing Health Care Services: Improving Access and Quality¹

Although it is widely recognized that hearing aids and hearing assistive technologies can be key components to improving hearing and communication abilities, the critical role that hearing-related services can play in hearing health care is often overlooked. These services include the systematic and comprehensive assessment of an individual’s hearing and communication difficulties, diagnosis of any underlying medical conditions, evaluation of the individual’s hearing loss and treatment needs, auditory rehabilitation, and counseling and other services that help the individual to maximize his or her hearing and communication abilities. These services are provided by a range of hearing health care professionals.

Hearing health care is facing challenges similar to those being addressed in many other facets of health care in the United States. Hearing health care is often expensive and underutilized by many of the people who need it. Entry into the hearing health care system can occur by multiple pathways (audiologists, hearing instrument specialists, otolaryngologists, primary care providers, self service, and others) (see Box 3-1). Consumers can be left with no clear guidance on what will best fit their financial, health, social, and hearing needs (NIDCD, 2015). When left to traverse this complex system, even those patients who are fortunate enough to have the time,

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¹ For accuracy when referring to findings and conclusions in published studies on hearing health care services, only the specific professions included in a given study are referred to in the study-related text of this report. However, following the discussion of such studies, the committee’s commentary on the larger implications and applications of the study findings are broadened to include all relevant hearing health care professions.

finances, knowledge, skills, and patience necessary to navigate the process may find the process and outcomes to be frustrating and unsatisfactory (Pacala and Yueh, 2012). Furthermore, there have been few randomized controlled trials that have examined the degree of relative effectiveness of and the quality of care provided by these various services; much remains unknown. For individuals in need of hearing health care but unable to overcome the time, financial, and information barriers, there is a lack of information about the options available regarding services and technolo-

gies and little support to help the consumer understand and compare the potential benefit of various services and technologies.

Access to care has been defined as “the timely use of personal health services to achieve the best possible health outcomes” (IOM, 1993, p. 33), and according to Healthy People 2020, it encompasses the components of coverage, services, timeliness, and workforce (Healthy People, 2016). Quality of care is the “degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are

consistent with current professional knowledge” (IOM, 1990, p. 4). Equity is achieved by removing any systematic differences in the use and outcomes among groups regardless of whether these differences result from financial or other barriers to care (IOM, 1993). This chapter will delve into the practice and delivery of hearing health care and the opportunities to improve access, quality, and equity throughout the system.

SERVICES-BASED INTERVENTIONS FOR HEARING LOSS

Understanding the range of hearing health care services can be challenging. Hearing problems sometimes develop rapidly along with other symptoms such as ear pain, dizziness, or tinnitus, which can herald the onset of infection or disease. Sometimes hearing problems develop so slowly that they are not recognized until a family member or friend expresses concern about difficulties carrying on a conversation with someone due to that person’s apparent poor listening or inattention. This is often the case in age-related hearing loss. Hearing health care ranges from the identification and management of diseases or conditions that may cause hearing loss, which sometimes require advanced medical or surgical care, to rehabilitation and the use of hearing aids and hearing assistive technologies to minimize the psychosocial and quality-of-life consequences of permanent hearing loss. As a result, the consumers of hearing health care services may require services from physician or nonphysician professionals, depending on the cause of the hearing problem, the ability of modern medicine to treat any underlying condition (if present) and restore hearing, and the person’s need for help coping with difficulties experienced in day-to-day listening activities and communication challenges. Individuals with lower levels of health literacy may not understand the different types of, causes of, and service providers for hearing loss, which adds to the confusion these individuals may face when seeking care for hearing problems (Reese and Hnath-Chisolm, 2005). Furthermore, personal preferences, lifestyle, and communication needs, among other things, may drive different individuals with the same type of hearing loss to opt to use different services or different modes of service delivery (e.g., in-person, online, telehealth) to meet their needs.

Understanding the range of hearing health care is also important for identifying key indicators for the quality of care. Hearing loss can be understood in the context of disease, and quality can be defined as accurate diagnosis and appropriate and timely medical treatment within the context of the International Classification of Diseases. Hearing loss can also be understood within the context of communicative and psychosocial functioning, and in that case quality can be defined based on the International Classification of Functioning, Disability and Health (ICF). Therefore, defining quality depends on the dimension affected by the hearing impair-

ment. Hearing health care refers to services that can be focused on treating disease, function, or both. If the problem is disease focused, quality can be measured in terms of a timely and successful medical or surgical intervention or reduced morbidity associated with the disease. When the problem is function focused, affecting everyday auditory and communicative activities, social participation, and quality of life, the quality of care can be judged by improvement in hearing and communication abilities and in overall function and quality of life; objective measures are difficult to obtain so an individual’s satisfaction remains the primary metric. The quality of audiological management might be defined in terms of the degree of restoration of activities and participation (relative to optimum potential). When the problem is multifactorial, a combined approach is indicated.

Under optimal conditions, hearing health care is a coordinated system, capable of addressing hearing loss from both a medical/disease focus and a functional/rehabilitative focus. Thus, the key to offering efficient and effective hearing health care services is assessing hearing-related problems from both a disease and function perspective and accessing the right services and technologies for the specific needs of the individual, at the lowest cost.

Hearing Health Care Utilization

Most data available on the utilization of hearing health care are from surveys asking people if they have had a recent hearing test or about their use or nonuse of hearing aids. In the 2005–2006 and 2009–2010 National Health and Nutrition Examination Survey datasets, only 39.5 percent of adults ages 70 years and older had had a hearing test in the previous 4 years (Nieman et al., 2016). Overall rates of recent hearing testing were similar for white Caucasians, African Americans, and Mexican Americans (39.1 percent, 43.3 percent, and 41.5 percent, respectively). Within the same study population of adults 70 years of age or older, a multivariable model controlling for age, degree of hearing loss, marital status, and self-reported health conditions found that African Americans, people who were widowed, and those with a college education were more likely to have had hearing tests than were white Caucasians, people who were married, and those with a high school education, respectively. There was no difference in the extent of recent hearing testing between Mexican Americans and white Caucasians. These national data do not address disparities for other minority groups and may not reflect regional or local variations in testing.

In the population-based Epidemiology of Hearing Loss Study cohort, whose participants had an average age of approximately 66 years, 36 percent had never had their hearing tested before the baseline examination in 1993–1995 (Cruickshanks et al., 1998). More recently, in the study which

followed up on the adult children (with and without hearing loss) of the participants in that study, 78 percent of those adult children had not talked with their doctors about a hearing problem in the past 5 years, and only approximately 34 percent of the adult children ages 21 to 69 years and approximately 55 percent of the adult children aged 70 years and older had had their hearing tested in the previous 5 years (Nash et al., 2013). Among those who had not had hearing testing in the previous 5 years, 9 percent had a mild to severe hearing loss according to the audiometric examination, which was part of the study. Because audiometric testing is not routinely performed in the United States, many adults with hearing loss remain unaware of a decline in their auditory function. With few published studies addressing hearing health care in the general U.S. population, little is known about the factors or types of symptoms or complaints that make individuals more likely to seek hearing health care.

It is well recognized that the prevalence of hearing aid use is quite low in the United States compared with the prevalence of hearing loss. Data on the extent of hearing aid use are discussed in Chapter 4.

Screening and Case Finding

In 2011 the U.S. Preventive Services Task Force (USPSTF) examined the issue of screening for hearing loss as a population-wide measure during primary care visits for asymptomatic adults aged 50 years and older but did not recommend screening due to insufficient evidence to adequately weigh the balance of potential benefits and harms of screening for this asymptomatic population (I Statement²) (Chou et al., 2011; USPSTF, 2014). The USPSTF noted that potential harms from screening could include anxiety, labeling, stigma, or other psychosocial effects but that no studies were available at the time of their analysis to evaluate these outcomes. The USPSTF added, “Because screening and confirmatory testing for hearing impairment are noninvasive and serious harms of treatment are rare, there are probably little to no adverse effects of screening for hearing loss” (USPSTF, 2014). The committee for the present report finds that lack of a USPSTF recommendation for population-wide screening for hearing loss in asymptomatic adults (such as has been recommended for colorectal screening) should not diminish the importance of discussing hearing health on an individual basis in primary care visits when patients present with complaints or the provider has reason to be concerned.

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² An “I Statement” from the USPSTF means that “the USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of the service. Evidence is lacking, of poor quality, or conflicting, and the balance of benefits and harms cannot be determined” (USPSTF, 2013).

Hearing difficulties can negatively affect communication in any setting, and effective communication is particularly important in the health care setting both for patient safety (Middleton et al., 2010) and to enable the person-centered approach toward which the U.S. health care system is moving. For these reasons, it is important to consider changes in hearing ability during patient wellness and medical visits for those patients who express concern about their hearing and are seeking help (see section on primary care providers later in this chapter).

Because hearing tests are usually not a routine part of primary care visits, the onus often remains on the individual or family to recognize the symptoms and seek appropriate hearing health care. There are ongoing efforts to improve hearing health literacy, including the development of tools to help individuals determine when their hearing problems might stem from a medical condition and whether the problems can be managed by audiologists or other nonphysician professionals. Development is ongoing, but initial results are encouraging (Zapala et al., 2015).

Evaluation and Diagnosis

Individuals presenting for a hearing evaluation may be seeking audiological services for several reasons, including self-recognized concerns about the ear and hearing; a referral following signs of poor hearing found during a medical evaluation; the request of family members or friends who suspect hearing loss; or as part of routine health care. The evaluation may vary somewhat among individuals based on such factors as risk for ear disease. Regardless, the objective of the evaluation is always to identify treatable conditions and to assess the impact of any hearing loss on overall function.

Patient History and Otoscopic Exam

The first step is to obtain a general medical and hearing history in order to gather information about the duration and severity of hearing loss, hearing-related medical history (e.g., previous ear infections, symptoms of ear pain or drainage, family history of hearing loss, prescription and over-the-counter medication history, etc.), and previous use of hearing loss interventions. Further interview questions and standardized questionnaires may be used to assess the impact of hearing loss on the individual’s day-to-day life.

Second, an otoscopic examination is performed to evaluate the pinna (outer ear), external auditory canal, and tympanic membrane for any conditions that could be contributing to hearing loss or that may require further evaluation and treatment (e.g., cerumen impaction, an abnormality of the tympanic membrane, etc.). Based on the findings during the history and

exam, it may be appropriate to refer the patient to a physician for additional evaluation.

Diagnostic Testing

Pure tone audiometry Pure tone audiometry measures the lowest intensity level at which an individual can detect calibrated pure tones at specific frequencies between 250 and 8,000 hertz (Hz). The level at which a person is estimated to detect a calibrated pure tone 50 percent of the time is defined as a “threshold.” Intensity levels are calibrated in decibels (dB) relative to average normal hearing (dB hearing level or dB HL) and can range from −10 to 120 dB HL. Typically, pure-tone thresholds between −10 and 20 dB HL are considered within normal limits.

Pure tones can be delivered through headphones to the right and left ears individually so that the sound travels through each ear canal and middle ear to the cochlea within the inner ear (termed “air conduction” hearing). Alternatively, pure tones can also be delivered to the skull using a bone oscillator so that the sound passes through the skull and directly stimulates the cochlea, bypassing the ear canal and middle ear (“bone conduction” hearing). By looking at the patterns of air conduction and bone conduction thresholds, the practitioner can make some conclusions about the nature of the hearing loss. When hearing loss is the result of damage to or disease of the ear canal, eardrum, or middle ear, air conduction thresholds will be higher than bone conduction thresholds—termed a “conductive hearing loss.” When air conduction and bone conduction thresholds are similar but fall outside the limits of normal hearing, the hearing loss is called a “sensorineural hearing loss.”

Speech audiometry In the United States, speech audiometry uses simple, two-syllable words presented via headphones to each ear individually to determine the lowest intensity level at which 50 percent of the words are correctly repeated, termed a speech reception threshold. Speech reception thresholds ranging from −10 to 20 dB HL are considered within normal limits. There are also forms of speech-in-quiet and speech-in-noise testing designed to emulate commonly occurring listening environments, which can contribute to functional needs testing and to evaluating an individual’s expected benefits from amplification, described below. Disproportionately poor speech recognition performance in relation to an individual’s thresholds for pure tones may suggest changes to the function of the cochlea, auditory vestibular nerve, brainstem, or central processing.

Immittance audiometry Immittance audiometry (sometimes referred to as “acoustic impedance” or “admittance testing”) includes tympanometry and

assessments of the acoustic reflex threshold. These tests are typically used to establish middle ear pressure and to estimate the transfer of acoustic energy through the middle ear system, which can help differentiate between different disorders.

Functional Communication Assessment

The aims of a functional communication assessment are to define an individual’s audiologic and nonaudiologic needs related to hearing and communication, establish the impact of hearing loss on the individual and his or her communication partners (e.g., family), and to determine from which services and technologies the individual may derive benefits (ASHA, 2016f; Valente, 2006). When there is a strong relationship between measured hearing impairment and reported hearing and communication difficulties, managing the hearing difficulties through technologies and/or rehabilitation may be beneficial and sufficient. When there is a mismatch between reported difficulties and the magnitude of measured hearing difficulty, other factors must be explored, including the unique environments that the individual may operate in, the behaviors of other people who frequently interact with the individual, and psychological and cognitive factors such as intellectual capacity, anxiety, and depression. These factors match the biopsychosocial model underpinning the ICF.

Along the lines of the ICF framework, audiological testing captures primarily the impairment aspect of auditory function. However, audiologists must be mindful of hearing difficulties that arise with noncommunicative activities such as the detection of threats and alarms; the ability to localize sounds in space; and recognizing the sounds of events in the surrounding environment (a coin dropping on the floor, for example, or an automobile accident outside of the building). There are also communicative activities that can be difficult to assess and quantify because each individual lives in a unique auditory environment, but there are several touchstone conditions, such as the ability to understand a conversation in one-on-one and group settings, and the abilities to recognize and understand low-level or whispered speech, speech presented in background noise, and speech presented at high intensity levels.

Individuals being evaluated for the functional consequences of hearing loss most likely have a chronic problem, which is unlikely to improve spontaneously or through medical or surgical treatments. Consequently, treatment must focus on maximizing residual capacity to facilitate participation to the greatest extent possible.

Evaluation and Diagnosis Summary

The results of the audiological evaluation should answer the following questions:

• Is the hearing loss or other form of hearing loss a result of a disease process that requires medical care?
• Is the magnitude of any measured hearing loss sufficient to create a functional deficit, and if so, can diminished function explain the concerns of the individual being evaluated?
• If there is a mismatch between the magnitude of the hearing loss and the concerns of the individual being evaluated, are there identified psychosocial factors to explain the mismatch, and are any additional investigations or referrals necessary?
• If there is no mismatch, which strategies will be the most effective for maximizing function (e.g., technologies, rehabilitation)?
• If the magnitude of any hearing loss or other form of auditory impairment is not sufficient to cause concern about disease or impaired function at present, what is the risk for developing hearing loss in the future, and are there any health or lifestyle changes that might mitigate future risk?

The answers to these questions drive the individualized audiological treatment plan. When an audiological evaluation is performed as an adjunct to a physician’s medical evaluation, some of these questions may be deferred to the referring physician. The same set of tests of auditory function can be used to evaluate both the possibility of disease and the effects of hearing loss on function, although most of the traditional test battery is focused on the diagnosis of disease. Additional tests, such as otoacoustic emissions tests and tests for the characterization of tinnitus, may be used to distinguish between more complex forms of otologic disease or auditory dysfunction and are not reviewed here.

Treatment

Treatment for hearing loss can take many forms and will differ based on an individual’s type of hearing loss, unique needs in daily life, personal preferences, and financial means. Treatments can include such services as auditory rehabilitation and counseling as well as various technologies (see Chapter 4), although not every person with hearing loss is a candidate for a hearing aid or other assistive technologies. Medical and surgical treatments are not part of this report’s statement of task and will not be discussed.

Selection, Fitting, Maintenance, and Use of Hearing Technologies

Many hearing health care professionals provide services and support to users of hearing technologies. The most common device-related services are the provision of and assistance with using hearing aids (see Chapter 4 for a discussion of hearing aids and hearing assistive technologies), which includes hearing aid selection, fitting, verification, and validation within the context of the functional communication assessment (for best practice guidelines for audiologic management of hearing loss in adults, see ASHA, 2016f and Valente, 2006; for a review of the components of hearing aid fitting management across worldwide guidelines, see Oh and Lee, 2016). Following best practices in audiology in the United States, selection of a hearing aid is based on an individual’s needs and requirements for hearing aid gain, ear canal geometry, occlusion, special features (e.g., directional microphone, noise reduction circuit, feedback suppression, telecoil), ease of insertion and manipulating volume controls, and cosmetics. Determination of gain processing is initially based on a validated prescriptive procedure, such as those developed by the National Acoustics Laboratories (Byrne and Dillon, 1986; Byrne et al., 2001; Johnson and Dillon, 2001; Mueller, 2005). Other aspects of the hearing aid evaluation include selection of output limiting and compression features, and consideration of the need for special technologies that go beyond the scope of this report (e.g., bone-anchored hearing aids, contralateral routing of signal fittings, and middle-ear implants). Gain verification using a probe microphone (“real-ear” measures) is the most reliable method to validate that prescriptive gain targets have been achieved (Abrams et al., 2012; Mueller, 2001). Best practices for operating, maintaining, and using hearing aids are then discussed, with emphasis on both the devices and the individual. Device-related orientation includes instruction on hearing aid insertion and removal, use schedule, hearing aid features, reducing feedback, changing batteries, and performing maintenance. Patient-related orientation includes setting goals and expectations, methods for adjusting to amplification, counseling on communication strategies, and considerations for supplementary rehabilitation, such as speech reading or speech-perception training. Finally, a plan for assessment of treatment benefits is initiated using validated subjective and objective outcome measures (for examples, see Cox and Alexander, 1995; Cox et al., 2003; Dillon et al., 1997; Ventry and Weinstein, 1982). Follow-up visits may be required to perform further adjustments and to provide further education on the correct operation, maintenance, and usage of the hearing aid(s) or other technologies, including changing of batteries (Desjardins and Doherty, 2009). In the longer term, additional visits may be necessary to ensure that the hearing aids continue to perform optimally and that hearing remains stable.

Although hearing aids are the more common treatment for which hearing health care professionals provide services and support, these professionals can also provide similar services for hearing assistive technologies (such as products connecting with the television or phone, see Chapter 4) even if they do not sell those technologies. Increased attention to hearing assistive technologies is needed in hearing health care professional training to enable these professionals to provide individuals with hearing loss information on the range of technologies available and to help individuals determine what technologies might be useful to them given the nature and extent of their specific hearing loss and communications needs. Tables 3-1 and 3-2 provide the distribution of hearing health care professionals who fit hearing aids and the distribution of venues that provide hearing aids, respectively, from one survey of the field.

Auditory Rehabilitation

Pharmaceuticals and medical devices cannot always provide definitive solutions for chronic health conditions or meet the specific needs and preferences of every individual. Similarly, for individuals with hearing loss, hearing aids cannot unequivocally address the multifaceted challenges of living with hearing loss, such as the hearing loss itself, communication difficulties, changes in quality of life, and possible comorbidities (see Chapter 2). Like other chronic health conditions, hearing loss requires a holistic, individual-centered approach to care that blends both medical and non-medical solutions, such as auditory rehabilitation (also referred to as aural rehabilitation or audiological rehabilitation). Overall, auditory rehabilitation is designed to help individuals learn to live with hearing loss, provide information on the use of hearing aids and hearing assistive technologies, teach strategies for better listening and communication, and, in some cases,

TABLE 3-1
Hearing Aid Fittings Dispensed by Profession According to the 2008 MarkeTrak VIII Survey

SOURCE: Kochkin, 2009. Republished with permission of Newstex, LLC.

TABLE 3-2
Hearing Aid Modes of Delivery According to the 2008 MarkeTrak VIII Survey

SOURCE: Kochkin, 2009. Republished with permission of Newstex, LLC.

offer psychosocial support (ASHA, 2016b; Boothroyd, 2007; Sweetow and Palmer, 2005).

Auditory rehabilitation programs can take many shapes and reflect a variety of paradigms. For example, these programs may be offered with a group in a community setting or on an individual basis in an audiology clinic. Sessions may be led by an audiologist, a speech-language pathologist, or a trained volunteer (Bally and Bakke, 2007). Alternatively, individuals may take part in self-paced, multimedia rehabilitation programs from their home. Programs have been designed for an array of individuals with varying degrees and types of hearing loss and across all age groups. These programs may be focused on individuals who are new to using hearing aids, those who are experienced hearing aid users, or those who have hearing loss but do not use hearings aids. An individual’s needs, preferences, abilities, and goals, along with the specific characteristics of the person’s auditory disorder, should be considered in order to determine the type of auditory rehabilitation program(s) that would be best suited for that individual. This section will discuss the available evidence for auditory-based rehabilitation programs

and for counseling-based, supportive programs, both of which may include Internet- and computer-based designs that are becoming more common.

The goal of auditory rehabilitation programs is to improve speech communication through the use of auditory training, and most of the studies that evaluate auditory training focus on measuring the different aspects of speech recognition. This training may be analytic in nature, centered on differentiating and identifying different parts of speech (e.g., vowels and consonants), or it may be synthetic, teaching listening skills and applying linguistic and context-specific techniques. Some auditory rehabilitation programs combine both of these strategies to maximize the opportunities for positive outcomes for individuals with hearing loss. Although an individual’s family may be included in consultations and hearing aid orientation, auditory rehabilitation is typically designed to enhance the speech recognition of the individual with hearing loss and does not involve family members or other communication partners (some programs may incorporate family in home-based practice or in communication strategies training). Sweetow and Palmer (2005) conducted a review of available literature on auditory rehabilitation that included randomized controlled trials, cohort studies, and pre/post study designs, regardless of whether the study design included control groups or reported outcomes using subjective or objective measures; only 6 out of 213 studies met these defined inclusion criteria. The outcomes measured in these studies included factors connected to consonant recognition, speech perception with a range of one word to full sentences, and self-perception. Despite finding methodological shortcomings (e.g., small sample sizes, variable demographic data, a lack of long-term measures, a lack of blinding, inconsistent paradigms, variable outcome measures) and a lack of resounding evidence, the authors cautiously concluded based on a qualitative assessment that auditory training, specifically synthetic training, could be beneficial to individuals with hearing loss for the outcomes that were measured (Sweetow and Palmer, 2005).

Chisolm and Arnold (2012) updated the Sweetow and Palmer review and added four more studies to the analysis.³ To further examine the evidence in the 10 studies, Chisolm and Arnold (2012) conducted a meta-analysis using the studies that included comparable outcome measures (6 out of 10 studies) related to speech recognition, regardless of factors that varied across the studies, such as listening environment and stimuli. The authors found that in the short term there was a small, but reliable, effect for improvements in speech recognition. Based on their findings, they concluded that “clinicians should have increased confidence in recommending

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³ A comprehensive summary of the studies and the outcome measures that are described in these two reviews can be found in Chisolm and Arnold (2012).

the use of an auditory training program as a part of a comprehensive auditory rehabilitation plan” (Chisolm and Arnold, 2012, p. 249). However, they cautioned against assuming that improvements would be preserved over a longer timeframe, given a lack of data on long-term outcomes. In a more recent study by Kuchinsky and colleagues (2013), researchers used a physiologic measure of cognitive effort—pupil dilation—to study a speech-perception training program, which is a form of auditory training. The researchers found that participation in auditory training resulted in increased word recognition and that it reduced the cognitive effort required to identify words in the presence of background noise, a common complaint of people with hearing loss.

Of the 10 studies reviewed by Chisolm and Arnold in 2012, the authors concluded that only 1 study provided evidence and methodologies that were sound enough to be considered for clinical implementation—the 2006 study of the computer-based auditory training program, Listening and Communication Enhancement (LACE) (Chisolm and Arnold, 2012; Sweetow and Sabes, 2006). LACE is an interactive, adaptive program delivered in home settings that is available via the Internet, DVD, or CD (Neurotone, 2016; Sweetow and Sabes, 2006). The exercises included in the program are intended to produce “better comprehension of degraded speech, enhancement of cognitive skills, and improvement of communication strategies” (Sweetow and Sabes, 2006, p. 543). Studies of LACE have found statistically significant improvements on most of the outcome measures studied (usually tasks taught within the program related to improving speech recognition and the goals listed above), relatively high rates of compliance, better outcomes for new hearing aid users than for experienced users, and better outcomes for those who completed all of the training sessions than for those who did not (Chisolm et al., 2013; Henshaw et al., 2015; Olson et al., 2013; Sweetow and Sabes, 2006). However, a recent randomized controlled trial in a population of veterans found no statistically significant improvement in outcomes among those using LACE when compared to those using standard of care hearing aid intervention alone (Saunders et al., 2016).

Since the development of LACE, other computer-based auditory training programs have been tested with mixed results (Abrams et al., 2015; Dubno, 2013; Saunders and Chisolm, 2015). Henshaw and Ferguson (2013) conducted a systematic review of literature on these types of computer-based programs. The authors reviewed 13 studies out of 229 that were originally identified. These studies were randomized controlled trials, nonrandomized controlled trials, cohort studies, or pre/post studies. Although the authors identified statistically significant improvements on tasks that were taught within the various programs, the evidence was mixed in terms of improved speech recognition. The evidence suggested that, when reported, there were

high rates of compliance and that information presented during the training was retained for extended periods of time (up to 7 months). Unlike the Chisolm and Arnold (2012) review described above, a meta-analysis was not possible due to the heterogeneity of the studies. Henshaw and Ferguson also described challenges with the large variability in study design, protocols, outcome measures, participant inclusion, and individual benefits that resulted from the training. However, the authors did highlight the potential of computer-based auditory training programs, noting that these programs are easily accessible, customizable and flexible, and both cost and time efficient (Henshaw and Ferguson, 2013). Additionally, researchers have highlighted patient-perceived benefits associated with the use of computer-based auditory programs which include increased self-confidence and general satisfaction and enjoyment (Saunders and Chisolm, 2015; Tye-Murray et al., 2012). Current and ongoing studies of computer-based auditory programs (Miller et al., 2015; Saunders et al., 2016) hold promise for expanding the evidence base of these programs and informing decisions about the design of future programs.

Counseling-Based, Supportive Rehabilitation

Rehabilitation programs that concentrate on counseling/psychosocial support, personal adjustment/coping, and building communication skills offer a platform for improving attitudes and beliefs, building resilience, reducing experienced and perceived stigma, and empowering individuals to take a more active role in managing their hearing loss (also see Chapter 6). These types of programs are usually offered in a group setting and may be led by an audiologist or a trained health professional. Hawkins (2005) conducted a systematic review of rehabilitation programs of this nature which included randomized controlled trials, quasi-experimental study design, and nonintervention cohort studies. Unlike the case with auditory training, which can be evaluated using objective measures, the outcomes measured in these studies tended to be more subjective, assessing individuals’ self-perceived changes in personal adjustment/coping, limitations related to their hearing loss, and overall satisfaction with hearing aids. Based on an evaluation of 12 studies (out of 22 identified), Hawkins concluded that there is some evidence that these types of counseling-based programs had a positive effect on self-perception and self-esteem and also positively contributed to the use of enhanced communication skills and hearing aids (Hawkins, 2005). Most of the available studies identified for this review used nonexperimental designs, had small sample sizes (usually less than 50 people), and did not track long-term outcomes—common limitations in this area of literature. Hawkins (2005) hypothesized that the generally strong support among experts and clinicians for counseling-based group

rehabilitation, despite the lack of conclusive evidence, is a result of clinical experience and observed benefits for patients.

In a subsequent review of the literature, Chisolm and Arnold (2012) narrowed the inclusion criteria to randomized controlled trials with control groups that included outcome measures related to quality of life and reductions in limitations related to hearing loss. The authors found three new studies that met their criteria and revisited 7 of the 12 studies originally reviewed by Hawkins (2005). Upon assessment of the methodologies and the evidence presented in the studies, Chisolm and Arnold determined that the evidence for three of the counseling-based programs (i.e., Chisolm et al., 2004; Hickson et al., 2007; Preminger and Yoo, 2010) was supportive enough to warrant consideration for inclusion in clinical practice. To further examine the available evidence, the authors conducted a meta-analysis of the 10 studies and found statistically significant effects—but large variability—when assessing whether these programs reduced perceived limitations related to hearing loss. As with auditory training programs (discussed above), Chisolm and Arnold concluded that counseling-based rehabilitation programs offer small but reliable benefits and that health professionals can recommend these programs to individuals and their families with increased confidence (Chisolm and Arnold, 2012). Roets-Merken and colleagues (2015) conducted a systematic review and meta-analysis of the literature on counseling-based rehabilitation programs for both hearing loss and vision impairment. The authors evaluated the studies for outcomes specifically related to functional and emotional status, social engagement, and self-efficacy. Based on the six hearing loss studies that used randomized controlled trial or control trial designs and met the inclusion criteria, the researchers concluded that there was no statistically significant effect of these programs on the defined measures related to quality of life and well-being.

Since Chisolm and Arnold (2012) conducted their review of the literature, additional studies looking at counseling-based rehabilitation programs have been published. Box 3-2 provides two examples of recently evaluated rehabilitation programs in the United Kingdom and Sweden that employed interactive strategies to boost knowledge and to respond to the psychosocial needs of people with hearing loss. Borg and Borg (2015) described a rehabilitation program oriented toward young adults, using a nonexperimental design with subjective outcomes, and Ferguson and colleagues (2015, 2016) used a randomized controlled trial design to test an Internet-/computer-based educational intervention for new hearing aid users.

Some of the more integrative counseling-based rehabilitation programs have actively incorporated spouses, communication partners, and family members and have identified possible positive outcomes for both the person with hearing loss and the family member participants (Caissie et al., 2005; Habanec and Kelly-Campbell, 2015; Preminger and Meeks, 2010; Scarinci

et al., 2013). These types of inclusive, family-centered rehabilitation programs recognize the effects of hearing loss on family members (often referred to as a third-party disability), take the needs of family members into account, and are intended to increase awareness and enhance communication for everyone who is touched by the hearing loss within the family. Using randomized controlled trials, both Preminger and Meeks (2010) and Habanec and Kelly-Campbell (2015) engaged spouses of individuals

with hearing loss in group-based auditory rehabilitation sessions. Following participation in the programs, spouses reported statistically significant reductions in measures of third-party disability and improvements in communication. Despite the potential value of inclusive, group-based programs, this approach may not always be able to respond to the individual needs, circumstances, and preferences of each of the individuals in the group, suggesting that a combined approach to rehabilitation may optimize results.

In recent years, researchers have also explored the use of computer- and Internet-based modules as cost-effective, convenient mechanisms for increasing access to and use of counseling-based, supportive rehabilitation programs. Many of these programs have been developed using models from auditory training programs. Overall, evaluations of Web-based education and rehabilitation programs have identified positive outcomes, including increases in knowledge, decreases in perceived limitations related to hearing loss, and decreases in depression and anxiety (Ferguson et al., 2015, 2016; Laplante-Lévesque et al., 2006; Thorén et al., 2011, 2014). See Box 3-2 for a discussion of an Internet-based rehabilitation program that was recently tested by Ferguson and colleagues (2016) with 203 new hearing aid users. Internet-based education and rehabilitation programs offer a promising opportunity to extend the reach of limited resources, engage people with hearing loss and their families, and bolster knowledge and confidence.

OPPORTUNITIES TO IMPROVE HEARING HEALTH CARE SERVICES

In considering its task of improving accessibility and affordability of hearing health care, the committee identified a number of opportunities to change hearing health care services for the benefit of the patient and consumer. These opportunities, which are discussed in the sections that follow, include

• Enhance quality in patient–provider interactions
• Involve primary care providers in hearing health care
• Empower consumer and patient use of hearing health care
• Support and engage in quality improvement
• Overcoming disparities in services delivery and access
• Improve and expand the use of auditory rehabilitation programs
• Develop and evaluate innovative models of hearing health care delivery
• Examine the Medicare requirement for physician referral for diagnostic hearing testing

Enhance Quality in Patient–Provider Interactions

As is the case with other chronic health conditions, the effective diagnosis, treatment, and management of hearing loss is best achieved using a patient-centered approach to care and a collaborative and supportive relationship with the professionals who provide that care. However, interviews of individuals with hearing loss and their families indicate that interactions with health care providers and hearing professionals do not always meet their needs and expectations (Kelly et al., 2013; McCormack and Fortnum, 2013; Southall et al., 2010). Anecdotal evidence from people with hearing loss has shown that some health professionals, like their patients (see Chapter 6), may maintain the beliefs that hearing loss is a natural part of aging and that hearing aids and other treatment options have low levels of efficacy (Gilliver and Hickson, 2011; van den Brink et al., 1996; Wallhagen and Pettengill, 2008). Studies also indicate that hearing loss is often neglected or dismissed in primary care settings, implying that it is not always viewed as a priority despite the potential health implications (see Chapter 2).

Whether increasing slowly over time or occurring with a sudden onset, hearing loss is a condition that needs to be processed and accepted before an individual can be fully ready to take action and consider and adopt treatment options (see the discussion of the transtheoretical model in Chapter 6). Health care professionals can play a positive, supportive role in helping individuals accept and adjust to a diagnosis of hearing loss. However, a review of first-time consultations with audiologists in Australia found a lack of demonstrated empathy and a divergence between the patients’ needs and the goals of the audiologists (Ekberg et al., 2014). For example, when the audiologists delivered the diagnosis, two-thirds of them directly transitioned into a recommendation for hearing aids, without allowing the patient time to react or ask questions about the diagnosis and without discussing other available treatment options (e.g., hearing assistive technologies, communication programs, support groups) (Ekberg et al., 2014). Furthermore, audiologists in this study often overlooked the psychosocial needs of their patients. In approximately half of the encounters (51 percent), patients voiced psychosocial concerns and negative attitudes toward the idea of adopting hearing aids, sometimes with an emphasis on perceived stigma. However, the audiologists usually redirected the conversation to a discussion of the various models of hearing aids available. Given these unsatisfactory interactions, many patients left the consultation without agreeing to a treatment strategy. To improve these interactions with patients, Ekberg and colleagues (2014) suggested that the principles of personal adjustment counseling and patient-centered care should be emphasized in training for audiologists. Motivational interviewing—a patient-centered

approach to counseling and behavior change that has been applied in a number of medical settings (Lundahl et al., 2013)—may also benefit the patient–provider interaction following a diagnosis of hearing loss and in considering patient preferences and needs regarding treatment. At least one study is under way to investigate the potential for using motivational interviewing via the Internet to promote individuals to seek additional hearing health care if they have failed a prior hearing test (Weineland et al., 2015). Optimal patient–provider interactions following a diagnosis require that hearing health care professionals recognize the patient’s level of acceptance, adjustment, and readiness for action; identify the patient’s information needs; consider whether the patient’s level of health literacy may interfere with comprehension (see Chapter 6 for a discussion of health literacy); and provide the appropriate levels of support and empathy to the patient and his or her family, who may also be involved in decision making and care for the individual with hearing loss.

In the context of the social-ecological model (see Chapter 1), the role of health care and hearing health care professionals in educating and supporting individuals and their families about hearing loss, treatment options, and management is critical. The information provided and the attitudes projected by health care providers are consequential in shaping the attitudes and beliefs of individuals and the subsequent actions taken by those individuals. For example, interviews with individuals about the adoption and use of hearing aids indicated that individuals were more likely to pursue the use of hearing aids and overcome challenges in adapting to hearing aids when they developed a good relationship with their audiologist because of such factors as perceived consideration, warmth, and empathy (Dawes et al., 2014). Following a review of available literature, Clements (2015) suggested that the first consultation with an audiologist or other hearing health care professional may have a long-term effect on decision making and outcomes. If the encounter creates a negative patient response, it is more likely that that individual will return to a state of denial about his or her hearing loss (the pre-contemplation phase in the transtheoretical model in Chapter 6, Figure 6-2) and deny the need to take action, further delaying possible opportunities to improve quality of life and well-being (Clements, 2015). The likelihood that an individual will make appropriate decisions about how to move forward in treating hearing loss may be affected by multiple factors, including the cost and convenience of the treatment and the lifestyle and personal attitudes of the patient. One challenge that hearing health care professionals and patients face is ensuring that there is plenty of time for the discussion of options and next steps, particularly regarding the purchase and fitting of hearing aids. The patient may be asked to make a large investment in hearing aids at the same time that the patient is adjusting to a new diagnosis of hearing loss.

The literature on patient-centered care in various areas of health care is replete with examples of the benefits of listening and responding to patients’ concerns, considering patients’ specific needs and preferences, and engaging them in shared decision making about available treatment options (Epstein and Street, 2007, 2011; IOM, 2001, 2011c, 2014, 2015a; Meyers et al., 2010). Hearing health care professionals—as with other health care professionals—need to engage in best practices in patient-interaction processes and take the necessary time to understand the attitudes, concerns, health literacy needs, and priorities of individuals with hearing loss; discuss all available treatment options, not just hearing aids; know what community-based education and support resources are available both locally and online; educate individuals about the use, operation, and maintenance of hearing aids and hearing assistive technologies at an understandable level; and manage user expectations and beliefs. Providing a written summary of the discussion may also be helpful since an individual’s hearing loss can affect communication during the office visit.

Involve Primary Care Providers in Hearing Health Care

Enhancing discussions about hearing loss between patients and health care professionals as a part of regular health assessments in primary care settings could help improve hearing health, promote its importance as a health priority, and decrease delays in referral and treatment. Because primary care providers (such as family practice physicians, geriatricians, nurse practitioners, and physician assistants) are often the first to assess and diagnose patients with hearing loss (Bagai et al., 2006; DeVoe et al., 2011; Flocke et al., 1998; Green et al., 2001; Pandhi and Saultz, 2006; Phillips et al., 2014; Rosenthal, 2008; Saultz, 2003; Saultz and Albedaiwi, 2004; Saultz and Lochner, 2005; Worrall and Knight, 2006), they can play a vital role in referring patients to the hearing health care system and following up to ensure that the patient receives all necessary care. Furthermore, as health care professionals who may have long-term relationships with patients (DeVoe et al., 2011; Phillips et al., 2014), primary care providers can help patients and their family members navigate the hearing health care journey and serve as sounding boards, trusted advisors, and advocates. For example, tinnitus is a hearing concern that patients often present to primary care providers and, although it can occur without hearing loss, it frequently accompanies hearing loss (Hoare, 2013). Primary care providers can help navigate the medical and audiological evaluations that may be required, provide assistance in gaining access to other support services, and help facilitate referrals for patients who may benefit from a community support group or, for those requiring long-term care, a residential facility that specializes in supporting people with hearing loss (McKee, 2013; Yueh et

al., 2003). Primary care teams within the medical home can also provide support and education to patients having difficulty with the use of the technologies (e.g., inserting hearing aids, changing batteries, and adjusting hearing aids for different noise environments and to interface with different technologies such as a telephone, television, stereo, and other sources of sound).

In spite of the many opportunities the patient–primary care provider relationship can present for helping identify, inform, and possibly treat hearing loss, substantial evidence shows that hearing loss is often under-detected and undertreated in primary care settings (Cohen et al., 2005; Danhauer et al., 2008; Johnson et al., 2008). There are many reasons for this. Individuals might be reluctant to admit their hearing challenges to their primary care provider or may not experience hearing difficulties in the quiet setting of an exam room even though they do have hearing difficulties in noisier settings (Bogardus et al., 2003). Furthermore, primary care providers might find it challenging to add hearing screening to acute care visits due to time constraints, a lack of reimbursement, or a lack of a structured reminder (Johnson et al., 2008). For older adults, some primary care providers may think hearing loss is simply a normal part of aging and that there are no worthwhile treatment options. Additionally, primary care providers may not be aware of existing hearing health care resources and guidelines. Research is needed to determine how often primary care providers are discussing their patient’s hearing concerns, offering hearing assessments, and, ultimately, whether their interventions result in their patients getting the hearing health care they need.

As part of the Patient Protection and Affordable Care Act,⁴ the Medicare Initial Preventive Physical Exam and the Annual Wellness Visit include provisions for reviewing patient hearing status in the primary care setting. To make the best use of these provisions and the opportunity to detect hearing loss in any primary care visit, regardless of the type of insurance, studies are needed to identify the most effective methods for improving the likelihood and ease of detecting hearing loss in patients when a patient presents in the office of a health care professional who is not a hearing specialist. Some primary care providers have implemented systems to make hearing screenings a part of routine care. Examples include asking patients to complete a pre-exam survey, training nonphysician personnel to perform basic screenings, conducting an oral history, or exploring the potential for hearing loss concerns through a whisper or a finger rub test. In particular, primary care providers should be vigilant for hearing changes in patients who present with comorbid conditions such as depression or cognitive

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⁴ Patient Protection and Affordable Care Act, Public Law 111-148, 111th Cong., 2nd sess. (March 23, 2010).

dysfunction, which may be associated with or exacerbated by hearing loss and therefore might improve with the use of assistive technologies (Mulrow et al., 1990). As the first point of contact that many patients have with the health care system, primary care providers play a critical role in identifying hearing loss and facilitating patient access to additional hearing health care when appropriate, and they could be used more. However, primary care providers are only one part of the hearing health care team, and most individuals with hearing loss would likely benefit from services provided by many members of the team. Primary care providers are increasingly practicing within a patient-centered medical home and could benefit from additional training in supporting a team-based care approach specific to hearing health.

Empower Consumer and Patient Use of Hearing Health Care

There are multiple opportunities to empower consumers in their use of hearing health care which may also reduce barriers and improve access to hearing care.

Food and Drug Administration Regulations on Medical Evaluation or Waiver

Because the sale of hearing aids is regulated by the Food and Drug Administration (FDA) (see Chapter 4 for more detail), a dispenser selling hearing aids must follow the Code of Federal Regulations regarding the conditions of sale of hearing aids. Among other stipulations, FDA’s regulations require that prior to obtaining hearing aids, a patient must provide the hearing aid dispenser with a “written statement signed by a licensed physician that states that the patient’s hearing loss has been medically evaluated and the patient may be considered a candidate for a hearing aid” (see Box 3-3). The FDA regulation provides an alternative whereby patients 18 years of age or older can sign a waiver of that evaluation (see Box 3-3). This regulation was enacted in 1977 out of concern for the potential of hearing aids to be substituted for the medical or surgical treatment of hearing loss and possibly lead to further declines in patient health (Mann and Nandkumar, 2015). The committee explored this issue, obtained and evaluated data from the available literature and from the Department of Veterans Affairs (VA) and the Department of Defense (DoD), and concluded that the health risks are low, this regulation provides no clinically meaningful benefit, and the waiver presents a barrier to access with no substantial enhancement of patient safety.

First, the committee examined the nature and extent of the medical conditions listed in the FDA regulations as well as others that could be cause for concern. Although not directly tied to the medical evaluation

requirement, a separate section of the regulations (21 C.F.R. § 801.420) states that hearing aid dispensers should be aware of eight health concerns and “should advise a prospective hearing aid user to consult promptly with a licensed physician (preferably an ear specialist)” if those conditions are seen through actual observation or learned from other information such as patient history. The eight conditions that have been termed the “red flag conditions” are

• “Visible congenital or traumatic deformity of the ear
• History of active drainage from the ear within the previous 90 days
• History of sudden or rapidly progressive hearing loss within the previous 90 days
• Acute or chronic dizziness

• Unilateral hearing loss of sudden or recent onset within the previous 90 days
• Audiometic air-bone gap equal to or greater than 15 decibels at 500 Hz, 1,000 Hz, and 2,000 Hz
• Visible evidence of significant cerumen accumulation or a foreign body in the ear canal
• Pain or discomfort in the ear” (21 C.F.R. § 801.420).

Concerns related to not identifying these conditions prior to the dispensing of hearing aids include the following: (1) the patient’s condition could be resolved through medical or surgical procedures or treatments, without the need for hearing aids; (2) given the patient’s condition, hearing would not be expected to improve with hearing aids, so the patient would be sold a product he or she does not need; or (3) use of hearing aids could mask an ongoing health condition that could go untreated and possibly cause further detriment to hearing or health.

To determine whether the above-mentioned concerns were significant enough to justify keeping the medical waiver regulation in place, the committee assessed the data available in the scientific literature on the incidence and prevalence of the eight conditions and others that could relate to hearing loss. The committee also obtained data from the VA which reported the incidence of medical conditions in veterans requiring referral to otolaryngologists by audiologists, and the committee obtained data from the DoD on the incidence of hearing-related medical conditions in service members based on a review of medical coding data (see Table 3-3). The data show that these medical conditions are rare. Most of these medical conditions present with symptoms that are obvious to the patient or the provider (e.g., drainage, pain, deformity, conductive hearing loss) or could be symptoms of any number of medical conditions (e.g., dizziness). This is in contrast to the relatively high frequency of untreated hearing loss.

The FDA regulations stipulate that the contents of the user instructional brochure that manufacturers compile as part of the hearing aid packaging contain information about the eight red flag conditions so that consumers will be aware of these potential medical conditions that can cause hearing loss. It is not evident that a required physician evaluation or signing a waiver of that evaluation provides any additional clinically meaningful benefit. The committee was unable to find any analogous examples in health care where a similar waiver is required for adults. In most areas of health care, patients are empowered to seek the care they think they need for their symptoms and are not mandated by any regulation to obtain a physician’s evaluation. For example, glaucoma testing is often recommended prior to being fitted for prescription glasses, but it has not been mandated, even though the incidence of glaucoma—1.9 percent of people

TABLE 3-3
Medical Conditions That Can Present with Hearing Loss

NOTE: DoD = data on military service members; NA = data not available; VA = data on veterans.

^aCombined rate for cerumen impaction and foreign body removal.

^bPersonal communication. Email to staff for the Committee on Accessible and Affordable Hearing Health Care for Adults regarding incidence of medical conditions in the veteran population, from David Chandler, Deputy Chief Consultant, Department of Veterans Affairs. Received January 15, 2016. Available by request from the National Academies of Sciences, Engineering, and Medicine Public Access Records Office. For more information, email PARO@nas.edu.

^cThese estimates include children.

^dCombined rate for tympanic membrane perforation, ossicular discontinuity, and auditory nerve disorders.

^ePersonal communication. Email to staff for the Committee on Accessible and Affordable Hearing Health Care for Adults regarding incidence of medical conditions in military service members, from Mark Packer, Executive Director, Department of Defense Hearing Center of Excellence. Received August 7, 2015. Available by request from the National Academies of Sciences, Engineering, and Medicine Public Access Records Office. For more information, email PARO@nas.edu.

40 years of age and older in the United States (NEI, 2016)—is relatively high compared to the rates for the above-mentioned red flag conditions, there is treatment to slow its progression, and the consequences of the disease can seriously affect vision and are irreversible.

Second, the use of the waiver is common practice, and it is easily selected in online or mail-order sales. The committee could not find a recent peer-reviewed study with reliable data on the overall percentage of individuals who provide proof of a medical evaluation to hearing health care professionals or the percentage of individuals who sign the waiver, but several estimates provided to the committee by professional organizations

and anecdotal evidence indicate that approximately 60 to 95 percent of individuals purchasing hearing aids may be signing the waiver^5,6 (Adams, 1995; PCAST, 2015). The FDA regulations require hearing health care professionals to maintain records of the statements or waivers for 3 years (21 C.F.R. § 801.421). Hearing aids are also available for sale online, often with a requirement that the consumer provide an audiogram so that fitting can be done, but consumers are asked only to read the medical evaluation statement and check a box if they choose to waive the medical evaluation. The ease of selecting the waiver, much as in downloading a mobile app or software upgrade, can mean that the consumer does not read it thoroughly but rather agrees to it (or provides an electronic signature) as a routine step in the purchasing process. In addition, the regulations present a barrier to access by requiring a separate appointment (with additional costs that may be at the patient’s expense, depending on his or her health insurance coverage) for a medical evaluation that in most cases would not be helpful and would delay a patient from getting much needed assistance with hearing and communication.

In summary, the committee finds no evidence that the required medical evaluation or waiver of that evaluation provides any clinically meaningful benefit. The committee finds that the medical evaluation regulations are not effective, nor are they needed to protect patient health and safety. In weighing the rareness of the medical conditions, the incidence of hearing loss in adults, the widespread need for hearing health care, and the wide use of the medical waiver, the committee recommends removing this regulation to serve consumers’ best interests.

Access to and Portability of Hearing Health Care Records

Access to hearing aid–related records (including audiograms and programming history) and the ability to move those records between hearing aid dispensers is an area of concern. The President’s Council of Advisors on Science and Technology recommended that the Federal Trade Commission

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⁵ Personal communication. Letter to staff for the Committee on Accessible and Affordable Hearing Health Care for Adults, from Kim Cavitt, President, Academy of Doctors of Audiology; Judith Page, President, American Speech-Language-Hearing Association; and Larry Eng, President, American Academy of Audiology. Received August 27, 2015. Available by request from the National Academies of Sciences, Engineering, and Medicine Public Access Records Office. For more information, email PARO@nas.edu.

⁶ Personal communication. Letter to the Committee on Accessible and Affordable Hearing Health Care for Adults, from Kathleen Mennillo, Executive Director, International Hearing Society. Received January 15, 2016. Available by request from the National Academies of Sciences, Engineering, and Medicine Public Access Records Office. For more information, email PARO@nas.edu.

enact requirements for hearing health care professionals to provide or make available audiograms and hearing aid programming reports and settings to consumers (PCAST, 2015). Such a policy could facilitate consumers’ ability to change their hearing health care providers for subsequent care if their providers are not meeting their needs, or it could allow changes in providers if an individual moves to another location or is away from home for an extended period of time. (An additional challenge to changing providers is that hearing aids have proprietary software that can only be programmed by dispensers who have a relationship with the manufacturer of that particular hearing aid. See Chapter 4 for further discussion.)

The portability of and access to an individual’s own medical records is a legal right guaranteed under the Privacy Rule of the Health Insurance Portability and Accountability Act⁷ (HIPAA). The Privacy Rule grants patients a right to inspect and receive copies of certain health information about them—known as a designated record set—that is held by a HIPAA-covered entity (e.g., a medical office or hospital). The Privacy Rule regulates health care providers that conduct specific types of electronic transactions such as billing for health care services or verifying insurance benefits, so audiologists and hearing instrument specialists typically are subject to the HIPAA Privacy Rule. Under the HIPAA statute, patients have a legally enforceable right of access to their designated record set within 30 days of requesting them, a time limit that is subject to an extension under certain circumstances.

The audiogram as well as other hearing-related health records should be part of the individual’s designated record set. The Privacy Rule defines this record set as including medical, insurance, and billing records plus an additional category of other records “used, in whole or in part, by or for the covered entity to make decisions about individuals” (45 C.F.R. § 164.501). This definition strongly suggests that if an audiologist or hearing instrument specialist uses any part of the audiogram to make decisions about an individual, the entire file is part of that individual’s designated record set. However, a patient’s access may depend on the data retention policy of the audiologist or hearing instrument specialist. The rule allows individual access only to data that a health care provider “actually maintains” at the time that an individual’s request is received (79 Federal Register 7289). State regulations typically determine which records each provider needs to maintain.

Despite this broad right of access across all sectors of the health care system, patients report that they have difficulty obtaining access to their health data, and access problems perennially appear as sources of patient complaints under HIPAA. Patients who are denied access can file a com-

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⁷ Privacy Rule of the Health Insurance Portability and Accountability Act, Public Law 104-191; 45 C.F.R. § 164.524.

plaint with the Office for Civil Rights at the Department of Health and Human Services, and this office generally will attempt to work with the provider to explain its obligation to provide access. In other areas where patients have encountered difficulty accessing their health records, patient advocacy groups often develop programs to assist patients in exercising their rights and filing complaints if access is denied. Consistent with laws governing access and portability of other health records, hearing health care patients should have access to their audiograms and other hearing health care records held by HIPAA-covered hearing health care professionals.

Support of and Engagement in Quality Improvement

Measuring and Improving Quality

High-quality health care—regardless of the type of care, the geographic location where it is delivered, or the patient population receiving the care—must be safe, effective, patient centered, timely, efficient, and equitable (IOM, 2001, 2006a,b, 2011a, 2012b). Improving and maintaining the quality of care that patients receive can be accomplished through a variety of mechanisms from the individual provider level up through the system level on a national basis. For example, evidence-based clinical practice guidelines and standards of practice can be used to educate health professionals, inform practice patterns, and facilitate widespread adherence to best practices. Performance metrics can be used to standardize and incentivize high-quality care, assess quality in specific areas of care, and compare care across providers. Additionally, continuous quality improvement efforts can be used in practice settings and health care systems to evaluate current practices, inform adjustments in care delivery, and provide data to strengthen the evidence base. Like all aspects of health care, high-quality hearing health care and improvements to that care need to be built on a foundation of scientifically sound data and research methods, as is described throughout this report.

Clinical Practice Guidelines and Standards of Practice

The purpose of clinical practice guidelines and standards of practice is to provide direction for high-quality, evidence-based health care services and established best practices. In the United States, the Agency for Healthcare Research and Quality (AHRQ) catalogs clinical practice guidelines⁸

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⁸ AHRQ has adopted the Institute of Medicine definition of clinical practice guidelines, which states, “Clinical practice guidelines are statements that include recommendations intended to optimize patient care that are informed by a systematic review of evidence and an assessment of the benefits and harms of alternative care options” (IOM, 2011b, p. 4).

for various health conditions, treatments, and medical specialties in the National Guideline Clearinghouse. A set of stringent inclusion criteria (available at www.guideline.gov) is used to evaluate each of the guidelines submitted for review (AHRQ, 2014). In the case of hearing loss, a few relevant guidelines have met the inclusion criteria and are listed within the clearinghouse under otolaryngology and otolaryngologic health conditions (see Box 3-4; AHRQ, 2016). Typically, health care professional associations collaborate with researchers and clinicians to develop evidence-based clinical practice guidelines in areas where scientifically rigorous data and studies are available.

In addition to the National Guideline Clearinghouse, several professional organizations maintain standards of practice and clinical guidelines for public reference. Box 3-4 provides examples of clinical practice guidelines and standards of practice for hearing loss in adult populations. The American Speech–Language–Hearing Association (ASHA) also maintains an online collection of evidence-based clinical practice guidelines relevant to audiology and speech-language pathology (ASHA, 2016d). In 2005, ASHA’s National Center for Evidence-Based Practice in Communication Disorders began evaluating available guidelines and systematic reviews for this collection. To assess the guidelines, the center uses a scoring framework called the Appraisal of Guidelines for Research and Evaluation II framework, and systematic reviews are considered against unspecified quality indicators (ASHA, 2016g). It is important to note that only a handful of the guidelines and reviews listed are directly related to hearing loss, with many of them focused on screening for newborns and children.

To further guide the practice patterns for hearing health care, the American Academy of Audiology’s Professional Standards and Practices Committee sets and updates standards of practice for the profession. These standards were developed “to define acceptable standards of practice for services” that fall within the scope of practice for audiologists (AAA, 2012, p. 1). The current standards were updated in 2012 and focus on six areas: education, screening, evaluation and diagnosis, treatment, prevention, and research (AAA, 2012). In the late 1990s (1996–1999), ASHA, the American Academy of Audiology, and the VA convened the Joint Audiology Committee on Clinical Practice Algorithms and Statements to establish a consensus on clinical algorithms for audiology. The joint committee used the best available evidence at the time to develop five practice algorithms: overview of audologic services; comprehensive adult audiologic assessment; comprehensive pediatric audiologic assessment; hearing aid selection and fitting; and cochlear implant assessment, programming, and rehabilitation. Each of the algorithms is presented in a decision tree format with an accompanying practice statement that can be used to guide audiologists through the decision-making process for the specified scenarios (Joint Audiology Com-

mittee on Clinical Practice Algorithms and Statements, 2000). Although these algorithms may be useful in guiding practice, they have not been revisited or updated in almost two decades and may not reflect the most current and best available evidence, which is fundamental for ensuring high-quality, evidence-based care.

Guidelines and standards can only be effective if they are consistently applied across practice settings. Despite the online availability of guidelines and standards related to hearing health care, little is known about whether

health care professionals are aware of these resources, how frequently the resources are taught in health professional education, or how often they are applied in practice settings. The possible impact of these guidelines and standards on improving the quality of care is also unknown. In order to understand the reach and limitations of these resources and to develop strategies to ensure that best practices are implemented, surveys and additional research are needed. As new research findings become available, the guidelines and standards need to be updated to reflect best available evidence. Furthermore, efforts to widely disseminate revised guidance; teach students and health care professionals, including primary care providers, about the existence of the guidelines and how to implement them; and modify practice patterns will also be required to ensure that patients fully benefit from evidence-based practices.

Performance Metrics

Another mechanism for ensuring and promoting high-quality health care is the development, implementation, and analysis of performance metrics, which may also be tied to clinical practice guidelines. As broadly defined by previous Institute of Medicine work, performance metrics “encompass the wide range of measures of health care quality that include measures and indicators of clinical care, health care processes, and patient outcomes and satisfaction” (IOM, 2012a, p. 181). Performance metrics can also be used to increase accountability, enhance transparency, standardize care, and incentivize evidence-based care—all of which contribute to the delivery of high-quality care.

Across the health care landscape in the United States, there is a range of organizations, government agencies, insurers, health care systems, researchers, health professionals, and other stakeholders involved in the development and use of performance metrics. When applied nationally, performance metrics can serve as a basis for accreditation, certification, and pay-for-performance programs. Box 3-5 provides examples of organizations that develop and use performance measures on a national scale in order to improve the quality of health care.

In 2005, ASHA’s Working Group on Quality Indicators developed quality indicators for audiology and speech-language pathology programs across a variety of settings (e.g., schools and private practice). The indicators were designed to encourage quality improvement efforts; to provide a framework for developing, reviewing and updating programs; and to educate health professionals, students, and consumers about high-quality care. The indictors are grouped into five areas: purpose and scope of services, service delivery, program operations (e.g., administration, human resources, financial management), program evaluation and performance improvement,

and ethics (ASHA, 2005). As with the discussion of the clinical practice guidelines and standards above, it is difficult to know how these indicators are applied and what impact they have on quality, and it appears that they have not been revisited in more than a decade.

To further promote and ensure the delivery of high-quality care, the Centers for Medicare & Medicaid Services (CMS) launched a voluntary incentive program in 2006 called the Physician Quality Reporting System (PQRS) (formerly the Physician Quality Reporting Initiative), which has implemented performance metrics within the Medicare program. Physicians and various types of practitioners and therapists—including audiologists and speech-language therapists—who provide care to Medicare patients

under Medicare Part B’s Medicare Physician Fee Schedule are eligible to participate in the PQRS program (CMS, 2016a). The program has evolved through various legislative actions. For example, the Medicare Improvement for Patients and Providers Act of 2008 made the PQRS program permanent and required CMS to report online the participation in the program and some performance measures (AMA, 2015; CMS, 2016c). Additionally, the Patient Protection and Affordable Care Act of 2010 shifted the paradigm of the PQRS program so that, beginning in 2015, increasing penalties for nonparticipation were included rather than incentive payments for voluntary reporting of quality measures (AMA, 2015). In 2016 health care professionals and group practices are required to choose and report on at least nine individual measures and one crosscutting measure from a list of available measures for at least half of all Medicare patient appointments. Selected measures can be reported via Medicare billing claims, a registry-based reporting system, or certified electronic health records (CMS, 2016b). There is a 2-year gap between reporting and possible penalties; for example, health professionals and group practices that did not meet the 2015 requirements will see a downward adjustment in 2017 (AMA, 2015; CMS, 2015).

Because of the possible impact of PQRS requirements on the practice of audiology, 10 audiology organizations⁹ came together to form the Audiology Quality Consortium. The consortium develops possible quality measures for PQRS inclusion, monitors the PQRS program and quality measures, responds to proposed changes in the PQRS program, and provides education and guidance on PQRS requirements to audiologists. The consortium also maintains a website¹⁰ that lists the applicable PQRS measures and codes (e.g., Current Procedural Terminology [CPT^®], International Classification of Diseases, G-codes) for audiologists, provides claims forms, and offers other helpful resources (AQC, 2016a,b). The six PQRS measures relevant to audiology that are currently listed on the consortium’s website are (1) documenting current medications, (2) screening for depression, (3) risk assessment for falls, (4) care planning for falls, (5) screening and preventative care for tobacco use, and (6) referral for patients with acute or chronic dizziness (AQC, 2016b). As noted by the consortium, under the 2016 PQRS requirements, audiologists are required to report on all three of the crosscutting measures (i.e., medications, depression screening, and tobacco use), rather than only one, because there are fewer than nine individual quality measures that apply to audiology (AQC, 2016c).

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⁹ Academy of Doctors of Audiology, Academy of Rehabilitative Audiology, American Academy of Audiology, American Academy of Private Practice in Speech Pathology and Audiology, American Speech–Language–Hearing Association, Association of VA Audiologists, Directors of Speech and Hearing Programs in State Health and Welfare Agencies, Educational Audiology Association, Military Audiology Association, and National Hearing Conservation Association.

¹⁰ See http://audiologyquality.org.

Audiologists who provide services to fewer than 15 Medicare beneficiaries in a year are exempt from PQRS reporting.

The National Quality Forum estimates that by 2017 approximately 90 percent of Medicare payments will be tied to some form of performance metric (NQF, 2016c). It is becoming clear that performance metrics are driving change in the landscape of health care quality in the United States—within Medicare and beyond—and will also play a role in how hearing health care is delivered in the future. As electronic health records continue to be implemented and evolve, performance metrics and clinical pathways or algorithms will be integrated and used to inform and maximize the quality of care provided. Thus, it is essential that collaborative action, such as that of the Audiology Quality Consortium, be taken in order to develop clearly defined, evidence-based performance metrics that can be adopted for ensuring high-quality hearing health care.

Continuous Quality Improvement

Continuous quality improvement (CQI) is a process- and data-oriented mechanism that is used to enhance the quality of health care delivery and promote excellence. CQI efforts involve “capturing, analyzing, and regularly reporting data; translating the data and resulting information into actionable opportunities to improve performance at the local level; and developing plans for process changes that will further support effective, efficient, and value-added interventions” (IOM, 2015b, p. 338). Like performance metrics, CQI programs are becoming more commonplace among health care systems across the United States, as accreditation bodies (e.g., The Joint Commission, the National Committee for Quality Assurance) continue to emphasize measuring outcomes and CQI processes as part of their accreditation standards. ASHA developed the National Outcomes Measurement System with the goal of collecting and analyzing national outcomes data on the effectiveness of speech-language pathology and audiology services. The initial work focused on speech-language pathology outcomes, but efforts are under way to expand this work into audiology services (ASHA, 2016h; Mullen, 2003; Mullen and Schooling, 2010).

Within the field of hearing health care, the application of CQI principles and programs also holds promise for improving the quality and efficiency of care that patients receive. Under the research section of the American Academy of Audiology’s standards of practice, audiologists are called on to measure and evaluate clinical outcomes and to update practice policies and procedures as part of CQI efforts (AAA, 2012). Recently published literature that was centered on the use of CQI in hearing health care appears to be limited and has primarily focused on newborn screening programs (e.g., Deem et al., 2012) and administrative processes, such as

appointment management (e.g., Huddle et al., 2016). For audiologists and other health professionals who would like to implement CQI strategies in their practices, there are numerous resources and guides available (ASHA, 2016d; HRSA, 2016b; IHI, 2016; Taylor, 2013). Successful CQI efforts require proactive leadership, a culture of continuous learning, measurable outcomes, a reliable platform for ongoing data collection and analysis, opportunities to share feedback and exchange ideas, and strategies to implement necessary change (IOM, 2015b).

Summary

Measuring and improving the quality of hearing health care necessitates buy-in and collaborative effort among researchers, health professionals, health systems, insurers, advocacy organizations, people with hearing loss and their families, and experts in performance metrics and health care quality improvement. As described throughout this section, high-quality hearing health care is a multifaceted goal that can be promoted and accomplished through the development and implementation of mechanisms such as clinical practice guidelines and standards of practice, performance metrics, and continuous quality improvement efforts. However, guidelines, standards, and metrics must be regularly reviewed and updated to ensure that the most recent evidence is translated into best practices. Additionally, once guidelines, standards, and metrics are defined and deployed, a range of strategies—e.g., dissemination, education, and incentives and/or penalties—may be necessary to ensure uptake and implementation by hearing health care professionals.

Overcome Disparities in Services Delivery and Access

Disparities in health care can be defined as inequities in access to care or in quality of care (IOM, 2003). These disparities may contribute to differences in health outcomes across groups of individuals by race, ethnicity, income, education, age, and place of residence, among others. This section addresses the challenges to access and quality for underserved and vulnerable populations of adults with hearing loss, geographical disparities in the location of hearing health care providers, and issues of racial/ethnic and linguistic diversity in the professional workforce serving adults with hearing loss. Expanded health services research is needed to improve understanding of hearing health care disparities and to investigate how economic, racial, cultural, gender, and age-related factors may influence hearing health care use and patient-centered outcomes.

Socioeconomic, Racial, and Ethnic Disparities

A large proportion of the U.S. adult population has not had a recent hearing test (see earlier section on hearing health care utilization). Furthermore, many adults who have hearing loss and may benefit from using hearing aids are not using the devices (see Chapter 4). Only limited evidence is available on the use of hearing health care services by low-income adults and racial and ethnic minorities. Individuals living at or below the federal poverty level were found to be less likely to access hearing health care in the form of using hearing aids than individuals in higher-income populations (Bainbridge and Ramachandran, 2014). African Americans and Mexican Americans are also less likely to report using hearing aids than non-Hispanic White Americans (Lee et al., 1991; Nieman et al., 2016; Pugh, 2004), although one of those studies (Nieman et al., 2016) found that after adjusting for hearing loss, there were no significant differences for African Americans. Full exploration and analysis of the causes and effects of these findings have been hindered by the lack of hearing aid–using adults from racial/ethnic minorities being included in epidemiological studies (see Chapters 2 and 4). Researchers and funding agencies have called for more study of culture-specific interventions to better meet the needs of Hispanic Americans and African Americans (Donahue et al., 2010; Lee et al., 1991; Pugh, 2004). Ongoing research funded by the National Institutes of Health is targeted toward developing affordable and accessible interventions for hearing loss to meet the unique needs of older adults from racial/ethnic minorities.

Older Adults in Long-Term Care Facilities

Obtaining adequate hearing health care can also be challenging for the approximately 1.4 million older Americans who reside in nursing homes or other long-term care facilities (Cohen-Mansfield and Infeld, 2006; Harris-Kojetin et al., 2013). Several cross-sectional studies have shown that although the majority of older adults in nursing homes have hearing loss and many of them might benefit from hearing aids, only 14 to 30 percent of these residents use hearing aids (Cohen-Mansfield and Taylor, 2004a; Culbertson et al., 2004; Jerger et al., 1995). Potential barriers to hearing aid use among residents of nursing homes include individual-specific factors such as manual dexterity challenges that limit the use of hearing aids without assistance; institutional factors, such as a lack of knowledge among staff and a lack of care procedures to assist and support resident communication; and societal factors such as high costs of hearing aids (Carson and Pichora-Fuller, 1997; Cohen-Mansfield and Taylor, 2004b). Furthermore, hearing loss may be under-reported by residents of nursing homes and under-recognized by staff in the absence of objective screening

measures (Cohen-Mansfield and Taylor, 2004a; Corbin et al., 1984; Hoek et al., 1997). An additional challenge for staff and family members is to distinguish miscommunication related to hearing loss from miscommunication related to dementia (Haque et al., 2012; Slaughter et al., 2014). In one study of nursing home residents who used hearing aids, the vast majority (86 percent) needed help with the use and care of the devices, especially changing batteries, and the incidence of problems was high, with approximately two-thirds (69 percent) of hearing aids that belonged to the residents malfunctioning, and nearly half of the staff not having any training in how to use or maintain the devices (Cohen-Mansfield and Taylor, 2004b).

Further development of learning objectives and curriculum regarding hearing health care is needed across multiple disciplines, both within professional training programs and the continuing education of those who work with older adults in long-term care settings, to address the access, follow-up, and quality improvement challenges. A number of continuing education opportunities are regularly available to audiologists on issues related to geriatrics and aging through audiology professional organizations. Limited large-scale research exists on the impact of continuing education and interprofessional training on improving hearing health outcomes, but several examples in the literature have shown positive effects for residents and employees of long-term care institutions (Cohen-Mansfield and Taylor, 2004b; Hoek et al., 1997; Jennings and Head, 1994; Linssen et al., 2013; Robertson et al., 1997). Guidelines for delivery of audiology services in nursing homes were developed by ASHA and include discussion of the potential value of using a variety of hearing assistive technologies in addition to hearing aids (ASHA, 1997). Twenty years later, challenges persist. It is noteworthy that with more older adults choosing to stay in their homes as they age rather than move into long-term care facilities, some of the challenges highlighted in this section will also apply to individuals living in settings other than long-term care facilities.

Rural Populations

A higher percentage of older adults live in rural than in urban areas, and analyses of population changes suggest a migration of baby boomers to rural and small-town communities (Cromartie and Nelson, 2009). One factor that may affect access to hearing health care for rural populations is practice location. Residents of rural areas may not have a choice among providers or may have to travel greater distances than their urban-dwelling peers to access health services or in-network providers.

Further research is needed into the rural health issues potentially affecting hearing health care utilization and the unique needs of rural populations. Older adults in rural communities perceive a number of barriers to

general health care access, including problems with transportation, limited health care supply, a lack of quality care, social isolation, and financial challenges (Goins et al., 2005; IOM, 2006c). There is also evidence that older adults in rural areas are more socially isolated than older adults living in urban areas, with the suggestion that infrastructure and health care providers should plan for rural older adults’ needs and prevent isolation (Baernholdt et al., 2012). Given the potential association between hearing loss and social isolation in older adults (Mick et al., 2014), greater attention to the hearing health care needs of rural older adults may be an important consideration. Evidence of successful rural hearing health promotion programs from other countries suggests this may be a promising approach. For example, the development of a sensory support center in rural Scotland reduced social isolation and increased the functional independence of older adults (Smith et al., 2015) and the Farmsafe Australia project increased access to screening services in farming communities (Lower et al., 2010). Existing programs to address hearing conservation among farming communities, which have focused on young farmers (e.g., Ehlers and Graydon, 2011), might provide a bridge to increase rural community awareness on hearing health issues in the United States (see also Chapter 6). Tele-audiology programs at the VA and Alaska Federal Health Care Access Network have also been developed and implemented to begin to address rural health needs (Jacobs and Saunders, 2014) (see later section in this chapter for more information on tele-audiology).

Audiology Workforce Diversity

Racial and ethnic diversity within the hearing health care workforce is limited. Although not all audiologists are members of ASHA, member counts provide data that cover most of the audiology workforce. Racial data from a dues notice survey conducted in 2012 showed that of the audiologists certified by ASHA in audiology only, approximately 92 percent were white Caucasian and 3 percent were Hispanic/Latino (see Table 3-4; ASHA, 2016c). The most recent available data on gender are from the dues notice survey conducted in 2009, indicating a primarily female audiology workforce (84.6 percent of 11,867 respondents) (ASHA, 2016c).

These data are similar to demographic data from other health care professions. For example, Sánchez and colleagues (2015) note that even though the Latino population is the second-fastest growing nonwhite population in the United States, there has not been growth in the number of Latino physicians. Furthermore, nurses from minority backgrounds represent only 19 percent of the nursing workforce (American Association of Colleges of Nursing, 2015). At the same time, the United States is undergoing major demographic shifts that are projected to result in more than half of the

TABLE 3-4
Profile of American Speech–Language–Hearing Association Member and Nonmember Certificate Holders in Audiology Only, by Race and Ethnicity

SOURCE: ASHA, 2016c. Printed with permission from ASHA.

country’s population being from minority populations by 2044 (Colby and Ortman, 2014). It is not simply in the audiology workforce, then, that the match between health care professionals and the U.S. population is out of balance.

This shortage of health care professionals from minority communities has serious implications for health care access as well as health care outcomes. According to the Sullivan Commission report (2004), “studies suggest that increasing the diversity of the health workforce can improve patient access, patient satisfaction, and improve quality of life for all patients” (p. 15). More specifically, minority patients report better communication with their providers when the patient and the provider are from the same racial/ethnic group. Minority group patients tend to prefer physicians from their same racial/ethnic background and report higher levels of satisfaction when this occurs (Sullivan Commission, 2004).

Equally important to improving access to care is the promotion and support of increasing the number of providers in underserved communities. Zayas and McGuigan (2006) report that half of the medical school graduates expecting to practice in medically underserved areas are African American. A 2002 survey found that 45 percent of Hispanic/Latino dental school student seniors planned to provide dental care to underserved populations after graduation (Sullivan Commission, 2004) while another study found Latino physicians to be more likely to provide health care for Latino communities

and for populations that are medically underserved (Sánchez et al., 2015). Given minority patients’ preference for race-concordant health care professionals, increasing diversity in the hearing health care workforce has the potential to help reduce racial and ethnic hearing health care disparities.

This lack of diversity is unlikely to change in the near term due to the lack of diversity in the current audiology student population. Table 3-5 provides enrollment data for students in audiology graduate degree programs. In the 2013–2014 academic year, 69 out of 75 doctorate graduate degree programs in audiology responded to the Communication Sciences and Disorders Education Survey (CAPCSD and ASHA, 2015). According to the survey results, the clinical doctorate, entry-level programs had a total of 1,781 white Caucasian students (87.35 percent), 205 racial/ethnic minority students (noninternational, 10.05 percent), and 53 international students (2.6 percent). The group was also predominantly female (84.7 percent). The limited gender, racial, and ethnic diversity among recent graduates and enrolled students demonstrates that the audiology workforce will not mirror the gender and racial/ethnic diversity of the U.S. population with hearing loss for the foreseeable future. Recruitment and retention of diverse students to professional training programs in hearing health care would likely boost the diversity in the hearing health care workforce over time.

Increasing the diversity in the hearing health care clinical and research workforce has a number of benefits similar to increasing the diversity in other areas of health care, including increasing access to health services, improving equity (Cohen et al., 2002; IOM, 2003; Valantine and Collins, 2015), increasing patient satisfaction, and ensuring better patient communication with providers.

TABLE 3-5
Total Enrollment in Audiology Graduate Degree Programs for the Clinical and Research Doctorates by Gender and Race/Ethnicity, 2013–2014

SOURCE: CAPCSD and ASHA, 2015. Printed with permission from ASHA.

Linguistic diversity also affects audiologic care and management because language proficiency can affect performance on some clinical tests of speech recognition and outcomes (Reel et al., 2015; Warzybok et al., 2015). Data from ASHA’s 2015 member counts indicated 726 ASHA-certified audiologists self-identified as bilingual service providers, as defined by native or near-native proficiency in a second language. Of these bilingual audiologists, 266 ASHA-certified audiologists were Spanish-language service providers. State-level data indicated that the most bilingual ASHA-certified audiologists living in the United States were located in California, Florida, New York, and Texas. In 6 states, there were 10 or fewer bilingual service providers (ASHA, 2016e). International efforts are under way to develop valid and reliable multilingual test materials (Akeroyd et al., 2015). Academic and clinical training in cultural competency is required within audiology training programs (ASHA, 2014, 2016i). Cultural competencies are part of the knowledge and skills for national certification in audiology from both ASHA and the American Board of Audiology (ASHA, 2004).

The workforce and student enrollment data suggest the need for training programs and professional organizations to develop strategies to recruit and retain minority and bilingual audiologists and other hearing health care professionals. Enhancing and sustaining diversity in the hearing health care workforce will likely require the efforts of multiple stakeholders. Valuing cultural sensitivity and diversity is within the strategic plans and core values of audiology professional organizations (AAA, 2016; ASHA, 2016j). Increasing diversity among the audiology workforce is a stated goal of ASHA’s Envisioned Future 2025, both for gender and multicultural diversity. Funding to promote diversity in the hearing health research workforce is available through administrative supplements and individual training fellowships through the National Institute on Deafness and Other Communication Disorders (NIH, 2015; Valantine and Collins, 2015). However, there are no current, clear mechanisms targeted to increase the workforce diversity among audiologists or other hearing health care professionals. Incentive programs, such as tuition reimbursement used for those practicing in other areas of health care, might help diversify the hearing health care workforce. Strengthening cultural competency training and programs is another area that could help the hearing health care workforce fully address the issue of providing high-quality services to diverse and underserved populations (Awosogba et al., 2013; Shaya and Gbarayor, 2006).

Improve and Expand Use of Auditory Rehabilitation Programs

Although consumer organizations (e.g., the Hearing Loss Association of America and AARP) are actively engaged in advocating for the use of auditory rehabilitation and patient choice for hearing health care, reha-

bilitation programs, such as those described earlier in this chapter, are not widely available (Hawkins, 2005; Sweetow and Palmer, 2005; Thorén et al., 2011). Furthermore, little is known about what proportion of people diagnosed with hearing loss participate in such programs, despite supportive expert opinion across the field. In their literature review, Sweetow and Palmer (2005) indicated that the use of rehabilitation services by audiologists decreased in the 20 years preceding their work due to a number of factors, including a lack of reimbursement and time constraints.

The available evidence supporting auditory rehabilitation programs is generally favorable (see the section on auditory rehabilitation earlier in this chapter) and suggests that these types of programs would likely provide some short-term benefits (Chisolm and Arnold, 2012). However, the evidence is neither robust nor definitive. Reviews of both auditory training and counseling-based, supportive rehabilitation programs describe variability across individuals in terms of outcomes and possible benefits (Chisolm and Arnold, 2012; Hawkins, 2005; Henshaw and Ferguson, 2013; Saunders et al., 2016; Sweetow and Palmer, 2005). This variability may be the result of individual differences (e.g., baseline performance, functional abilities, communication needs, age, severity of hearing loss, motivation, support). These differences require audiologists and health professionals to match individuals with specific interventions—both rehabilitation services and technologies—in order to optimize the outcomes (Abrams and Chisolm, 2013). The development of metrics and biomarkers that could predict which individuals would benefit most from which interventions would greatly simplify decisions about appropriate hearing health care options. In advising their patients, audiologists and health professionals also need to consider the timing of rehabilitation programs. Studies have concluded that the first few weeks to the first few months of hearing aid adoption represent the timeframe when usage patterns are established (Dillon, 2012; Laplante-Lévesque et al., 2014; Ng and Loke, 2015). Also, individuals with new hearing aids are typically encouraged to schedule follow-up appointments within the first 6 months or sooner, as needed. Therefore, this may be a timeframe during which individuals’ information needs and receptiveness to rehabilitation efforts are heightened.

In the design phase of auditory rehabilitation programs, there are a number of foundational principles that could be used to promote successful uptake. For example, these programs should be designed to

• meet the needs and individual preferences of the person with hearing loss;
• be cost effective for both individuals and the care provider;
• be easily accessible and convenient;
• be functional, useful, and engaging;

• be interactive;
• provide sufficient feedback and reinforcement; and
• provide perceived value and positive outcomes to the user (Boothroyd, 2010; Henshaw et al., 2015; Laplante-Lévesque et al., 2010; Sweetow and Palmer, 2005; Sweetow and Sabes, 2006).

To promote wider acceptance and implementation of auditory rehabilitation programs, the efficacy and efficiency of the programs should be evaluated in a large-scale, long-term, and systematic way, using standardized outcome measures whenever possible in order to fully meet tests of scientific rigor. The evidence base needs to be bolstered and widely disseminated, and additional research efforts need to determine which individuals will derive the greatest benefit from these programs. Additionally, steps to expand the use of evidence-based auditory rehabilitation programs need to be taken, including the use of large-scale pilot programs. Where evidence-based programs are available, audiologists, health professionals, and advocacy organizations need to be aware of them and be encouraged to recommend them to their patients and constituents.

Develop and Evaluate Innovative Models of Hearing Health Care Delivery

As described earlier in this chapter, obtaining treatment for hearing loss in the United States generally follows a medical model of clinic-based care in which an individual visits a hearing health care professional for diagnostic evaluation, assessment, and care. While this model may be necessary for individuals with medical conditions requiring care by an otolaryngologist or for individuals with complex or more severe forms of hearing loss, this level of care may not always be required for all adults with hearing loss (AAA, 2006; Valente, 2006). For example, an individual with a longstanding age-related hearing loss that only moderately interferes with daily functioning may be reluctant to commit the resources and time needed to pursue this level of care given the multitude of steps required to obtain basic amplification (Cox et al., 2014; Donahue et al., 2010).

Alternative care models for other types of common and chronic medical conditions (e.g., presbyopia, diabetes, etc.) have rapidly expanded with the use of community health workers and retail clinics located in drugstores to complement the traditional medical model of care (Iglehart, 2015; Perry et al., 2014; Villaseñor and Krouse, 2016). Although these and other alternative models of care have not yet been widely used or investigated for hearing loss management specifically, these options may provide effective models for delivering more hearing health care to more people (see below and Chapter 5). In order to maximize the potential of these innovative

models and ensure that they are implemented where appropriate and most effective, the models will need to be evaluated for possible risks to safety, quality, value, and cost effectiveness.

Community Health Workers

A community health worker has been defined as a public health worker who is a trusted member of the community or who has an unusually close understanding of the community served (APHA, 2016). They can implement programs for and conduct outreach to community members with the goal of promoting, maintaining, and improving individual and community health (BLS, 2016). Community health workers have been used in many other health care sectors to increase access to care, improve the use of health services, and enhance successful chronic disease prevention and management (Johnson et al., 2012; Perry and Zulliger, 2012; Rosenthal et al., 2010). They may be trained and supervised in the provision of basic services to the community and serve as liaisons between the health care system and the community.

With regard to hearing health care in global settings, community health workers have been taught skills in basic audiometry using automated or manual audiometers, which can use a widely accepted threshold-finding algorithm (the modified Hughson-Westlake bracketing procedure) to generate an audiogram that meets current calibration standards and is consistent with ASHA guidelines (Shaw, 2015). Community health workers have also dispensed basic hearing assistive technology that may be pre-programmed or “ready-to-wear” (WWH, 2016).

Community health workers have the potential to play a role in helping an individual and his or her family cope with hearing loss as a chronic condition, potentially by teaching them about hearing strategies and effective communication skills, maximizing the use of hearing aids by pairing them with other assistive products and with other communications and emergency alert systems (see Chapter 4), and understanding their rights through disability and other relevant policies and laws. Basic hearing assessments might be able to be performed at the community clinic or in the home. In order to serve as an effective tool for community health workers, audiometric equipment should be reasonably priced, portable, and easy to use; and it should be calibrated according to American National Standards Institute specifications and any relevant state requirements. Quality assurance, adequate supervision, and ongoing training would also be important considerations. More research will be needed on the development of potential roles for integrating community health workers into hearing health care teams.

The community health worker model is also consistent with the trend toward providing initial health care services closer to the patient’s residence,

rather than requiring the patient to engage the health care system in large, complex facilities, such as academic medical centers and full-service outpatient clinics and hospitals. There is evidence that community health workers can successfully facilitate access to health care for subpopulations and deliver health education in a culturally appropriate manner (Brownstein et al., 2007; Ingram et al., 2012; Postma et al., 2009; Staten et al., 2012). Community health workers could serve as a conduit and liaison to the hearing health care system and the health care system as a whole. Given the prevalence of hearing loss in the United States and the multiple follow-up visits that are often needed for comprehensive hearing health care, community health workers offer a potentially beneficial mode of extending hearing health care to a broader segment of the U.S. population, and additional research is needed to further explore this model. Chapter 5 discusses the potential costs associated with the use of community health workers as well as possible reimbursement challenges and opportunities of this model.

Mobile Health Applications

Mobile health, or mHealth (and now “connected health”), typically refers to the use of mobile and wireless technologies to improve the delivery of health care to patients and to improve health and behavioral outcomes and prevention. Together with biological sensors that can collect and store data, these technologies have the potential to add value to hearing health care delivery and hearing health outcomes (HIMSS, 2016; WHO, 2011).

In an effort to improve health care delivery, mHealth applications and intelligent communication systems have been developed to increase access for patients by providing links to health care providers for reviews of symptoms, remote application of diagnostic tools, and ongoing medical management and treatment. In addition to tools that provide remote access for patients to health care providers through smartphones and tablets, diagnostic tools have been developed for mobile devices and their high-quality built-in cameras, microphones, and loudspeakers (Weinstein et al., 2014). Given the need for delivering and recording sound when providing hearing health care, these advances in mobile technologies expand the suite of options for hearing health care to include mHealth. Thanks to their portability, ease of use, and potential to lower costs, mobile devices can serve critical roles for delivery of hearing health care to underserved populations, military conflict locations, rural and remote regions, and low- and middle-income areas of the United States (Källander et al., 2013; Osborn and Mulvaney, 2013; Pew Research Center, 2015). These technologies can be used in real time to (1) perform an otologic examination (as with an otoscope); (2) assess the magnitude of hearing loss; (3) determine an individual’s ability to understand speech against various backgrounds (using a

digits-in-noise or similar task); (4) perform a self-assessment of communication skills; (5) conduct self-paced speech-perception training or listening and communication training; and (6) engage with others in peer-support groups for patients and family members (Moren, 2014; Olson, 2015). Smartphone apps have recently become available that enable individuals to systematically adjust the gain and frequency response of their hearing aids during the hearing-aid selection process, with the assistance of their audiologist (Paglialonga et al., 2015). Evaluations of these various uses in improving hearing health care are critical.

Some applications are designed to be used without direct access to hearing health care providers and instead employ algorithms that evaluate images (such as audiograms or the results of video otoscopy), determine diagnoses, and recommend treatments or referral (Hussein et al., 2015). Applications are also available to determine if patients’ hearing aids are in good working order, to allow audiologists to remotely set certain hearing aid features, and to enable individuals to adjust their own hearing aids as they move in and out of different environments (Picou, 2014). In the immediate future, self-fit or pre-programmed hearing aids will become more widely available, and these options could be fit with the assistance of a smartphone app and a remote connection to an audiologist (as needed) (Romano, 2014). However, just as each individual’s hearing loss and hearing needs are unique, a self-fit or pre-programmed option may work well for some and not for others.

Mobile technologies and wearable devices are creating new opportunities for personal health monitoring, tracking, and management, which in turn should lead to improved health behaviors, outcomes, and prevention and also reduced health risks (Bastawrous and Armstrong, 2013; Hall et al., 2015). These devices make it possible to apply mobile technologies to personal or family activities related to health and wellness, which can include communication abilities. At the same time, they can monitor the indoor environment, such as levels of environmental noise. Some devices can serve as health assistive technologies, including for hearing and communication. The large amount of data collected and aggregated by devices creates potential options for health assessments and might be adapted to improve communication-related outcomes (Gay and Leijdekkers, 2015). Because technology advances quickly, the development of many more uses for mHealth in hearing health care is likely.

Research on the benefits, risks, and cost effectiveness of mHealth is lagging behind the use of mHealth technologies by consumers. Research questions for mHealth systems science concern the technologies’ efficacy, or the extent to which the use of mobile technologies improve health and wellness outcomes, as well as the validity and reliability of mHealth technologies (Conroy et al., 2014; Knight et al., 2015; Payne et al., 2015; Stoyanov et

al., 2015; Yang et al., 2015). Evidence of the effects of mobile technologies and mobile networks on access to hearing health care across demographic groups is also needed. It will also be of interest to determine how mHealth technologies can best be deployed to motivate people to engage in healthy behaviors related to hearing and communication and the impact of changing communication patterns between patients and providers. Other questions include (1) the effects on the hearing health care provider workforce; (2) the need for regulatory controls to ensure information privacy, confidentiality, and security of mHealth data; (3) the risks to user safety from health behavior and engineering perspectives; and (4) technical challenges, such as the need for interoperability among networks. Because research is already lagging behind consumer use, and because technology evolves quickly, it is critical that research into mHealth use for hearing care be given much more attention (Bastawrous and Armstrong, 2013).

Tele-Audiology

One of the earliest forms of “connected health” was telehealth, which is the exchange of health information across remote sites through various forms of telecommunication technologies, such as smartphones, live video conferencing, asynchronous (cloud-based) services for the “store-and-forward” communication of records, email, and other forms of wireless communication. These systems have been used in some form for decades, primarily to connect hospitals in large urban centers to rural areas where health care services may be limited (especially specialty services), with the goals of improving access, reducing cost, and increasing efficiency, while maintaining the quality of care. The use of telehealth technologies has grown rapidly in recent years due to the widespread availability of Wi-Fi and Internet access to support these services. Telehealth options are now available beyond hospitals, such as in private practice offices, assisted living centers, business centers, and patients’ homes.

As telehealth has grown, tele-audiology services provided by audiologists have become more widely available in some areas, according to a professional association survey (ASHA, 2016a). Tele-audiology fills a specific need for people who live in rural areas, for those who do not have transportation or are not physically able to travel to obtain audiology services, and for those who move to other locations and wish to maintain a relationship with their hearing health care provider. Current teleaudiology technologies provide capabilities for audiometry, obtaining case histories and completing self-report questionnaires, Web-based support groups, professional-to-professional communication, hearing screening, auditory rehabilitation programs, video otoscopy, and the programming of hearing aids.

One of the leading users of tele-audiology services is the VA, which serves a large number of patients who live outside urban areas and far from VA medical centers (West et al., 2010). Access to audiology services is provided by 455 VA clinical facilities and 132 sites with telehealth carts containing audiology equipment; more than 16,000 tele-audiology patient encounters were completed in fiscal year 2014 (Chandler, 2015). A pilot program launched in 2009 used community-based outpatient clinics as teleaudiology sites and focused on the remote programming of hearing aids. Starting from 10 pilot sites, the program has expanded to 71 sites across the country and has evolved to include remote audiometry with calibration capabilities. Tele-audiology outcomes in the VA are reported to be as good as or better than traditional face-to-face encounters (Beck, 2015). Among the innovative tele-audiology technologies that may increase access in the future are home hearing tests, the scanning and transmission of ear canal images, and the programming of hearing aids in the home through smartphones or tablet computers. The VA has demonstrated that tele-audiology can be a successful program (Gladden et al., 2015). In order to realize the full potential of tele-audiology services, a number of questions will need to be resolved, including how to ensure the accuracy, reliability, and quality of diagnostic evaluations; how to provide high-quality communications between patients and providers; how to confirm patients’ understanding of the results; and how to promote patients’ acceptance of technologies and auditory rehabilitation services. Questions also remain regarding the costs of the required technologies; cost effectiveness of telehealth and tele-audiology (see Chapter 5); maintenance of confidentiality; and data security. There may also be challenges connected to state licensure laws—e.g., if a hearing health care professional provides care via tele-audiology to a patient located in another state; possible effects on malpractice risk; and reimbursement regulations (see Chapter 5).

Retail Clinics

Among the newest innovations in health care delivery is the trend to provide simple services at lower cost using new technology, staff with less training (e.g., less expensive providers), and increased automation through the use of strict protocols, algorithms, and clinical practice guidelines. As has been the case with the remote services provided by mHealth applications and telehealth, in-person health care visits at sites other than traditional provider offices (such as retail clinics) have been growing in popularity. For example, there were an estimated 10.5 million visits at retail clinics in 2012 (Bachrach et al., 2015). These in-person visits at community locations provide many of the same benefits as remote services (mHealth and telehealth), including decreased overall costs, lower overhead, reduced

patient out-of-pocket costs, improved access, increased efficiency, and reasonably short wait times (Salinsky, 2009; Thygeson et al., 2008). Furthermore, although retail clinics were originally viewed as a place to provide basic care for health concerns that were not likely to require follow-up care (e.g., sore throat, ear infection, urinary tract infection, flu vaccination), these clinics are evolving to also manage chronic conditions (e.g., diabetes) (Bachrach et al., 2015). Some evidence suggests that the quality of care in retail clinics is the same as, or better than, that provided in physician offices, urgent care clinics, and emergency departments while the per-episode costs are lower (Mehrotra et al., 2009). Customer satisfaction with retail clinics has been reported to be high. In one national online survey, nearly 80 percent of respondents who had been to a retail clinic rated their experience as being the same as or better than previous interactions with a traditional site of care (Smith et al., 2016). In the same survey, one quarter of respondents reported that they would be willing to use a retail clinic to manage a chronic condition (Smith et al., 2016). However, thus far, retail clinics appear to attract a younger population of patients who do not have existing relationships with primary care providers, which may increase overall utilization but may not improve access to underserved communities or older adults (Mehrotra, 2015).

Within the realm of hearing health care, retail clinics are beginning to explore opportunities to gain a share of the market and expand services for hearing loss. For example, in 2014, Walgreens (with 8,000 locations in the United States) merged with Alliance Boots (a large pharmacy chain based in the United Kingdom) to form Walgreens Boots Alliance. In the United Kingdom, Alliance Boots manages approximately 390 hearing care practices within its pharmacies (SEC, 2014). Since the companies joined forces, Walgreens launched an evaluation of a concept for offering hearing health care services and technologies within its pharmacies at four locations in the United States: Chicago, Dallas, Orlando, and Phoenix (Taylor, 2015). Connect Hearing (Sonova) is working with Walgreens to manage the hearing aid satellite clinics at these four locations, but no decision on future activities between the two companies beyond this limited time project has been announced. In addition to this pilot, Costco Wholesale has opened hearing aid centers in approximately 500 of its warehouses across the United States (see Chapter 5 for additional discussion of the Costco Wholesale model). It remains to be seen whether these clinics are successful in terms of health outcomes, consumer satisfaction, and improving accessibility and affordability. Chapter 5 discusses cost and reimbursement for care that is provided in retail settings.

Research on retail clinics is limited, and little is known about their effects on quality (a potential problem because of the limited availability of local supervision), their impact on long-term outcomes and follow-up

care, or their effects on downstream costs (Iglehart, 2015). In order to integrate retail clinics into the hearing health care system and maximize their value for people who have hearing loss, the clinics will need supporting technology and infrastructure to provide basic levels of hearing health care. Care providers who work in retail clinics will need training and support to perform hearing tests, discuss treatment options with patients, and serve as a link to the health care system when referrals are needed for follow-up care.

Summary

The emergence of innovative models of hearing health care and hearing technologies (described in Chapter 4) necessitates research to investigate the relative risks and benefits of these new approaches in comparison to the traditional models of hearing health care delivery, which include hearing aids that are dispensed by hearing health care professionals. A 2009 IOM report that identified priorities for comparative effectiveness research highlighted the importance of investigating and understanding different hearing loss treatments as a priority (IOM, 2009). Since the release of that report, there has been scant new published research investigating these treatment options, particularly on broader and more critical patient-centered outcomes. While there have been several studies on tele-audiology (Blamey et al., 2015), there has been limited research on other hearing health care delivery models (e.g., community health workers, retail clinics) or on direct comparison of different technologies (e.g., over-the-counter devices, high-versus low-end hearing aids) (Cox et al., 2014). Comparative effectiveness research needs to focus on patient-centered outcomes, such as the benefit to real-world communicative function and health-related quality of life, rather than focus on traditional audiologic outcomes, such as hearing and speech tests that are performed in a sound-treated booth.

Examine the Medicare Requirement for Physician Referral for Diagnostic Hearing Testing

The pathway by which an individual enters the hearing health care system can depend on whether that person has insurance coverage that dictates the terms for reimbursement. Individuals who do not have hearing health care insurance coverage can enter the hearing health care system by seeing an audiologist without first obtaining a referral from a physician or nonphysician medical practitioner and pay for all of the services out of pocket, i.e., without reimbursement. Being able to see an audiologist without first obtaining a referral is commonly referred to as “direct access.” In contrast, if an individual has Medicare coverage, an audiologist-provided diagnostic

hearing testing will be covered by Medicare only if the individual first obtains a referral from a physician or nonphysician medical practitioner (e.g., a physician assistant or a nurse practitioner).¹¹ In cases where a Medicare beneficiary expresses concern about his or her hearing to a primary care provider, the provider could choose to refer the patient to an audiologist for diagnostic hearing testing or to an otolaryngologist for an initial evaluation, and then a provider in that otolaryngology practice—likely an audiologist—in turn may conduct a diagnostic hearing test. In the case of either referral pathway, the Medicare beneficiary must go through at least one provider visit to obtain the referral before any hearing evaluation is performed by an audiologist that can be covered by Medicare. The nature of the hearing evaluation covered by Medicare is limited to tests needed “for the purpose of obtaining information necessary for the physicians’ diagnostic medical evaluation or to determine the appropriate medical or surgical treatment of a hearing deficit or related medical problem” (CMS, 2008, p. 6). The referral pathway to access diagnostic hearing testing follows Medicare policy for all diagnostic testing (CMS, 2007). Audiologist-provided evaluations designed to assess an individual’s functional or communicative abilities or auditory rehabilitation candidacy are not covered by Medicare. Nor is any care related to obtaining a hearing aid covered by Medicare because of the explicit exclusion in the Social Security Amendments of 1965.¹²

Other federally funded programs with hearing health care coverage provisions include the Federal Employees Health Benefit plans (plans approved through the Office of Personnel Management and offered by individual carriers), the Department of Defense Medical Health System, and the Veterans Health Administration. As of 2005, approximately 60 percent of the Federal Employees Health Benefits plans, which cover many federal employees and members of the U.S. Congress, provided coverage for hearing testing performed by an audiologist without requiring a referral from a physician or nonphysician medical practitioner; the coverage depends on the individual plan, similar to the case with insurers in the private sector (CMS, 2007). Coverage of audiologist-provided diagnostic testing for active duty military (provided through the Department of Defense Medical Health System) and for veterans (provided by the Veterans Health Administration) follows a similar model of not requiring a referral from a physician or nonphysician medical practitioner (CMS, 2007; Packer and Henselman, 2015). The Veterans Health Administration employs its own licensed audiologists who work in the same facilities as other health care providers, so this model is different from a community care model.

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¹¹ Centers for Medicare & Medicaid Services, 42 C.F.R. § 410.32.

¹² Social Security Amendments of 1965, Public Law 89-97, 89th Cong., 1st sess. (July 30, 1965).

For patients, there are advantages and disadvantages with both the referral pathway and the direct access pathway. The disadvantages of referral can include a lack of access to medical providers due to financial barriers, appointment wait times, or transportation difficulties. Hence, if medical referral is thought to be advisable, it should be balanced by a benefit to the consumer in the form of better, more coordinated primary and specialty health care. For those who have limited access to transportation or who rely on others to accompany them to provider visits, each trip to see a provider can present a burden. Patients generally develop hearing impairment slowly over time, so appointments are usually not needed urgently. However, the average wait time to see a family physician is approximately 19.5 days, and a shortfall in primary care physicians by 2020 has been projected—both of these factors may delay the time it takes to get evaluated and receive a diagnosis (HRSA, 2016a; Twiddy, 2014). In one recent study, 71 percent of members of the American Academy of Otolaryngology—Head and Neck Surgery reported being able to see a new patient in 2 weeks or less.¹³ Studies have demonstrated that the overall ear disease prevalence in the population of adults with age-related hearing loss is low (Zapala et al., 2015) and that patient populations in health systems that do not require a referral do not have higher rates of missed disease (Zapala et al., 2010) (see Table 3-3).

Conversely, the current medical model in which Medicare coverage for hearing health care requires a referral follows the “medical home” model (NCSL, 2012), which ensures that those with hearing loss see a physician or nonphysician medical practitioner who can assess the possible relationship between the individual’s general health and hearing loss. Given the negative health outcomes that can be associated with hearing loss (see Chapter 2), ensuring that a physician or nonphysician medical practitioner stays involved with and informed of a patient’s hearing ability and any diagnosis may be important for overall health. The medical home model ensures that older adults with hearing loss receive coordinated care for their hearing loss, and also ensures that providers are aware of communication limitations with their patients to whom they must convey critically important health information (such as instructions for medications, etc.). Geriatric medicine is characteristically interdisciplinary, due in part to the interplay of reduced function in multiple physiological systems in older adults and the impact on sensory systems, including hearing and balance.

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¹³ Personal communication. Letter to the Committee on Accessible and Affordable Hearing Health Care for Adults, from James Denneny III, Executive Vice President/CEO, American Academy of Otolaryngology—Head and Neck Surgery. Received January 22, 2016. Available by request from the National Academies of Sciences, Engineering, and Medicine Public Access Records Office. For more information, email PARO@nas.edu.

In addition to having an increased incidence of hearing loss, the Medicare population is more likely to have problems with dizziness and imbalance, and those who do have an increased incidence of falls (Agrawal et al., 2009). While inner ear vestibular disorders are thought to account for some of the cases involving dizziness that are presented to primary care providers, other causes include cardiovascular disease, systemic infection, psychiatric conditions, metabolic disturbances, and medications (for a review, see Sloane et al., 2001). The association of hearing loss with these conditions may indicate that the primary care provider should be an integral part of the initial episode of care related to any diagnosis of hearing loss, and thus direct access, which bypasses general medical providers, may not be in the patient’s best interests.

The committee considered direct access versus requiring a referral with particular focus on how it relates to the committee’s task of increasing access and affordability of hearing health care for adults. On one hand, the current Medicare policies requiring a referral may help ensure coordination and completeness of care for older adults who are Medicare beneficiaries and may help preserve a primary care provider as a central repository of all of an individual’s health care information. On the other hand, providing a direct pathway to audiologists without requiring a referral might safely decrease the burden on Medicare beneficiaries while increasing accessibility to hearing health care, and communication between audiologists and primary care providers could accomplish the same team-based approach that the current Medicare referral requirement provides. Both pathways have their merits in terms of patient health and hearing health care access. Some committee members thought there were sufficient data to support recommending direct access without referral for Medicare beneficiaries. Other committee members were concerned about removing medical practitioner involvement and did not think there were sufficient data to understand how direct access would impact the effectiveness of the medical home for Medicare beneficiaries. Consequently, the committee could not come to a consensus on this issue. The committee thought that additional evidence might clarify these benefits and challenges for Medicare beneficiaries.

NEXT STEPS AND RECOMMENDATIONS

This chapter has covered a large number of critical issues regarding hearing health care services, and it has reviewed opportunities to improve these services, including needed areas of research. As new programs and delivery models are explored, it will be critical that research be conducted to support evidence-based practice. Ensuring that consumers are informed about their options and that they receive quality services that meet or exceed performance standards and also reach diverse and underserved

populations will require coordinated efforts among federal, state, and local government agencies and a range of professional organizations, manufacturers and other private-sector businesses, health care providers, and advocacy organizations. The committee offers the following goals and recommendations for improving hearing health care services. In addition, in Chapter 5 the committee recommends demonstration projects and studies that tie health care service delivery to affordability.

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