Older adults with multimorbidity often consult their primary care providers (PCPs), making these health care professionals some of the most important stakeholders in the quality enterprise. There is a movement afoot in geriatric medicine for a single point of contact to whom the patient will turn, for example, with a simple question: “Who shall I see so I can remain connected to my family and friends?”
A recent report by Desai et al. revealed that rather than “shopping” for a health care provider based on cost, older adults prefer to proceed with referrals from their doctors (JAMA 2016;315:1874 http://ow.ly/ZefM300Tmfm). When considering health care provider recommendations, patients put a premium on the relationship with their doctor and the emphasis placed on outcomes. Out-of-pocket expenditures are oftentimes considered a secondary concern.
WHAT DOES IT TAKE FOR A PHYSICIAN TO REFER A PATIENT TO AN AUDIOLOGIST?
When patients raise concerns about their hearing, physicians tend to provide referrals, and they increasingly refer to professionals who value the alignment of patient treatment and outcomes (http://ow.ly/xG7I300uVEl).
Cohen et al. conducted a survey of referral patterns of primary care physicians (Ear Nose Throat J 2005;84:26 http://ow.ly/Xd7a300TmjI). The majority of respondents (82.4%) thought their patients who used hearing aids were more likely to be socially active, and 52 percent rated their patients as satisfied with their hearing aids. With few exceptions, respondents felt that hearing loss affected the quality of life of their patients. Despite the perceptions of the benefits of hearing aid use, 40 percent of respondents indicated that they did not evaluate their patients for hearing loss, the major reasons being time constraints, more pressing medical priorities, and lack of clarity regarding approaches to evaluating hearing status. Close to 20 percent of respondents reported that they assessed hearing status only when a patient recognized a hearing problem. They acknowledged a patient reporting a change in hearing was a trigger for referral to an audiologist or an otolaryngologist. The authors concluded that the dearth of referrals could be attributed to uncertainties about where to refer and which patients were potential candidates for audiology services.
Fischer et al. shed additional light on the motivation to refer for hearing health care (Am J Public Health 2011;1018:1449 http://ow.ly/yrqe300Tmmv). They found that the rate of physician consultation for hearing loss was based on patient perception of the quality of their hearing, whether it was bothersome, whether others had complained about their hearing, or whether others had advised them to obtain hearing aids. The perception that hearing aids were not necessary, the cost and inconvenience of a hearing aid purchase, and the poor experience of others were the major reasons the study respondents did not purchase hearing aids.
HOW DO WE CHANGE THE CONVERSATION AND REFERRAL PATTERNS?
What is the most effective way for on-boarding physicians and helping them appreciate that hearing loss is not a benign condition, but rather a chronic condition with health and economic consequences for which effective treatments are available?
First, the audiology profession should no longer be synonymous with the sale of hearing aids. We should be seen as professionals focused on restoring hearing and the ability to more effectively communicate, which are vital to social participation, connectedness and well-being. Let's change our emphasis to quality metrics that are patient-, not disorder-oriented. We should adopt the new standard of care increasingly employed in geriatric medicine that focuses on what matters most to the patient and to the members of the team managing the patient's health care (http://ow.ly/xG7I300uVEl). The outcomes most valued are those that are specific, measurable, and actionable.
In addition, we should intervene earlier and offer accessible and affordable hearing health care solutions with an eye toward patient preferences and stage of readiness. Hearables or directed audio systems may be a starting point leading to hearing aids purchase when the benefits from “starter” systems do not translate into important universal outcomes, including social connectedness and improved quality of life. It is critical that we leverage our expertise and focus on self-management strategies and auditory-cognitive rehabilitation using ecologically relevant material that will foster improved listening comprehension and social engagement so critical to morbidity and mortality (Smith. Front Psychol 2015;6:1394 http://ow.ly/Kxk8300TmqZ).
WHY IS MESSAGING IS IMPORTANT?
Older persons with hearing loss have higher health care costs, poorer self-rated health, and greater odds of office-based, out-patient, and emergency department visits (Simpson. JAMA Otolaryngol Head Neck Surg doi:10.1001/jamaoto.2016.0188 http://ow.ly/s7qF300TmtX; Genther. JAMA 2013;309:2322 http://ow.ly/58Uh300TmvA). Make sure the primary care physicians you work with are aware that untreated hearing loss is costly in terms of hospitalization risk, annual hospitalization rate, and length of hospital stay (Genther. J Am Geriatr Soc 2015;63:1146 http://ow.ly/qLpa300TmxC). While acknowledging methodologic limitations, Genther et al. also noted that self-reported hearing aid use in their sample was independently associated with shorter mean hospitalization, but not with risk of hospitalization.
The connection between hearing loss and negative health-related effects is clear. If there is speculation that the link may be mediated through social isolation (which is associated with cognitive decline, risk of falls, and fear of falling), then hearing health-related interventions play a significant role in helping people with age-related hearing loss maintain healthy aging (Genther. 2015; Simpson. 2015).
A partnership with PCPs to optimize healthy aging is within our reach. It is up to us to communicate that our efforts can help minimize care burden, that our focus is on personal life outcomes patients and providers want from their health care, and that our dedication is truly on the universal outcomes that matter most—function, quality of life, and quality of care. Adopt a new mantra after explaining results of hearing tests and consider saying, “There are different treatments that we could do, now that I understand your goals and preferences I think we can start with …” Communicate to the referring doctor that the patient preferred a particular intervention and you are working together to realize the actionable goals they verbalized. It is worth a try, as this could be the creative destruction hearing health care needs.