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Outcome Measurement in Audiology: A Call to Action

Weinstein, Barbara E. PhD

doi: 10.1097/01.HJ.0000469512.69675.4f
Golden Rules

Dr. Weinstein 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.

The use of quality measurement is growing throughout the U.S. healthcare system. Stakeholders are increasingly applying healthcare analytics to drive better outcomes and differentiate providers.

Typically, quality of care is measured using patient-level or process-related outcomes (American Journal of Managed Care; Module 3: Measuring Quality in the Quality Enterprise http://www.ajmc.com/journals/supplement/2013/ipub002_13jul_qualityenterprise_suplmnt/iPub002_13jul_Mod3_MeasurQ_S174to9). Audiologists tend to embrace clinician-related outcomes in lieu of the more traditional patient-reported outcome measures (PROMs).

Patient-level outcomes reflect whether the intervention made a difference in terms of the patient's psychosocial needs, well-being, and functional status ( Quality Matters December 2011/January 2012 Issue http://www.commonwealthfund.org/publications/newsletters/quality-matters/2011/december-january-2012/in-focus).

While there is no single approach that captures the value or the results of healthcare, it is well accepted that PROMs can bridge the gap between what happens in the clinic and the patient's world ( Ear Hear 2015; published ahead of print http://journals.lww.com/ear-hearing/pages/articleviewer.aspx?year=9000&issue=00000&article=99326&type=abstract; BMJ 2015;350:g7818 http://www.bmj.com/content/350/bmj.g7818.long).

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CARE IS A PROCESS

Process-related outcomes, on the other hand are designed to reveal the technical aspects of how care is delivered. They reflect the sum of actions involved in giving and receiving care ( Int J Qual Health Care 2003;15[6]:523-530 http://intqhc.oxfordjournals.org/content/15/6/523.long).

The degree of personalization of treatment, the delivery of services, and the perception of problem resolution are important metrics for gauging the care process (American Journal of Managed Care; Module 3: Measuring Quality in the Quality Enterprise http://www.ajmc.com/journals/supplement/2013/ipub002_13jul_qualityenterprise_suplmnt/iPub002_13jul_Mod3_MeasurQ_S174to9).

Subjective assessments of interactions with staff, communication with clinicians, and accessibility, responsiveness, and timeliness of care are also used to evaluate process-related outcomes and the patient experience ( Perm J 2009;13[4]:72-78 http://www.thepermanentejournal.org/issues/2009/fall/163-service-outcomes-and-resource-stewardship.html).

Regarding the functional side of service quality, patients who perceive an encounter with their clinician to be patient centered—i.e., the clinician listens to the patient and has good verbal and nonverbal communication skills—tend to be more compliant with their treatment plan and show better health outcomes ( Perm J 2009;13[4]:72-78 http://www.thepermanentejournal.org/issues/2009/fall/163-service-outcomes-and-resource-stewardship.html; J Fam Pract 2000;49[9]:796-804 http://www.jfponline.com/home/article/the-impact-of-patient-centered-care-on-outcomes/78c6a0031eb6ef3aae1e31851a4b8327.html).

Hearing aids delivered within the context of some form of auditory rehabilitation are the standard intervention for hearing loss. The final metric in the hearing healthcare quality enterprise relates to how audiologists in clinical practice define quality.

According to a recent scoping review, outcomes used in auditory rehabilitation research include self-reported daily hours of hearing aid use, adherence to hearing aid use, satisfaction, and speech recognition ( Ear Hear 2015; published ahead of print http://journals.lww.com/ear-hearing/pages/articleviewer.aspx?year=9000&issue=00000&article=99326&type=abstract).

Hearing health behavioral measures, including self-reported hearing health status and health-related quality of life, have been used in selected clinical trials. Clinicians rarely measure process and patient-level outcomes, presuming that communication skills and quality of life have improved if the patient does not return the product ( The Hearing Journal April 2015 issue, p. 6 http://journals.lww.com/thehearingjournal/Fulltext/2015/04000/The_Future_of_Audiology___An_Optimistic.2.aspx).

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PRACTICAL APPLICATIONS

The incongruity is clear; hearing loss is increasing in prevalence, interferes with social interactions, and detracts from enjoyment of life.

Despite the psychosocial consequences of hearing loss and the technological advances of hearing devices:

* Fewer than one in seven older adults with hearing loss uses hearing aids.

* Estimates of hearing aid nonuse range from five percent to 40 percent.

* About one-third of hearing aid fittings result in failure (Ear Hear 2015; published ahead of print http://journals.lww.com/ear-hearing/pages/articleviewer.aspx?year=9000&issue=00000&article=99326&type=abstract; J Am Acad Audiol 2010;21[10]:642-653 http://aaa.publisher.ingentaconnect.com/content/aaa/jaaa/2010/00000021/00000010/art00006; MarkeTrak VIII: Hear Rev 2011;18[6]:10-12 http://www.hearingreview.com/2011/06/marketrak-viii-reducing-patient-visits-through-verification-amp-validation/).

Would we be able to bridge this gap by focusing on the value of hearing aids and by gathering and disseminating outcome data demonstrating that our patients are enjoying the quality of their lives and communicating more effectively and efficiently after hearing aid fitting ( The Hearing Journal April 2015 issue, p. 6 http://journals.lww.com/thehearingjournal/Fulltext/2015/04000/The_Future_of_Audiology___An_Optimistic.2.aspx)?

Achieving high value for patients must become our overarching goal, with value defined as our ability to meet the full set of patient needs ( N Engl J Med 2010;363[26]:2477-2481 http://www.nejm.org/doi/full/10.1056/NEJMp1011024).

As depicted in figure 1, outcome types do overlap. It is incumbent on each of us to align clinical outcomes with the patient's expressed needs. In addition, treatment outcomes should be sustainable; our interventions must have long-lasting effects.

The table depicts a possible framework for incorporating patient-reported outcome metrics important to stakeholders in the hearing healthcare enterprise (see figure 2). PROMS can prove invaluable in helping the clinician provide evidence of treatment effects on function, and they can help optimize patient-centered care ( BMJ 2015;350:g7818 http://www.bmj.com/content/350/bmj.g7818.long;; Quality Matters December 2011/January 2012 Issue http://www.commonwealthfund.org/publications/newsletters/quality-matters/2011/december-january-2012/in-focus).

By asking some of the simple, well-validated questions shown in the table and communicating the outcomes to our patients and referral sources, we can become partners in healthcare committed to maximizing patient-centered services, health outcomes, and wellness.

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