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Tuesday, May 26, 2020

By Joseph J. Murray, PhD

The global Covid-19 pandemic has brought rapid changes around the world in a short span of time. For deaf, deafblind, and hard-of-hearing people, the pandemic has been accompanied by an information quarantine, wherein critical public health information has not been made available in signed languages and closed captions to this population. While over 100 countries have had at least some national sign language interpretation at public health briefings, this number hides inconsistent and uneven access.[1] In the United States, state governors have American Sign Language interpreters (ASL) during their press conferences whereas the White House has yet to provide ASL interpreters for its public health briefings as of this writing.

These inconsistencies should concern us all. If one group is not able to partake in necessary public health measures due to a lack of information, this has a negative impact on the overall response. The World Federation of the Deaf (WFD) and World Association of Sign Language Interpreters (WASLI) have issued guidelines on access to public health information which stress the need to ensure qualified professional sign language interpreters are present on all media channels and platforms and clearly visible onscreen throughout the entire broadcast.[2] While an initial standard of 25 percent of the screen was adopted for interpretation not done in person, the pandemic has revealed a preference for 50 percent of the screen to be allotted to sign language interpretation, and this new standard is being put in place in different countries from Germany to India.

In many countries, deaf associations and community organizations have taken it upon themselves to produce their own information and voluntarily disseminate to deaf communities via social media. While a necessary measure in the short term, in the long-term governments should recognize deaf organizations as front-line information providers and ensure their efforts are integrated into the overall government response. Ensuring official public health information is available in the national sign language, as is the case in Norway,[3] Rwanda,[4] and Nepal,[5] (among other countries), enhances the overall pandemic response.[6]

Optimal access to medical services during the pandemic can be achieved through the continuation of previous best practices with some adaptations. Hospitals should have a stock of transparent face masks or face shields available for use when a deaf patient is admitted. These facilities should have policies ensuring national sign language interpreters are called in when requested by the deaf patient. These interpreters are to be treated as essential health personnel and be given the necessary personal protective equipment (PPE) to ensure their safety.[7] Deafblind people face extra challenges, and their representative organizations have called for a continuation of necessary interpreting and guide services during the pandemic.[8] Other best practices include using preloaded communication phone applications (apps), such as video interpreting apps or note-writing apps, on patient and hospital communication devices. Deaf and Deafblind patients should be placed in rooms with Wi-Fi connectivity to ensure these apps can function optimally.[9] In no case should a person’s health needs be deprioritized based on their disability, nor should this disability be used as a factor in triage decisions.[10]

One area that is not of concern is that the sign for “coronavirus” varies between and within different national sign languages.[11] While there are multiple ways to sign “coronavirus,” language variation is unproblematic and a natural part of any language community. A sign from Chinese Sign Language has been widely used in International Sign and is being adopted in several national signed languages. The real issue during the pandemic is not language variation but access to public health information and services for deaf communities in national sign languages.  

Front-line providers of public health information and health services should adopt a wide range of accessibility measures, including consistent use of national sign languages, directly and via interpreters, clear face masks, closed captions, as well as communication devices preferred by deaf patients, to ensure deaf and hard of hearing people have equal access to communication during this pandemic.

ABOUT THE AUTHOR: Joseph J. Murray, PhD, is a professor of American Sign Language and Deaf Studies at Gallaudet University in Washington, D.C., and the president of the World Federation of the Deaf.

Thoughts on something you read here? Write to us at hj@wolterskluwer.com.

REFERENCES:

[1]Statement of the World Federation of the Deaf at the Seventy-third World Health Assembly.  Statements by non-State actors in official relations with WHO at the WHO governing bodies meetings. World Health Association.  May 2020.  

https://extranet.who.int/nonstateactorsstatements/meetingoutline/6

[2] World Federation of the Deaf and World Association of Sign Language Interpreters. Joint Guidelines on Providing Access to Public Health Information in National Sign Languages during the Coronavirus Pandemic. 18 March 2020.  http://wfdeaf.org/news/resources/guidelines-on-providing-access-to-public-health-information/

[4] Rwanda National Union of the Deaf. Guidance on use of barrier masks. 30 April 2020. Rwanda National Union of the Deaf

[5] National Federation of the Deaf, Nepal. How to protect yourself against Covid-19 https://www.facebook.com/NDFNNepal/videos/1265363590321763/

[6] Joseph J. Murray.  Remarks at IDA Facebook Live webinar 11 May 2020. https://www.facebook.com/InternationalDisabilityAllianceIDA/videos/1591026214390431

[7]Joint Statement by the World Federation of the Deaf (WFD) and World Association of Sign Language Interpreters (WASLI) On Access to Health Services and Interpreter Occupational Health During the Coronavirus (Covid 19) Containment Efforts. 3 March 2020.  http://wfdeaf.org/news/opinion-sign-language-interpreters-who-work-in-emergency-and-health-settings-should-be-given-the-same-health-and-safety-protections-as-other-health-care-workers-dealing-with-covid-19/ ; World Federation of the Deafblind. Recommendations on inclusive policies from the global deafblind community  17 April 2020. https://www.wfdb.eu/2020/04/17/covid-19-and-deafblindness/

[8] World Federation of the Deafblind. Recommendations on inclusive policies from the global deafblind community  17 April 2020. https://www.wfdb.eu/2020/04/17/covid-19-and-deafblindness/

[9] National Association of the Deaf.  COVID-19: Deaf and Hard of Hearing Communication Access Recommendations for the Hospital. https://www.nad.org/covid19-communication-access-recs-for-hospital/

[10] International Disability Alliance.Toward a Disability-Inclusive COVID19 Response: 10 recommendations from the International Disability Alliance.  19 March 2020 http://www.internationaldisabilityalliance.org/content/covid-19-and-disability-movement

[11] Castro, Helena, Alex Lins Ramos, Gildete Amorim and Norman Ratcliffe.  “COVID-19: don’t forget deaf people”  Nature 579, 343 (2020) doi: 10.1038/d41586-020-00782-2

Wednesday, May 20, 2020

By Sophie Brice, PhD, GradCert, Msc, BMedSci (Hons), and Elaine Saunders, PhD, MAudSci, BSc

Self-management holds great value in achieving improved clinical outcomes of people with chronic conditions including hearing loss. With hearing health care branching out of clinic-based services and into blended and online models of hearing care delivery including app-based services, the importance of successful self-management has become even more evident. Here, we review the evidence and opportunities in modern hearing health care support to effectively use the principles of self-management.  

SELF-MANAGEMENT IN HEARING CARE 

The most recent MarkeTrak X report—a  highly regarded market analysis and consumer trends survey in hearing health care—released in 2019 showed an estimated hearing aid adoption rate of 34 percent among individuals who would benefit from hearing care.1 While the reason for such low adoption rate remains unclear, it has been postulated that the clinician-centric model of hearing care delivery may be a factor.2-5

 

Person-centered care in medicine was discussed in chronic health literature by Clark6 and Wagner7 in the early 90s, culminating in the development of the Chronic Care Model along with the adoption of Bandura’s ideas behind self-efficacy. Initially applied to education and learning, the ideas of self-efficacy were soon applied to health behavior.8 The Chronic Care Model is a strong model to adopt in improving audiological care, whereby self-management is valued and supported.9 Wagner, et al., showed that self-management and behavior change support improved outcomes across chronic health. Four elements were consistently seen in successful care programs, thereby shaping the consequently proposed Chronic Care Model7, 10: (1) Collaborative problem defining, (2) Goal setting, (3) Continuum of self-management training and support services, and (4) Active and sustained follow-up.

 

In this article, we propose an adaptation to support effective rehabilitation in hearing care:

(1) Control: Client controlled hearing aid fitting and programming

(2) Adjustments: Ability to adjust hearing aid settings, and   

(3) Rehabilitation: Tools to assist expectation management.


CONTROL

Do clients really want to be in control? Interpreting the work of Goldstein and Stephens on rehabilitation types, the answer is unlikely to be consistent across the current and potential client population. In a  client-centered model, the control or decision making is shared with or owned by the client, as supported by audiological literature.9, 11, 12 The tools for the client are generally offered via software or an app that is easy to use. Control has been listed as one of nine vital factors needed for clients to more likely accept telemedicine applications,13 as a sense of safety comes from a sense of control over a situation. This is consistent with evidence in telepsychiatry that online interactions with a health professional allow greater engagement, which is thought to be due to the notion of control by the technology user over the interaction.14 For example, it is by far easier to end a call than to remove someone else from the room. Dario, et a.,l15 reported a high level of acceptability of user-driven telehealth technology, as well as high user satisfaction that increased over time.15

 

Installation of hearing aid fitting software by the client offered with an option for a follow-up appointment to be conducted online or in the clinic has shown a positive skew in client choice toward remote support appointments.16 One concern could be that first time hearing users have unidentified needs due to lack of prior experience with hearing aids. Brannstrom, et al.,17 have shown that overall satisfaction and positive hearing aid outcomes among first time hearing aid users actually improved when post-fitting support was delivered via teleaudiology. Furthermore, Amlani, et al.,18 very recently showed that an app-based interface for hearing support led to improvement in perceived benefits and reduction of perceived barriers of wearing hearing aids. It is encouraging to see research findings that suggest greater user control may in turn enable greater user satisfaction.

 

Over-the-counter (OTC) devices are becoming a reality in the United States. Direct-to-consumer (DTC) hearing aids are available globally, and all major hearing aid manufacturers are now offering user apps to manage various aspects of their hearing care.  The idea of a client in control is gaining traction, partly, and importantly, driven by the consumers.

 

ADJUSTMENTS

Different degrees of user control are provided in the apps supplied to adjust the hearing aids. The range of control varies from simple controls such as volume levels to customizable programs, daily experience surveys to direct communication with a clinician, clinician-altered settings, and self-fitting of hearing aids in some cases. These capabilities have also allowed data logging that can be reviewed remotely in individual and big data sets. There are two key aspects of the value and benefit of client self-adjustments:

 

1. Will clients be happier with their own adjustments?

Strong evidence supports the answer to be positive. Perceived benefit and hearing aid satisfaction are positively associated with hearing aid self-adjustments (self-efficacy).19-24 A valuable tool in assessing satisfaction is the use of third-party feedback surveys. A blended service model offers online and traditional clinic based services, equally and interchangebly supported by teleaudiology. A 2018 study found that online users gave higher satisfaction ratings to a blended model of self-fit hearing aid products and services than their clinic based counterparts.25 These ratings may be due to several interacting factors that merit further investigatation, but other studies point to factors such as convenience and user control26 as well as a sense of empowerment.27

 

2. Should self-fittings be a concern for clinicians?

The underlying question relates to the client not choosing one of the common fitting formulae targets, and potentially negatively impacting the audibility benefit from hearing aids and devices. Recent studies have shown that client-based adjustments show consistently reproducible preferences, with variations according to the listening environment and potentially according to the type of hearing loss.24, 28, 29 Of note, these studies also showed speech intelligibility scores equivalent to those obtained with pure-tone audiometry and prescription fittings. In a true client-centered model, client preferences of the auditory experience are of paramount importance. Such client preferences can even be used to identify improvements to fitting prescriptions.30

 

Satisfaction is a significant factor in compliance for chronic disease management31 that is likely also observed in the modern provision of hearing aid and devices. Should the impact of allowing clients to make their own adjustments, in turn, be directed to providing effective support and intervention such as counseling and adjustments (guided or clinician-controlled) by the clinician instead?


REHABILITATION


Stephens and Kramer describe auditory rehabilitation as a dynamic problem-solving process that should optimize participation and feedback from the client.32 They aptly use the term enablement to better describe this process. The IDA Institute has developed, and shared, tools for audiology professionals to use with clients in assisting clients to achieve successful outcomes with hearing aids. They are predominantly designed for face to face interactions though many are transferable to an online setting.

 

Auditory rehabilitation programs delivered online have been shown to improve quality of life for experienced hearing aid users.33, 34 Hearing aid users with self-efficacy values below normative values may require additional training from their audiologist.20 Counseling is a highly valued skill in audiological care, has been shown to impact the likely success of fitting and auditory rehabilitation with hearing devices,35, 36 and can be designed to operate as part of app-based support. Successful results of this already have been seen.27, 37

 

Evidence shows the benefit of appropriate counseling and client-centered communication in improving adherence and improved outcomes with hearing aids.36, 38, 39 Services and communication may differ between service models, and so different metrics of success, failure, and outcome measurements may be required. Replicating a clinic-based model onto an online delivery is not necessarily a solutions based-approach, nor may it be best practice. A clinician in a client-led hearing service model will use the most appropriate tools to deliver the support and outcome that the client seeks or needs.

 

Technological developments offer an opportunity to address and improve aspects of current care practices. In hearing care, a relatively low uptake, and clinician centric practices have been problems to solve. Incorporation of apps, self-fitting hearing aids, internet-based interventions, and support can expand ways to deliver high-quality and effective hearing care by supporting self-management in a variety of ways. 


ABOUT THE AUTHORS: Sophie Brice, PhD, GradCert, Msc, BMedSci (Hons), is an adjunct faculty, a teleaudiology consultant, and a lead researcher in digital health specializing in teleaudiology at Swinburne University in Melbourne, Australia. Elaine Saunders, PhD, MAudSci, BSc, has pioneered a client-centered, blended teleaudiology and face to face service of hearing health care. She is an adjunct professor at Swinburne University of Technology.


Thoughts on something you read here? Write to us at hj@wolterskluwer.com.


REFERENCES:

1. Powers T, and Rogin, C.. MarkeTrak 10: Hearing Aids in an era of disruption and DTC/OTC devices.  26(8), https://www.hearingreview.com/uncategorized/marketrak-10-hearing-aids-in-an-era-of-disruption-and-dtc-otc-devices-2 (2019).

2. Pryce H, Hall A, Laplante-Lévesque A, et al. A qualitative investigation of decision making during help-seeking for adult hearing loss. International Journal of Audiology 2016; 55: 658-665.

3. Poost-Foroosh L, Jennings MB, Shaw L, et al. Factors in client–clinician interaction that influence hearing aid adoption. Trends in Amplification 2011; 15: 127-139.

4. Ekberg K, Grenness C and Hickson L. Addressing patients' psychosocial concerns regarding hearing aids within audiology appointments for older adults. American Journal of Audiology 2014; 23: 337-350.

5. Kelly TB, Tolson D, Day T, et al. Older people’s views on what they need to successfully adjust to life with a hearing aid. Health and social care in the community 2013; 21: 293-302.

6. Clark NM, Becker MH, Janz NK, et al. Self-Management of Chronic Disease by Older Adults: A Review and Questions for Research. Journal of Aging and Health 1991; 3: 3-27. DOI: 10.1177/089826439100300101.

7. Wagner EH, Austin BT and Von MK. Improving outcomes in chronic illness. Managed care quarterly 1996; 4: 12-25.

8.  Bandura A. Self-Efficacy and Human Functioning. In: Schwarzer R (ed) Self-Efficacy: Thought control of action. 2 Park Square, Milton park, Abingdon, Oxon, OX14 4RN, U.K.: Routledge, 1992, pp.3-38.

9. Convery E, Hickson L, Keidser G, et al. The Chronic Care Model and chronic condition self-management: An introduction for audiologists. In: Seminars in hearing 2019, pp.007-025. Thieme Medical Publishers.

10. Austin B, Wagner E, Hindmarsh M, et al. Elements of Effective Chronic Care: A Model for Optimizing Outcomes for the Chronically Ill. Epilepsy & Behavior 2000; 1: S15-S20. DOI: 10.1006/ebeh.2000.0105.

11. Yardley L, Morrison L, Bradbury K, et al. The person-based approach to intervention development: application to digital health-related behavior change interventions. J Med Internet Res 2015; 17: e30. 2015/02/03. DOI: 10.2196/jmir.4055.

12. William G, Barr C, Meyer C, et al. Are You Providing Person-Centered Hearing Care? The Hearing Journal 2019; 72: 18-20.

13. Buck S. Nine human factors contributing to the user acceptance of telemedicine applications: a cognitive-emotional approach. J Telemed Telecare 2009; 15: 55-58. 2009/02/28. DOI: 10.1258/jtt.2008.008007.

14. Yellowlees P and Shore JH. Telepsychiatry and health technologies: a guide for mental health professionals. American Psychiatric Pub, 2018.

15. Dario C, Luisotto E, Dal Pozzo E, et al. Assessment of Patients' Perception of Telemedicine Services Using the Service User Technology Acceptability Questionnaire. Int J Integr Care 2016; 16: 13. 2016/09/13. DOI: 10.5334/ijic.2219.

16. Angley GP, Schnittker JA and Tharpe AM. Remote Hearing Aid Support: The Next Frontier. J Am Acad Audiol 2017; 28: 893-900. 2017/11/14. DOI: 10.3766/jaaa.16093.

17. Brannstrom KJ, Oberg M, Ingo E, et al. The initial evaluation of an Internet-based support system for audiologists and first-time hearing aid clients. Internet Interv 2016; 4: 82-91. 2016/01/26. DOI: 10.1016/j.invent.2016.01.002.

18. Amlani AM, Smaldino J, Hayes D, et al. Feasibility of Using a Smartphone-Based Hearing Aid Application to Improve Attitudes Toward Amplification and Hearing Impairment. American Journal of Audiology 2019; 28: 125-136. DOI: 10.1044/2018_aja-17-0068.

19. West RL and Smith SL. Development of a hearing aid self-efficacy questionnaire. Int J Audiol 2007; 46: 759-771. 2007/12/01. DOI: 10.1080/14992020701545898.

20. Smith SL and West RLJAJoA. The application of self-efficacy principles to audiologic rehabilitation: A tutorial. 2006.

21. Hickson L, Meyer C, Lovelock K, et al. Factors associated with success with hearing aids in older adults. J International journal of audiology 2014; 53: S18-S27.

22. Meyer C, Hickson L, Lovelock K, et al. An investigation of factors that influence help-seeking for hearing impairment in older adults. J International Journal of Audiology 2014; 53: S3-S17.

23. Kelly-Campbell RJ and McMillan A. The Relationship Between Hearing Aid Self-Efficacy and Hearing Aid Satisfaction. Am J Audiol 2015; 24: 529-535. 2015/12/10. DOI: 10.1044/2015_AJA-15-0028.

24. Boothroyd A and Mackersie C. A "Goldilocks" Approach to Hearing-Aid Self-Fitting: User Interactions. Am J Audiol 2017; 26: 430-435. 2017/10/20. DOI: 10.1044/2017_AJA-16-0125.

25. Brice S and Lam E. Comparing Teleaudiology and traditional audiology client journeys: what counts and what to consider. In: The 3rd British Society of Audiology E-Conference Online, 1-31st December 2019 2019.

26. Keach E. Investigation of Hearing Aid Provision via the First-fit Efficacy of Three Adaptive Dynamic Range Optimisation (ADRO®) Fitting Methods. University of Auckland, New Zealand, 2013.

27. Maidment DW, Ali YH and Ferguson MA. Applying the COM-B model to assess the usability of smartphone-connected listening devices in adults with hearing loss. Journal of the American Academy of Audiology 2019; 30: 417-430.

28. Dreschler WA, Keidser G, Convery E, et al. Client-Based Adjustments of Hearing Aid Gain: The Effect of Different Control Configurations. 2008; 29: 214-227. DOI: 10.1097/AUD.0b013e31816453a6.

29. Nelson PB, Perry TT, Gregan M, et al. Self-Adjusted Amplification Parameters Produce Large Between-Subject Variability and Preserve Speech Intelligibility. Trends Hear 2018; 22: 2331216518798264. 2018/09/08. DOI: 10.1177/2331216518798264.

30. Bajan N, and Blamey, P.. Maximising speech perception benefits; An investigation of ADRO fitting guidelines. In: Audiology Australia 2018 National Conference (ed Australia A), Sydney, NSW, Australia, 20-23rd May 2018 2018.

31. Nagy VT and Wolfe GR. Cognitive predictors of compliance in chronic disease patients. Medical Care 1984: 912-921.

32. Stephens D and Kramer S. Living With Hearing Difficulties: The Process Enablement. 2009. West Sussex, United Kingdom: John Wiley & Sons Ltd, 2009.

33. Preminger JE and Rothpletz AMJAJoA. Design considerations for Internet-delivered self-management programs for adults with hearing impairment. 2016; 25: 272-277.

34. Thorén ES, Öberg M, Andersson G, et al. Internet interventions for hearing loss. American Journal of Audiology 2015; 24: 316-319.

35. Meibos A, Munoz K and Twohig M. Counseling Competencies in Audiology: A Modified Delphi Study. Am J Audiol 2019; 28: 285-299. 2019/04/26. DOI: 10.1044/2018_aja-18-0141.

36. Monjot M. Counseling: a vital component to aural rehabilitation across the lifespan for the hearing impaired and their families. Capstone Project, Ohio State University, 2012.

37. Ferguson M and Henshaw H. Computer and internet interventions to optimize listening and learning for people with hearing loss: accessibility, use, and adherence. American Journal of Audiology 2015; 24: 338-343.

38. English K and Archbold S. Measuring the effectiveness of an audiological counseling program. International Journal of Audiology 2014; 53: 115-120.

39. Zolnierek KBH and DiMatteo MR. Physician communication and patient adherence to treatment: a meta-analysis. Medical Care 2009; 47: 826.

Monday, May 18, 2020

By Kathleen Wallace, AuD
 
               The COVID-19 outbreak has jolted nearly every aspect of human life into the virtual sphere, including how we work, connect with social networks, and receive health care. Yet, this shift has been far from equitable; it is highly dependent on one’s access and ability to utilize technology. As audiologists, we must be cognizant of these disparities as many of our patients need extra support in transitioning to the digital realm. While our patients’ ability to hear is likely at the forefront of our concerns, it would behoove us to also consider the value in using this time to improve our patients’ technology literacy. Perhaps the best service for our patients right now is to ensure they can communicate virtually with ease, for the sake of their livelihood, their health, and their mental wellbeing.
 
STEP 1: ENSURE ACCESS
 
With patient populations skewed towards the aging, access to now commonplace technology is certainly not a given. Older Americans, even more so for those who are low-income and non-white, display lower access to technology than the overall population.1 While 96 percent of Americans report currently owning a cell phone, only 53 percent of those over the age of 65 reported owning a smartphone, dropping to only 40 percent of those in the Silent Generation.2 Also, only 51 percent of seniors have access to high-speed internet3. Although these numbers have promisingly increased over the last decade, the actual use of technology is far from ubiquitous.
 
STEP 2: ASSESS ABILITY
 
Access alone does not equate to proficiency. Adults between 65 and 69 years old are nearly two times as likely as those over 80 years old to use the internet. This may be due to a difference in perceived value, however, a difference in comfort level is more likely responsible. Slightly more than one-third of older internet users reported little to no confidence in their ability to use an electronic device to perform tasks. Furthermore, nearly half (48%) of seniors stated that if they were to get a new device, they would need someone else to set it up or show them how to use it.3 This confidence gap likely perpetuates the lack of proficiency. Without sufficient training and orientation, their use of electronic devices may remain low.

Table 1 Wallace.jpg
 
STEP 3: FACILITATE ACCESSIBILITY
 
Technology is now at the forefront of our daily lives. Zoom, a major videoconferencing platform, reported 200 million Zoom call participants per day in March, a 20-fold increase over their numbers from March 2019.4 And with it came the occasional frozen screen, garbled speech, microphone malfunction, and onslaught of background noise—all of which spelled trouble for patients with hearing loss. Among audiologists, this tech support has not always been embraced but remains a realistic aspect of our job. Prior to the explosion of telehealth and virtual socialization, audiologists were well equipped to assist in the pairing of hearing aids to cell phones, provide instructions on app use, and implement the use of supplemental technology and accessories.
 
Audiologists are also veterans in counseling good communication strategies for people with hearing loss and their communication partners. Yet, with a change in our communication patterns, patients now require new digital communication strategies. Rather than focusing on how to best position oneself at a cocktail party, patients must now know how to troubleshoot a zoom call. Instead of reliance on lip reading, patients should feel empowered to utilize captioning.
 
By embracing the current tech-driven realities of our patients, we are embracing person-centered care and meeting the demands of their new hearing needs. As hearing healthcare providers, we aim to ease the reception of communication and to maintain social engagement. The best way we can do that in the current climate is to ensure our patients have the access, the ability, and the accessibility to utilize technology to its best ability. These lessons will build trust with patients and provide them with transferable tools to facilitate human connection and communication far beyond the current pandemic.

Tips Wallace.JPG

ABOUT THE AUTHOR: Kathleen Wallace, AuD, is a clinical audiologist at the New York Otolaryngology Group of Northwell Health in New York and an assistant adjunct professor in the AuD program at The Graduate Center of the City University of New York (CUNY). 

REFERENCES:
1. Pew Research Center,  “Fact Sheet Mobile” Pew Research Center, 12 Jun 2019  https://www.pewresearch.org/internet/fact-sheet/mobile/
2. Vogels, E. “Millennials Stand Out For Their Technology Use, But Older Generations Also Embrace Digital Life”, Pew Research Center. 9 Sept 2019, https://www.pewresearch.org/fact-tank/2019/09/09/us-generations-technology-use/
3. Anderson, M. & Perrin, A., “Tech Adoption Climbs AmongOlder Adults”, Pew Research Center, 17 May 2017, https://www.pewresearch.org/internet/2017/05/17/tech-adoption-climbs-among-older-adults/
4. Yuan, E, “A Message to Users”, Zoom, 1 Apr 2020,  https://blog.zoom.us/wordpress/2020/04/01/a-message-to-our-users/

Monday, May 18, 2020

By Jackie Clark, PhD; Jeremy Donai, AuD, PhD; Nina Kraus, PhD; Kenneth Smith, PhD; Sarah Sydlowski, AuD, PhD; and Fan-Gang Zeng, PhD

Editor's note: This article is published ahead of print. Send comments to hj@wolterskluwer.com. 

The global COVID-19 pandemic has caught us by surprise. People are now forced to stay at home, schools have been shut down, and hospitals have canceled or postponed nonessential surgeries and procedures, including those related to hearing.1 Although hearing health care providers were not included in the list of “Essential Critical Infrastructure Workers During COVID-19 Response,”2 clearly the ability to communicate remains an essential human function. Our main goal in this article is to examine the challenges faced by people with hearing loss and providers of audiological services during the pandemic while sharing some exceptional solutions in response to unprecedented situations. We also identify extraordinary opportunities that could positively impact audiological care and service delivery after the pandemic.

ESSENTIAL HEARING CARE

First, although the Office of Homeland Security did not classify audiologists as essential workers, there are audiological services that are unquestionably critical for sustaining the quality of life and cannot be dismissed or postponed. Patients with acute ear pain need to seek immediate care for potential causes related to infection of the ear, nose, or throat. Notably, sudden hear-ng loss requires immediate attention due to the short period (around two weeks) during which treatment can be effective in helping patients recover their hearing. For children whose long-term trajectories could be permanently altered by delays, cochlear implantation may also be considered. Finally, audiological diagnostics, monitoring, and evaluation are needed to support urgent and potentially life-threatening cancer or cholesteatoma surgeries. Interestingly, although the coronavirus has been shown to cause short-term sudden loss of smell and taste,3 little is known about its effect on hearing abilities at present.

Second, for people with hearing loss in this time of crisis, functional hearing and communication are essential to daily life. For example, some of the 13,000 deaf residents in Wuhan, the first pandemic epicenter in China, reported: “We are always a step slower than normal-hearing folks, from getting the latest news to [not] getting food and masks or waiting for buses that never showed up due to the lockdown.”4 The pandemic and the ensuing shelter-in-place and physical distancing measures have required people with hearing loss to rely on their limited hearing ability more than usual to get news reports from the radio, television, and internet, and/or to communicate virtually (via phone, Zoom, and other virtual platforms) with loved ones. One can easily imagine a situation where a hearing device user awakes to a nonfunctional hearing device (for whatever reasons); audiological care and service are certainly essential for these urgent and critical matters of safety and communication.

MASK.jpg
 
Figure. A sign language interpreter wears a transparent mask during a press conference in Beijing, China (published with permission from Beijing News4).

Third, the pandemic has posed an additional challenge unique to people with hearing loss. To minimize the spread of infection, personal protective equipment (PPE) such as face masks is required for health care providers and has been widely used by the general public. Face masks degrade the intensity and quality of acoustic signals and significantly im-pair lip-reading cues. A person with hearing impairment who contracted COVID-19 shared in a report: “I could not understand anything the doctor said because all the cues I rely on were distorted or unavailable with the masks and goggles.”4 Because a significant other was not allowed to accompany this patient, the doctor needed to write down everything, thereby taking away the physician’s time and attention from other critical tasks. With this reliance on written communication, one must also ask: What if the patient has vision problems, or what if the physician’s handwriting is difficult to read? A spokesperson at the Beijing COVID-19 Press Conference displayed a prototype self-made transparent mask to enable viewers’ lip-reading abilities (Figure). As wearing masks be-comes a new social norm, there is an urgent need to develop an acoustically and optically transparent mask.

IMPLEMENTING SHORT-TERM DEVELOPMENTS

Despite the previously described needs, the reality is that regular audiology services have been disrupted, including the effective and important universal newborn hearing screening and early hearing intervention programs.5 Even if some audio-logical services are available, many individuals, particularly the vulnerable elderly population, are often compelled to cancel or postpone in-office appointments for fear of infection. Audiological professionals have developed novel solutions to meet their patients’ needs during the current crisis.
 
  • Few have kept their offices open, serving mostly urgent care needs while limiting hours and patient contact and employ-ing stringent safety measures. Walk-in visits are either not allowed or require additional screening before accommodating the urgent need.
  • Some practices have adopted drive-through or curbside services where a hearing health provider can deliver devices, accessories, or batteries to a patient or the patient can return them without entering the office. Andrea Yost, AuD, the owner of Yost Hearing in Morgantown, WV, shared: “Offering drive-up services has allowed us to serve our patients, especially the vulnerable elderly population, during this difficult time. Initially, the goal was to create a sense of security and ease of access for our patients, which it has, but I honestly can see the potential for this delivery approach in the future.”
  • Many offices have added teleaudiology services that may include a patient’s virtual visit via telephone or videoconference for post-hearing aid fitting follow-up. Recent technological advances allow audiologists to remotely connect their computer to a patient’s hearing aids or a remotely located cochlear implant programming computer to make adjustments or conduct subjective evaluations, log data, provide counseling, and, in some instances, conduct hearing aids real-ear measurement and on-ear verification. With the proliferation of YouTube videos, many resources can be recommended to patients as a supplement to interactions with an audiologist or an audiology assistant. In a shelter-in-place scenario, the challenge still arises in the use of field-validated diagnostic (air, bone, speech in noise, immittance, otoscopy, otoacoustic emissions) audiometry for new patients without an assistant facilitating the equipment on the patient side.
  • Telerehabilitation has been utilized in the effective delivery of counseling and support. For example, Henry and col-leagues6 have developed an effective telehealth-based progressive tinnitus management system for veterans who live in remote areas or have mobility issues, but the system is now providing flexibility and expanded care to telehealth during the current crisis. A challenge is to provide telerehabilitation for children whose parents may not have time to supervise them at home.
  • Tele-education is perhaps the biggest winner of them all. Online-based learning has been criticized for various concerns such as the following: It’s difficult to build a trusting relationship online, the quality is not the same as face-to-face education, someone with lesser or no skills can take over the academic domain, or it’s just too difficult and confusing. Many are realizing what enterprising progressive professionals have known for years: There is a panacea of online interaction options to ensure that all contact is con-textually driven to meet the learners’ emotional and physical needs using available resources. Every aspect of clinical and academic interactions has been achieved through videoconferencing,­ online videos, and content/instructions delivered through electronic messaging or simply by phone. Many years ago, this restricted, gray, drab, and one-dimensional world was replaced by a vibrant, multidimensional, and global domain, ready to be molded into the contextual needs of individuals. Although videoconferencing can pose challenges to people with hearing difficulties because degraded signals and subtle audiovisual asynchronies require greater listening effort, several strategies and tools can optimize this encounter. For example, use instant captioning and translation services that may be provided by some vendors (e.g., Google) or require a third-party plug-in (e.g., Zoom). Remove other accessories on computers and around the videoconferencing space that may be distracting, posing challenges to individuals with auditory processing difficulties, which often overlap with attention difficulties. If you’re leading a meeting or class, en-courage frequent breaks (at least two to three minutes rest for every 30 minutes of the meeting). With consent, con-sider recording meetings or lectures so your colleagues or students can review them later at their own pace.
LONG-TERM COMMITMENT

Teleaudiology, telerehabilitation, and tele-education have produced an unprecedented and widespread use of innovative technology for business matters and personal interactions. Swanepoel and Hall in the June 2020 issue of The Hearing Journal7 estimated that existing technology can serve 95 percent of adults with hearing loss in low- and no-touch models of audiological care. The pandemic is pushing for innovations in remote technologies in audiology. One such technology is a smartphone-based system that can perform otoscopy and tympanometry with commonly available accessories at home while making an initial diagnosis or uploading the data for an expert opinion. Recently, the University of Washington researchers developed a smartphone-based system that not only outperformed a commercial acoustic reflectometry system in detecting middle ear fluid in children but, more importantly, could be easily operated by parents without formal medical training.8 Though it is unknown whether most parents will want to purchase technology for infrequent use, the palette has been prepared for a beautiful picture of the future of ear and hearing provision.

In addition to some technical limitations that are rapidly being mitigated by manufacturers, regulation and reimbursement remain the primary barrier to accessing teleaudiology and telerehabilitation care and service. Effective for services starting March 6, 2020, and for the duration of the COVID-19 public health emergency, Medicare could broadly utilize their waiver capability to allow payment for expanded telehealth service by recognized providers for certain codes.9 This flexibility allowed for the rapid deployment of remote health care services for recognized providers, allowing many health care systems to quickly pivot from delivering the majority of outpatient care in person to delivering these services remotely. Regulatory modifications prevented numerous barriers to health care that would have otherwise been suffered by ­patients unable to be seen in person. However, hearing and balance services were initially excluded. Fortunately, on April 30, 2020, the waiver was expanded to include all providers who are eligible to bill Medicare for their professional services, including audiologists.10 Additionally, cochlear implant programming codes (92601-92604) have been approved to be billed using telehealth.9 The current situation helps audiologists highlight the importance of being recognized similarly to other non-physician providers to ensure continuity of care for patients. In the short term, the extension of this waiver to audiologists will allow audiologists flexibility to provide some re-mote care to patients where state law allows. Providers may also benefit from directly reaching out to commercial payers to ensure that audiology codes are at least temporarily approved for remote delivery. In the long term, the passage of legislation that classifies audiologists as practitioners will be essential.

To ensure financial viability during times of reduced revenue, audiology practices are finding ways to maximize their cash on hand and are considering future investment opportunities that generate non-operational revenue. In consultation with certified accountants, practice owners need to develop a rainy day fund to cover business expenses for a pre-determined number of months and situations similar to the current crisis. The fact that many companies are reporting difficulty obtaining funds from the governmental Payroll Protection Program highlights the importance of this planning. Doing so will help protect against a break in vital service delivery during emergencies that require physical distancing and result in subsequent reductions in operational revenue.

LOOKING AHEAD

Without a doubt, we have learned many important lessons— sociologically, psychologically, and professionally—during this pandemic. Some beautiful examples are the national and international virtual concerts that are bringing humanity together during this challenging time. In the same way, the challenges of COVID-19 have created a tremendous opportunity for audiological communities to change, improve, and expand care and service delivery by embracing new technologies and developing new business models. Drive-through services and teleaudiology have met physical distancing requirements while providing a high level of patient convenience and satisfaction. Technological advances in artificial intelligence and virtual reality have the capability of removing place, time, and even language barriers to some-day allow an audiologist in Australia to counsel a patient in Africa in troubleshooting a malfunctioning hearing aid or a patient in the United States to seek tinnitus relief from a meditation practitioner in India. Vast opportunities lie in advocating for telehealth legislation on local and national levels, as well as updating the scope of practice at state licensing lev-els. COVID-19 shall pass eventually with lifestyle changes and development of effective drugs and vaccines, but it has provided a once-in-a-lifetime opportunity for audiology to learn and fully embrace new clinical technologies and business models for improved reimbursement, service delivery, and patient satisfaction.   

ABOUT THE AUTHORS: Dr. Clark is a clinical professor at the University of Texas at Dallas. Dr. Donai is an assistant professor in audiology at West Virginia University. Dr. Kraus is a professor of auditory neuroscience at Northwestern University. Dr. Smith is the vice president and director of operations for the Hearing Center of Castro Valley in California. Dr. Sydlowski is the audiology director of Cleveland Clinic’s Hearing Implant Program. Dr. Zeng is the director of the Center for Hearing Research and a professor at the University of California, Irvine. The authors are members of The Hearing Journal Editorial Advisory Board, with Dr. Zeng as the chairman.

Thoughts on something you read here? Write to us at hj@wolterskluwer.com.

REFERENCES:
1. Woodson, E, and Sydlowski S. CI Surgery Cancellations due to COVID-19. The Hearing Journal. 2020;73(4);38.
2. Cybersecurity and Infrastructure Security Agency, 2020. https://www.cisa.gov/publication/guidance-essential-critical-infrastructure-workforce
3. Lechien, et al. Olfactory and Gustatory Dysfunctions as a Clinical Presentation of Mild-To-Moderate Forms of the Coronavirus Disease (COVID-19): A Multicenter European Study. Eur Arch Otorhinolaryngol. 2020 Apr 6;1-11. doi: 10.1007/s00405-020-05965-1.
4. The Beijing News. Feb. 20, 2020). http://www.bjnews.com.cn/feature/2020/04/22/719838.html
5. Yoshinaga-Itano, C. Challenges to EHDI Systems Amid the COVID-19 Crisis. The Hearing Journal. 2020;73(5);34.
6. Henry, J, et al. Telehealth-based Progressive Tinnitus Management. The Hearing Journal. 2020;73(5);32.
7. Swanepoel, DW, and Hall, J. Audiology Provisions During a Pandemic. The Hearing Journal. 2020;73(6);20.
8. Chan, et al. Detecting middle ear fluid using smartphones. Sci Transl Med. 2019 May 15;11(492):eaav1102. doi: 10.1126/scitranslmed.aav1102.
9. CMS, 2020. https://www.cms.gov/Medicare/Medicare-General-Information/Telehealth/Telehealth-Codes).
10. CMS, 2020. COVID-19 Emergency Declaration Blanket Waivers for Health Care Providers. https://cdn.ymaws.com/www.acialliance.org/resource/resmgr/advocacy/summary-covid-19-emergency-d.pdf

Monday, May 4, 2020

By Grace Smith
 
When beginning our doctoral careers in audiology four years ago, the Class of 2020 shared a common daydream throughout grueling clinic days and study sessions. Dozing off in-between masking dilemmas, I vividly imagined the day we would walk across a stage, smiling to our friends, family, and mentors, finally being presented as Doctors of Audiology—a white coat pushing any lingering thoughts of imposter syndrome to the auditorium floor while entering our long-awaited futures.
 
Like the rest of the world, audiology students received news of COVID-19’s impact slowly at first. Perhaps an email was sent with precautionary changes to a work schedule, a conference cancelled, or instructions were relayed to stay at home as clinical sites determined how to proceed with ever-changing public health updates. Many students, including myself, initially did not mind the extra—and seemingly temporary—time to finish up doctoral theses and research projects, edit résumés, and apply for jobs while preparing for a graduation ceremony that we thought would still happen. After three years of academia and clinical externships, full-time clinical work as residents in our fourth and final year left little time for these tasks, so these transitionary days felt like a respite. However, this feeling would soon be replaced with grim emails and meetings escalating in severity to match an advancing pandemic crisis.
 
Full-time residency placements quickly dismissed student and resident clinicians as state mandates intensified. Universities made recommendations to bar students from participating in clinical activities and to transition to online learning. Our graduating class realized, with most of us resigned to our living rooms, that our final year as doctoral residents concluded before celebrations of a lifelong achievement could even commence. The seemingly endless existence as a student suddenly was eclipsed by poignant concerns of our identities as soon-to-be audiologists now entering a world of health care that has changed permanently.   
 
A REMOTE FINISH LINE
 
The landscape of the final weeks of the academic year has become unrecognizable. Worry and helplessness took up their own residencies in our thoughts. With a premature ending to our required clinical experiences, many members of the graduating class are saturated with questions: Do I have enough patient contact hours to graduate and obtain licensure? Will I have to defend my thesis on Zoom? Are my supervisors in good health as they continue to see patients for essential appointments? Is a job also just a daydream now? Am I being selfish?
 
From simulated appointments replacing in-person patient contact hours, to navigating a shrinking job market as current hearing care providers become unsure of their own livelihood, audiology students are not alone in their current post-grad outlooks. “There’s a lot of uncertainty about the potential of jobs as many clinics are at a standstill. There is not much that can be done when the world is in quarantine,” said Victoria Dillon, a fourth-year doctor of audiology (AuD) student at the CUNY Graduate Center. Dillon’s uneasiness about job security appears to be shared by other graduating students. Evangeline Wong, a fellow fourth-year AuD student at the CUNY Graduate Center, commented on the situation’s dissonance: “It’s an unfortunate situation as our celebrations and accomplishments seem to be diminished during this uncertain time, yet our anxiety and stress around finding employment have only been amplified.” Wong’s concerns are not unfounded. Many clinics, whether under the umbrella of a major hospital system or an independent private practice, have turned their focus to supporting current staff while designing plans for re-opening skeletal patient schedules in the future. Moreover, audiologists practicing in hospital settings have faced discussions of redeployment efforts to assist COVID-19 front line staff if possible, introducing more evidence that clinics are far from ready to get back to their previous routines. With these realities in mind, it is a daily battle to remain tenacious and optimistic.
 
FLATTENING THE CURVE WITH SOARING RIGOR
 
Between unexpected hiring freezes and budget cuts, audiology students accustomed to taking initiative and being proactive—qualities that carried them through their doctoral programs—are questioning how to maintain that momentum. Some students have utilized this opportunity to expand their foundational skillsets, as well as deepen their understanding of familiar topics, which previous busy patient schedules left little time for. Similar to participating in programs for Continuing Education Units (CEUs) required for practicing audiologists to maintain licensure or certification, fourth-year AuD students, like myself, began to organize trainings with industry manufacturers to stay sharp while flattening the curve. Online courses, which are popular continuing education and professional development resources for audiologists, have also become a daily companion for both new and experienced clinicians. Whether sessions focused on exploring single-sided deafness fitting strategies, enhancing programming software literacy, or asking questions about product offerings, fourth-years have shown they are committed to staying engaged regardless of their work environment. 
 
It is safe to say that priorities have shifted not only in the job marketplace, but also in how practicing audiologists are assessing ways to move forward. Despite a video conference sign-off not quite providing the closure we anticipated, observing how the audiology corner of health care is evolving with COVID-19 is captivating. With physical distancing becoming part of our new normal, personal protective equipment (PPE) remaining a luxury, and technology savviness being necessary to maintain a business, questions about how to continue providing patient-centered care safely and ethically have overwhelmed the audiology community.
 
Professional collaboration and networking on social media among audiologists have risen to new heights. My membership in these specialized groups has given me a window into what obstacles more seasoned providers are facing every day. Recommendations and considerations when embarking on telehealth, patient stories of hope and positivity, and updates from audiology professional organizations are just a few topic areas covered. I know I am not the only student who is touched by the brilliance of the clinicians paving the way for innovative patient-centered care in today’s health care climate.
 
Any perceptions that the Class of 2020 has less clinical experience or is unprepared for clinical practice due to COVID-19 interruptions should be dismissed. Students rose to the occasion, gaining skills in crisis management and problem-solving in novel circumstances. Students have also worked to stay connected to their former residency sites, aiding their teams through any and all remote assistance. Anything from writing new clinical protocols and investigating technical difficulties specific to telehealth, to offering insightful perspectives from their personal experiences during the pandemic, fourth-years did not dwindle in their participation in various clinical projects. Students’ readiness to lend a helping, albeit gloved, hand hopefully will not go unnoticed by future supervisors and colleagues as a testament to their resilience. Lauren McCauley, another fourth-year AuD student at the CUNY Graduate Center, echoed this sentiment. “No one could have predicted the situation we’re in. We want to be happy and celebrate, but it’s difficult when the ramifications of what’s happening are far-reaching and widespread,” she said. “There’s not much to do other than hope we’ll return to our new normal soon and be needed in our field.”
 
While we settle into this new normal, admiring the privilege of what working in health care stands for, the newest doctors of audiology are rebuilding their day-dreams to include life beyond the auditorium stage. Better yet, we are gaining the confidence to transform these dreams into realities as the world offers us opportunities for innovation and creative thinking like never before. And what better cause for celebration than the start of new traditions? So, join me in congratulating the Class of 2020, one masked smile at a time. 

GSMITH HEADSHOT.jpgABOUT THE AUTHOR: GRACE SMITH is a fourth-year AuD student at the City University of New York (CUNY) Graduate Center. She is completing her residency at Lenox Hill Hospital’s New York Head and Neck Institute in Manhattan.

Thoughts on something you read here? Write to us at hj@wolterskluwer.com.