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How to Advance the Audiologist–Primary Care Physician Relationship

Weinstein, Barbara E. PhD; Taylor, Brian AuD

doi: 10.1097/01.HJ.0000462426.80632.31
Golden Rules

Dr. Weinstein, left, is professor of audiology and founding executive officer of Health Sciences Doctoral Programs at the Graduate Center, City University of New York, and coauthor of the Hearing Handicap Inventory for Adults and the Elderly. Dr. Taylor, right, is director of practice development & clinical affairs for Unitron. During the first 15 years of his career, he practiced clinical audiology in medical and retail settings.

Figure

Figure

A longer life span and aging baby boomers have led to unprecedented growth in the number and proportion of older adults. Age-related hearing loss (ARHL) is one of the most significant chronic conditions in this population, affecting nearly two of three Americans 70 years of age and older.1,2

A growing body of evidence suggests that age-related hearing loss is independently related to several comorbidities, including diabetes, falls, cerebrovascular disease, hypertension, cardiovascular disease, incident dementia, and increased mortality.3-8 Despite these associations, hearing impairment is often underreported, undiagnosed, and untreated.

Figure. Ba

Figure. Ba

For example, 85 percent of older adults with hearing loss reported that they had not had their hearing screened nor did their primary care practitioner inquire about their hearing loss, showed Margaret I. Wallhagen, PhD, APRN, and Elaine Pettengill, PhD, RN.9

Figure. B

Figure. B

Scott D. Nash, MS, and colleagues found that, of the approximately 3,000 participants in their prospective population-based study, only 21.6 percent of respondents had talked with a doctor about their hearing in the past five years.2 Interestingly, respondents who had spoken with a physician about their hearing were more likely to have had a hearing test in the last five years.

Most alarming, though, are the data derived from the Medical Expenditure Panel Survey Household Component (MEPS-HC), which revealed that people with self-reported hearing loss had lower ratings of physician–patient communication and overall healthcare than did people with normal hearing.7

Communication, or the ability to be understood and to understand others, is a cornerstone of healthy aging.10 Healthy aging enables people to live a safe, healthy, and socially inclusive lifestyle.11

As part of the healthy aging movement, agencies like the Centers for Disease Control and Prevention (CDC) are allocating resources toward the creation of environments, policies, and programs that will enable older adults to live longer, healthier lives and stay fully engaged and independent.

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BETTER COMPLIANCE, OUTCOMES

The central question for audiologists is: How will baby boomers and the healthy aging movement change the healthcare industry in general and the hearing healthcare industry in particular?

A fundamental principle underlying healthcare delivery in the 21st century is the availability of “appropriate decision partners.”12 Patients must have access to clinicians with skills suitable for a particular encounter, and arrangements should be “made for the communication needed among all relevant clinicians.”12 To this end, audiologists should be included in the process of providing care to patients of all ages, especially those with milder hearing loss that can jeopardize the patient–clinician encounter.

Interventional audiology requires audiologists to change their orientation toward patient care. Rather than focusing on supplying a hearing aid, interventional audiology revolves around societal awareness of good hearing and communication's central role in both a vibrant lifestyle and patients’ active engagement in the care process.12

Given that untreated hearing loss is a risk factor for selected chronic medical conditions in people older than 55, audiologists must be involved on an interdisciplinary team to ensure patient–physician partnerships.

Although it is tempting to capture the attention of a younger audience by simply creating some catchy new marketing slogan, there must be a fundamental change in the way we practice. Our underlying vision or mantra should be that better hearing leads to better patient compliance and better overall outcomes, hence the increasing importance of our role in the overall healthcare system.

If primary care physicians (PCPs) come to accept unrecognized hearing loss as a factor leading to poor patient compliance with medical care, which will be costly to physicians in an era when value-based reimbursement is becoming the norm, interventional audiology can help PCPs boost their bottom line and improve quality of life for aging baby boomers.13

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MAKING THE TRANSITION

Three proposed approaches may help catalyze change:

1. Initiate interdisciplinary efforts linking hearing to healthy aging and healthy living, and emphasize the critical role hearing professionals play in maintaining a vibrant lifestyle for all ages.

To this end, audiologists should familiarize themselves with the scientific evidence linking age-related hearing loss to a variety of chronic medical conditions. Newly minted AuD graduates must understand the relationships between hearing loss and comorbidities, as well as their role in the change process. Course work in geriatric and interventional audiology will help achieve these goals.

Similarly, professional associations that have a mission and vision to promote quality hearing healthcare must foster closer relationships with academies and societies in other health disciplines that share an interest in promoting healthy aging, such as the American Academy on Communication in Healthcare, American Diabetes Association, and American Geriatrics Society. Presenting scientific papers at their conferences or publishing research in their journals about the contribution of hearing to healthy aging would help open many doors necessary for reaching those with age-related hearing loss who go untreated.

2. Incorporate into daily practice motivational interviewing techniques. Once patients have the intrinsic motivation and the sense of self-efficacy critical to success with hearing healthcare interventions, a true treatment partnership will emerge, with the patient empowered to solve the challenges posed by untreated hearing loss.

Motivational or solution-based interviewing helps to strengthen the intrinsic desire for adopting certain behaviors. As part of a patient-centered care philosophy, motivational interviewing allows audiologists to guide patients through the process of behavioral change toward accepting and addressing problems associated with hearing loss. Once patients realize that audiologists are not trying to “sell” them a product, a more trusting relationship is promoted, and patients can work at their own pace to improve communication effectiveness.

Further, motivational interviewing techniques may provide opportunities to offer effective stand-alone services to patients not ready to use hearing aids but still requiring the expertise of an audiologist.

3. Partner with primary care physicians and accountable care organizations, becoming part of their preventive care teams. Audiologists must demonstrate to stakeholders how early identification and management of age-related hearing loss directly leads to healthcare savings and improved quality-of-life and quality-of-care metrics.

Clinicians must incorporate into daily practice patient-reported outcome measures, such as the Montreal Cognitive Assessment, which document the value added by hearing healthcare interventions. These measures should include, but are not limited to, the social domain (engagement metrics), emotional domain (loneliness and depression), and stress domain (reduced caregiver burden and decreased listening effort).

By collecting and sharing data on interventions’ outcomes for daily living beyond communication, audiologists will establish their value in the healthcare arena to the many stakeholders collaborating to improve quality of life for older adults.

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PROVIDING THE TOOLS

It is hoped that by partnering with primary care, practicing interventional audiology, and becoming involved in preventive hearing healthcare early audiologists can help reduce overall healthcare expenditures, especially for people with multiple morbidities.

To support this objective, we have created an easy-to-implement tool kit that incorporates best available evidence designed to educate physicians and their staffs on the importance of maintaining good hearing throughout life.

Table

Table

The content of the tool kit focuses on areas of deficiency revealed by a recent physician survey looking at knowledge of age-related hearing loss. The tool kit includes, but is not limited to, information about:

  • unique features of age-related hearing loss;
  • behavioral symptoms typical of age-related hearing loss;
  • presenting medical comorbidities that warrant hearing screening;
  • hearing loss as a risk factor for conditions associated with mortality;
  • targeted solutions to hearing and communication challenges posed by age-related hearing loss;
  • a proposed screening protocol;
  • a case highlighting features of routine assessment, treatment goals, and desired outcomes; and
  • specific communication strategies, as shown in the table.

Our hope is that by sharing the tool kit with primary care physicians, geriatricians, geriatric care managers, and other health professionals involved in the care of older adults, we will help reduce the magnitude of the unmet need for hearing healthcare.

The content is designed with an eye toward highlighting the critical role physicians play in initiating hearing healthcare and helping move their older patients from problem recognition to solution. The evidence is clear that merely talking with a physician about a hearing or ear problem is associated with increased odds of undergoing a hearing test.2

Hearing healthcare professionals may request a copy of the tool kit by visiting unitron.com/HHCPToolkit http://www.unitron.com/HHCPToolkit, and physicians may request a copy by visiting unitron.com/PhysicianToolkit http://www.unitron.com/PhysicianToolkit.

The ability of our profession to intervene in the hearing care of healthy agers has the potential to reverse the market for hearing healthcare services, which historically has been a challenge to penetrate, despite advances in technology, increasing prevalence of hearing loss, and mounting evidence regarding the consequences of untreated hearing loss.

Let's partner with stakeholders and take action using available evidence and tool kits to turn an invisible handicap into a condition for which treatment effects are visible physically, socially, emotionally, and financially.

Authors’ note: Portions of this paper were presented at the Academy of Doctors of Audiology 2014 Convention in November.

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REFERENCES:

1. Lin FR, Niparko JK, Ferrucci L. Hearing loss prevalence in the United States. Arch Intern Med 2011;171(20):1851-1853. http://archinte.jamanetwork.com/article.aspx?articleid=1106004
2. Nash SD, Cruickshanks KJ, Huang G-H, et al. Unmet hearing healthcare needs: the Beaver Dam Offspring Study. Am J Public Health 2013;103(6):1134-1139. http://ajph.aphapublications.org/doi/abs/10.2105/AJPH.2012.301031?url_ver=Z39.88-2003&rfr_id=ori%3Arid%3Acrossref.org&rfr_dat=cr_pub%3Dpubmed&
3. Bainbridge KE, Hoffman HJ, Cowie CC. Diabetes and hearing impairment in the United States: audiometric evidence from the National Health and Nutrition Examination Survey, 1999-2004. Ann Intern Med 2008;149(1):1-10. http://annals.org/article.aspx?articleid=741394
4. Lin FR, Yaffe K, Xia J, et al, for the Health ABC Study Group. Hearing loss and cognitive decline in older adults. JAMA Intern Med 2013;173(4):293-299. http://archinte.jamanetwork.com/article.aspx?articleid=1558452
5. Genther DJ, Frick KD, Chen D, Betz J, Lin FR. Association of hearing loss with hospitalization and burden of disease in older adults. JAMA 2013;309(22): 2322-2324. http://jama.jamanetwork.com/article.aspx?articleid=1696091
6. Lin FR, Ferrucci L. Hearing loss and falls among older adults in the United States. Arch Intern Med 2012;172(4):369-371. http://archinte.jamanetwork.com/article.aspx?articleid=1108740
7. Mick P, Foley DM, Lin FR. Hearing loss is associated with poorer ratings of patient–physician communication and healthcare quality. J Am Geriatr Soc 2014;62(11):2207-2209. http://onlinelibrary.wiley.com/doi/10.1111/jgs.13113/abstract;jsessionid=7458DE4FC4EE51480FB075F6A627B894.f02t02
8. Genther DJ, Betz J, Pratt S, et al, for the Health ABC Study. Association of hearing impairment and mortality in older adults. J Gerontol A Biol Sci Med Sci 2015;70(1):85-90. http://biomedgerontology.oxfordjournals.org/content/70/1/85.abstract
9. Wallhagen MI, Pettengill E. Hearing impairment: significant but under-assessed in primary care settings. J Gerontol Nurs 2008;34(2):36-42. http://www.healio.com/nursing/journals/jgn/2008-2-34-2/%7B592feef9-85f2-4962-a9d6-4703593c1978%7D/hearing-impairment-significant-but-underassessed-in-primary-care-settings
10. Lin FR. Introduction, background, and overview of the workshop. In: Forum on Aging, Disability, and Independence; Board on Health Sciences Policy; Division of Behavioral and Social Sciences and Education; Institute of Medicine; National Research Council. Hearing Loss and Healthy Aging: Workshop Summary. Washington, D.C.: National Academies Press; 2014. http://www.ncbi.nlm.nih.gov/books/NBK202191
11. Active Aging: A Policy Framework. Geneva, Switzerland: World Health Organization; 2002. http://whqlibdoc.who.int/hq/2002/who_nmh_nph_02.8.pdf
12. Paget L, Han P, Nedza S, et al. Patient–clinician communication: basic principles and expectations. Washington, D.C.: National Academy of Sciences; 2011. http://www.iom.edu/~/media/Files/Perspectives-Files/2012/Discussion-Papers/VSRT-Patient%20Clinician.pdf
13. Taylor B, Tysoe B. Forming strategic alliances with primary care medicine: interventional audiology in practice. Hearing Review 2014;21(7):22-27. http://www.hearingreview.com/2014/06/forming-strategic-alliances-primary-care-medicine-interventional-audiology-practice/
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