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Monday, August 9, 2021

In this month's Special Issue, Audiology Business Handbook,​ we discuss “all things business”—from strategies to successfully run a lucrative private practice, to financial management of investments/divestments, to marketing initiatives that effectively ​promote your products and services, and more. To set the stage for this discussion, we ask audiology owners and experts critical questions that explore the fundamental query: Is private practice right for me? Read on and share your thoughts. 

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Tuesday, June 15, 2021

By Gordon Glantz

Editor's note: This is an online-exclusive supplement to the June 2021 cover story. Read it here. 

While Led Zeppelin may have unknowingly caused hearing loss with its music, one song – “Communication Breakdown"—still resonates like an amplifier from Jimmy Page's electric guitar.

Ironically, there is a major disconnect—or communication breakdown, if you will—between primary care physicians/geriatricians and audiology professionals.

Studies show no more than 50 percent (and that might be generous) of PCPs discuss hearing loss with age 50-plus patients at office visits.

This is the age group where there is an opportunity to be more proactive.

For geriatricians, the numbers are not much better with patients 65 and over.

Well aware of the situation is Dr. Virginia Gural-Toth AuD CCC/A, who is the manager of the Tinnitus, Balance and Audiology Programs at Hackensack Meridian Health JFK Johnson Rehabilitation Institute in Edison, NJ with over 30 years of clinical experience specializing in tinnitus management and amplification.   

“As a profession, audiology needs to be proactive in informing the PCPs of the services we provide and the positive outcomes that are achieved," said Gural-Toth. “For example, the positive impact treating hearing loss has on cognition in the elderly. An opportunity exists for the audiologist to contact the PCPs directly to discuss results as opposed to just forwarding a report."

She went on to add that communication can establish rapport, engage in a question and answer discussion, and is a great educational tool for teaching the PCPs about the benefits of audiology.

Danielle S. Powell, AuD, PhD, has a clinical background as an audiologist, completing her AuD in 2013. She worked in the greater Washington D.C. area for a number of years before beginning a PhD program in Epidemiology at the Johns Hopkins Bloomberg School of Public Health in 2017, where she was a fellow at the Cochlear Center for Hearing and Public Health.

“I can kind of think about two main breakdowns between PCP/geriatrics and audiology," she said. “For many, even other health care providers, as a field, we haven't made hearing and hearing test results very easily understood. Terms like 'mild or moderate hearing loss' are meaningless to others out of context.

“While the attention of primary care physicians and geriatricians towards hearing has grown in recent years, there is, of course, a long way to go."

 Gural-Toth also brought up the issue of consumers directly accessing information about audiology on the internet rather than through their PCP.

She said: “The wealth of information that is available can be confusing to the consumer on how to access services. In light of this, having an informed PCP helps guide the consumer to the correct professional and service."

As for the idea of self-administered tests, lasting 1-2 minutes that patients can take as part of their visits to the doctor, Gural-Toth could foresee better outcomes.

She noted benefits to a quick screen as a preliminary test during a physical to confirm suspected hearing loss and let the consumer know when they need to see an audiologist. 

“However, there are limitations to these quick screens including the type of device used, the way it was administered as well as the noise in the room when it is administered," she said.  “All of these limitations can lead to both false positives and false negatives." 

Also, audiologists on the long list of specialists—eye doctors, dentists, podiatrists, etc. —that were, and still are, placed on hold due to COVID.

“It has been our experience, during the height of the pandemic, that consumers were not returning," said Gural-Toth. “However, that trend seems to be slowly changing. To counter some of these fears, we provided information to our patients as well as offered curbside hearing aid services for those that were concerned about entering the facility."

In addition to age, the role of socio-economics with older people (lack of transportation, etc.) looms large with older patients not seeing the process all the way through.

This can be the case, even if they are referred to an audiologist from a primary care physician/geriatrician.

“As professionals, we are concerned about the social determinants of healthcare that create barriers to patients receiving healthcare including Audiological care," said Gural-Toth, adding that audiology professionals must work toward a common goal of removing these barriers.

She added: “Whichever it is -- transportation, cost of services, or lack of knowledge of our services, working with local agencies for transportation services, offering payment plans as well as working with our PCPs to help the consumers understand our services are just a few things that we can do."

Powell is aware of the same hurdles.

“For parts of the country, simply having access to hearing care can pose significant challenges as there are regions, especially in rural areas, where older adults have to drive extended lengths to reach a hearing provider," she said. “Many other older adults, in general, find navigating the health care system – and Audiology services in particular with all of the steps involved like additional appointments with PCP and ENT – very challenging and therefore get lost in the process."

 Going forward, Gural-Toth views bridging the communication gap as a grassroots effort.

“Audiology has an opportunity to work with their local communities and PCPs to educate them on the services we provide," she said. “On a national level, Audiology has an opportunity to become more involved in their organizations to promote more visibility and support these initiatives that allow for greater access to services."

Powell pointed to campaigns such as “Know Your PTA" as being lifelines, in terms of what a given degree of hearing loss means, as it presents new ideas on ways in which those outside the realm of Audiology and Otolaryngology can better understand hearing loss and communication needs.

“This, in turn, may help educate patients and providers on the impacts of hearing loss and potential treatment strategies," she explained. “Up until recently, however, our research evidence hasn't really shown the importance of hearing loss across other aspects of health beyond communication ability. This will take time to sink in for providers across other disciplines."

Editor'​s note: This is an online-exclusive supplement to the June 2021 cover story. Read it here. 

Wednesday, April 28, 2021

By John Eichwald, MA; Padmaja Vempaty, MSW, MPH; and Yulia Carroll, MD, PhD

NOTE: This article is published ahead online. 

The Noise Control Act of 19721 directed the Environmental Protection Agency (EPA) to protect the health and welfare of Americans from unregulated noise and formed the EPA Office of Noise Abatement and Control (ONAC). In 1974, ONAC recommended an equivalent sound exposure level of 70 decibels over a 24-hour period to protect the public from hearing loss.2 At that time, ONAC also recommended levels regarding interference or annoyance of 55 and 45 decibels for outside and inside activities, respectively. In 1982, ONAC was defunded, transferring the primary responsibility of regulating noise to state and local governments. An analysis of 491 U.S. noise ordinances in 20163 revealed most communities used multiple standards to regulate noise exposure including nuisance, zoning, audibility decibel levels, time of day, and distance.

METHODS

Investigators reviewed and classified 60 existing community noise ordinances. Searches were conducted on local government webpages or via legal code databases. The 10 most populated U.S. cities were analyzed as well as 50 community noise ordinances randomly chosen from across the nation. Ordinances were specifically reviewed to identify 22 key aspects of noise ordinances. These included five key noise control measures: audibility, time of day, decibel level, zoning, and specified quiet zones to protect vulnerable communities (e.g. hospitals, schools). Ordinances were also reviewed for legal language identifying the entity or agency responsible for enforcement and the penalties, if any.

RESULTS

Of the 60 jurisdictions reviewed, 32 (53.3%) were small, 16 (26.7%) were medium, and 12 (20.0%) were large. Sound sources that were specified by law were identified in all but two (96.7%) of the ordinances. Time-of-day restrictions were found in 55 (91.7%). Zoning restrictions were used in 53 (88.3%) jurisdictions. Activities deemed to be noise disturbances were specified in 46 (76.7%) ordinances. Disturbing the peace was identified in 50 (75.0%), nuisance/annoyance in 42 (70.0%). Audibility, decibel level, and quiet zones were included in 37 (61.7%), 35 (58.3%), and 29 (48.3%) of the ordinances, respectively. Restrictions on vehicles were found in 52 (86.7%) and noisy animals in 31 (51.7%) of the ordinances.

Law enforcement, e.g., the police or sheriff, was identified as at least one of the designated authorities in charge of the noise ordinance in 31 of the reviewed ordinances. Officials in charge of codes, inspections, and other types of regulations were identified in 12 (20.0%) of the ordinances. Health agencies were listed as having authority in 10 (16.7%). Noise control authorities were clearly specified in 4 (6.7%) ordinances. Jurisdictional administration, such as the city council, and other administrative offices, e.g., housing, animal control, public safety, had authority in 20 (33.3%). In 14 (23.3%) ordinances, the authority of regulation was not identified or unclear.

Figure 1. Penalties and enforcement identified in community noise ordinances.

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Among the 60 communities, 40 (66.7%) included fines in their ordinances. Civil penalties or infractions were found in 21 (35.0%). Charges of misdemeanor were listed as penalties in 18 (30.0%), and 6 (10.0%) stated violation could result in imprisonment. In 21 (35.0%) jurisdictions, local ordinances specified that infractions constituted a civil violation. As shown in Figure 1, seven communities (11.7%) had no penalty and no enforcement clauses in their noise codes, two (3.3%) had enforcement but no penalties, six (10.0%) had penalties but no enforcement, and 45 had both written enforcement and penalties. Among the ordinances reviewed, communities with enforcement and penalties written into their noise ordinances were mostly in the South and coastal States. It should be noted that community noise ordinance might not have penalties or enforcement if a superseding chapter for penalties and enforcement supplants multiple ordinances in the code. Some of the ordinances reference a superseding chapter, others do not. Because only ordinances with the word “noise" in the title were reviewed, cross-referenced penalties and enforcement were not identified. Figure 2 shows the number of key noise control measures identified within the jurisdiction's ordinance. All five of the measures were identified in 14 (23.3%) communities, 17 (28.7%) communities had four of the five, and 29 (48.3%) had three categories or fewer.

Figure 2. Number of key noise control measures (pink ≤ ​3, red = 4, and maroon = 5). Noise control measures: plainly audible, time of day, decibel levels, zoning, and quiet zones (e.g. hospital or school).

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DISCUSSION

Exposure to loud sounds puts millions of people in the United States and across the globe at risk not only of hearing loss, but several highly prevalent health effects including ischemic heart disease, hypertension, injuries, anxiety, sleep disruption, stress, and cognitive impairments.4,5,6 While three of four of the jurisdictions reviewed cited annoyance, nuisance, or disturbance as a primary purpose for the noise control ordinance, only slightly more than half cited health as a primary purpose.

Almost all jurisdictional noise ordinances reviewed included time-of-day restrictions, demonstrating that communities recognize excessive noise at certain hours can be more problematic. Half of the jurisdictions listed the police or sheriff's department as the enforcement authority. Only four communities had a noise control officer, or a specific noise control authority identified. As a result, noise enforcement relegated to the responsibility of police departments may not be prioritized as a violation. Of concern is the finding that nearly one-fourth of noise ordinances did not have an enforcement body identified, although a general enforcement statute may be listed elsewhere in the local code. If a community has a noise ordinance and a disturbing the peace ordinance, it may be easier for law enforcement to cite disturbance of the peace, which is likely more subjective and has less stringent legal requirements.

Although the number of key noise control measures in a jurisdiction reveals the variety of methods used, it is not necessarily a measurement of its effectiveness. A community could potentially include all five of the controls but find them ineffective, confusing, and difficult to enforce. Objective measurements might not be available for noise monitoring, or enforcement officials may not have the necessary training to properly utilize noise measurement equipment. In such situations, enforcement officers might be more likely to cite a more subjective ordinance, such as disturbing the peace. This review did not account for noise regulations included in ordinances related to disturbance of the peace, land use or zoning, and in other parts of the local code. These regulations are not always cross-referenced in the noise ordinance.

To help offset the harmful effects noise may have on health, ordinances can incorporate quiet zones into communities. Quiet zones, or noise-sensitive zones, can be designated in areas that should have a lower threshold for noise, such as areas with hospitals or elderly care homes. Issues such as sleep disturbance affect the elderly and persons with chronic illness.7 Schools and daycare centers should also be in quiet zones, as even moderate traffic noise does not detract from academic performance.8

PUBLIC HEALTH IMPLICATIONS

Because local jurisdictions do not have up-to-date federal noise guidelines to follow, local noise ordinances reviewed in this article are varied in terms of their noise control strategies, enforcement, and penalties. With up-to-date guidelines that consider the health implications of noise and recent noise monitoring technology, jurisdictions might be better informed and could follow a set of common standards. State and local governments might consider using the World Health Organization's Environmental Noise Guidelines for the European Region9 as a framework when crafting their legislation to protect health from exposures of environmental noise.

​ABOUT THE AUTHORS: Mr. Eichwald is an audiologist within the Office of Science at the Centers for Disease Control and Prevention (CDC) National Center for Environmental Health (NCEH). Ms. Vempaty is a Public Health Analyst for Policy and Issues Management in the CDC/NCEH Division for Environmental Health Science and Practice. Dr. Carroll is the Associate Director for Science at the CDC/NCEH Division for Environmental Health Science and Practice.

ACKNOWLEDGMENTS: The authors thank Monica S. Hammer, JD and Les Blomberg, MA for their expert advice on noise ordinances; the in-kind support of the CDC Center for State, Tribal, Local, and Territorial Support, Public Health Law Program; and Mahad Gudal, a Morehouse College IMHOTEP program summer intern.

DISCLOSURE: The findings and conclusions in this report are those of the authors and do not necessarily represent the views of the Centers for Disease Control and Prevention/the Agency for Toxic Substances and Disease Registry. 

REFERENCES:

  1. Noise Control Act of 1972, 42 USC. §4901–4918 (1988). Available at: Noise Control Act of 1972, 42 USC. §4901–4918 (1988). Available at: https://www.law.cornell.edu/uscode/text/42/chapter-65. Accessed April 26, 2021.
  2. United States Environmental Protection Agency. Information on levels of environmental noise requisite to protect public health and welfare with an adequate margin of safety. No. 2115. US Government Printing Office. EPA Publication No: 550976003 https://nepis.epa.gov/Exe/ZyPDF.cgi/2000L3LN.PDF?Dockey=2000L3LN.PDF. Published March 1974. Accessed April 26, 2021.
  3. Blomberg, L. Preliminary results of an analysis of 491 community noise ordinances. Paper presented at: NOISE-CON; June 13-15, 2016; Providence, Rhode Island. https://nonoise.org/regulation/preliminary%20results.pdf. Accessed April 26, 2021.
  4. World Health Organization. World report on hearing. https://apps.who.int/iris/bitstream/handle/10665/339913/9789240020481-eng.pdf?sequence=1. Published March 2021. Accessed April 26, 2021.
  5. Hammer MS, Swinburn TK, Neitzel RL. Environmental noise pollution in the United States: developing an effective public health response. Environmental health perspectives. 2014;122(2):115-9. https://doi.org/10.1289/ehp.1307272.
  6. Münzel T, Schmidt FP, Steven S, Herzog J, Daiber A, Sørensen M. Environmental noise and the cardiovascular system. Journal of the American College of Cardiology. 2018;71(6):688-97. https://doi.org/10.1016/j.jacc.2017.12.015
  7. Kim R, Van den Berg M. Summary of night noise guidelines for Europe. Noise and health. 2010;12(47):61-63. doi: http://dx.doi.org/10.4103/1463-1741.63204.
  8. Wilensky J, Winter M. Quiet zones for learning. Human Ecology. 2001;29(1):15. https://search.proquest.com/scholarly-journals/quiet-zones-learning/docview/213829069/se-2?accountid=26724.
  9. World Health Organization. Environmental noise guidelines for the European region. Available at: www.euro.who.int/en/env-noise-guidelines. Published 2018. Accessed April 26, 2021. 

Wednesday, April 21, 2021

As automated audiometry becomes more widespread for busy clinics and teleaudiometry, GSI interviewed Dr. Robert Margolis to discuss his automated method for testing auditory sensitivity (AMTAS).

GSI: What motivated you to think of automated audiometry?

Dr. Margolis: When I was the director of the University of Minnesota Hospital Audiology Clinic I was dissatisfied by the amount of time my highly-trained, competent staff was spending doing pure-tone audiometry which occupied more of their time than any other billable activity. Two experiences solidified my belief that this was an inappropriate use of professional time.

I performed a hearing evaluation on a highly-educated professional man who, after watching me through the window of the sound booth, said “Why do you have to push those buttons?" It was obvious to him that the procedure was perfectly amenable to automation. Why was I pushing those buttons when Wayne Rudmose said in 1963: The number of audiometric examinations made today has grown to such a magnitude that it is only natural that some of the techniques of measurement should become automated (Rudmose, 1963).

Not long after that, I had an unpleasant meeting with the hospital director who questioned whether my staff was productive enough. When I pointed out that they typically were in the clinic until 6 and then took reports home to write, she offered, "Maybe you need to automate some of those procedures".

Since that time, I have looked outside the walls of the clinic. In the U.S. the number of hearing tests that can be conducted by all the audiologists is less than half of the need (Margolis & Morgan, 2008). Most countries don't have any audiologists. Increasing access to hearing testing has become my major goal in developing automated tests.

GSI: How does automation help audiologists?

Dr. Margolis: Automated audiometry helps audiologists by allowing more efficient use of their time, increasing the accuracy and repeatability of test results, and standardizing our test methods. Perhaps more importantly, automation helps hearing-impaired people by increasing access to audiology services.

GSI: How can audiologists trust the results?

Dr. Margolis: Over time, audiologists become very good at assessing the quality of their test results and modifying their technique to ensure accuracy. The information they use to determine accuracy can be incorporated into an automated test and then the computer can do it better than a human. We developed a method for assessing the quality of automated test results that statistically estimates the accuracy of the test (Margolis 2007). Computer programs for measuring auditory thresholds have been around since the 1960's. When you take the audiologist out of the procedure, it is not the process of selecting and presenting stimuli that is lost, it is the expertise of the audiologist for ensuring accuracy. Quality control is a critical feature of automated clinical tests.

GSI: How does the audiologist build rapport with the patient if he or she isn't doing the pure tones?

Dr. Margolis: That's a riot. One of my favorite audiologists told me that manual pure tone audiometry is important for building rapport with patients. My experience has been when you put someone in a metal room, close the doors, watch them through a dimly lit window, and ask them to listen to sounds they can barely hear, I don't make any friends. I have to build rapport in other ways.

GSI: Has automated audiometry been evaluated in real-world situations?

Dr. Margolis: Automated audiometry trials have been conducted in a variety of clinics in at least four countries and in the homes of hearing-impaired people. There is a growing literature that establishes the validity of automated tests.

GSI: How was the development of automated audiometry funded?

Dr. Margolis: Some equipment manufacturers developed automated protocols for pure-tone audiometry internally. That kind of development is proprietary and manufacturers usually don't share their validation methods and results. AMTAS® was developed with funding from the U.S. National Institutes of Health and the U.S. Department of Veterans Affairs. Validation methods and results are published in the audiology research literature.

GSI: Can you bill for automated hearing tests?

Dr. Margolis: In 2010 the Centers for Medicare & Medicaid Services (CMS) established Category III CPT codes for automated hearing tests (pure-tone and speech audiometry). Category III codes (sometimes called t-codes) are for emerging technologies. It is legal to bill using Category III codes but they may not be reimbursed. The Category III codes for automated audiometry are scheduled to be sunsetted in 2026. There is an effort underway to convert the Category III codes to Category I codes.

GSI: What is the business case for using automated tests if they are not reimbursed?

Dr. Margolis: Clinics should analyze the costs and revenue associated with their services. With the low level of reimbursement for pure-tone audiometry, and the cost of doctoral-level clinicians, the personnel costs probably exceed the revenue. It is not cost-effective to use doctoral-level practitioners to perform routine tests that can be automated if the reimbursement doesn't exceed the cost of the professional time. That time can be used more profitably for clinical services that require the skills of audiologists.

GSI: What other audiologic tests can be automated.

Dr. Margolis: Some already are. The first clinical instrument for tympanometry required the user to set the ear-canal air pressure manually and acquire the tympanogram point by point. It was quickly automated (without a peep from the audiology community). Several electrophysiologic tests are automated or semi-automated. Automated speech recognition tests have been developed and validated. Speech-recognition thresholds and word recognition scores can be obtained by an automated forced-choice procedure that requires the patient to select the response from a set of alternatives presented visually. The test scores differ from those we obtain with open set tests because chance performance is 1 over the number of alternatives (25% if there are four alternatives). Forced-choice tests have been around for decades and are a perfectly legitimate way to measure speech recognition ability but require different interpretation guidelines than our usual open-set tests.

GSI: If Rudmose said we should automate our hearing tests in 1963 why has it taken so long?

Dr. Margolis: When I started working on automated hearing test in 2000, I was shocked at the resistance from many audiologists. I expected audiologists to see what my patient and hospital administrator saw – an opportunity to move our profession forward with technology. Some sources of that backlash are

  • Fear of losing audiology jobs. We published our analysis of the capacity and need for hearing testing to address this fear (Margolis & Morgan 2008). In 2000, all the audiologists working full time on basic hearing testing could not deliver half the need. That gap will continue to increase at the baby-boomers age.
  • Fear of giving up an important part of our scope of practice. When I started this work, the AuD conversion was just beginning. Now that we are a doctoral profession, we need to view our roles like other doctors. By automating basic testing audiologists' time can be focused on activities that require doctoral skills.
  • Reimbursement. Although the costs of performing basic tests by doctoral practitioners usually exceeds the reimbursement, clinicians are reluctant to perform clinical procedures that are not reimbursable. It is important that we establish the value of automated tests and establish Audiology as the profession that is best able to interpret the results and formulate treatment plans.
  • Training programs. Our clinical training programs have been slow to incorporate the teaching of the methods and advantages of automation.
  • Inertia. In every profession, there is a reluctance to change methodologies especially when current methods produce the needed results. There is an interesting parallel with optometry, a profession that is transitioning to automated tests faster than we are. The refraction needed in our lenses is being determined entirely by physical measurements, abandoning the “Which is clearer, this or this" procedure (although some optometrists are reluctant to change just like us.) One of the reasons for the change in optometry is the finding that manual testing requiring subjective responses is subject to bias, which has also been shown to be the case in audiometry (Margolis et al., 2015, 2016).

REFERENCES:

Margolis, R.H., Morgan, D.E.. Automated Pure-Tone Audiometry: An Analysis of Capacity, Need, and Benefit. Amer J Audiology, 17, 109-113, 2008.

Margolis, R.H., Saly, G., Le, C., Laurence, J. Qualind. A Method for Assessing the Accuracy of Automated Tests. J. Amer. Acad. Audiol., 18, 78-89, 2007.

Margolis, R.H., Wilson, R.H., Popelka, G.R., Eikelboom, R.H., Swanepoel, D.W. Distribution characteristics of normal pure-tone thresholds. Int. J. Audiology, 54, 796-805, 2015.

Margolis, R.H., Wilson, R.H., Popelka, G.R., Eikelboom, R.H., Swanepoel, D.W. Distribution Characteristics of Air-Bone Gaps: Evidence of Bias in Pure-Tone Audiometry. Ear & Hearing, 37, 177-188, 2016.

Rudmose, W. (1963) Automatic audiometry. in J.Jerger, (ed): Modern Developments in Audiology, New York, Academic Press, 30-75.

Thursday, March 11, 2021

By Richard S. Tyler, PhD; Najlla O. Burle; and Patricia C. Mancini, PhD

               Patients with tinnitus often seek help from audiologists when it disrupts their thoughts and emotions, sleep, concentration and/or hearing. This can have dramatic effects on their quality of life.1 Some of the patients can be very distressed, and there are no pills or surgery for sensorineural tinnitus.  Unfortunately, many healthcare professionals choose not to help them.  Audiologists are qualified to provide counseling, but reimbursement is difficult. The evidence is sufficient for reimbursement for counseling— period. Counseling can also be performed by a wide variety of other health care professionals, including physicians, nurse practitioners, and psychologists.

WE ARE QUALIFIED

​Tinnitus patients usually have hearing difficulties, caused by a hearing loss or their tinnitus.  We can provide counseling as our training in aural rehabilitation includes the understanding of the psychological consequences of hearing loss, tinnitus, and other such auditory conditions. If emotional consequences become severe, we can and should refer to other professionals.  Sometimes we receive referrals from psychiatrists and psychologists who need our help with their tinnitus patients. While these professionals can help with the emotional aspects, they are not trained regarding tinnitus and hearing loss and their consequences. Thus, many refer their patients for an audiologist's help.

Audiologists can help patients understand their tinnitus—how it affects their hearing, thoughts and emotions, sleep and concentration, and how they react to it. We suggest ways they might change their behavior to help manage challenges. In fact, several counseling and sound therapy treatments were designed by and taught by audiologists.2-7

REIMBURSEMENT ISSUES

As most of these patients have hearing loss, we can be reimbursed for diagnosing and measuring their hearing loss, and provide hearing aids 8.  This is an important contribution.  Which services get reimbursed and the reimbursement rate is influenced by many factors, including lobbying by organizations. Audiology services are valuable and should be reimbursed appropriately. However, because of the limited reimbursement, many cannot justify helping tinnitus patients.

EVIDENCE-BASED JUSTIFICATION

The effectiveness of any counseling largely depends on the individual interactions between the patient and the clinician. Systematic strategies can help, but the outcome is strongly influenced by the individual clinician. Even following the same counseling protocol, some patients will see relief of symptoms, but not others. Recently, a study challenged the effectiveness of cognitive behavior therapy (CBT)9 generally, and this has been applied to CBT for tinnitus 10.  The study concluded that the individual clinician is the main factor in the outcome of the CBT. Each patient with tinnitus experiences different symptoms, and research should focus on individuals, not groups. 11 Unfortunately, this rarely occurs in research studies.

               Many argue in favor of the need for “evidence-based" research studies to support treatments. With respect to tinnitus, CBT is promoted as a strategy to treat patients.12 Interestingly, for smoking cessation and weight management, evidence (and reimbursement) is available for counseling, but it does not have to be CBT counseling for weight management; it is just “counseling for weight management."

               While some tinnitus patients benefit from reading online information or those from patient handouts, others may not find these resources helpful and need personalized.4,6 Millions of dollars can be spent on each study documenting each variation of counseling for tinnitus patients. The government should direct money for counseling.

               While some patients may choose to independently seek out health care information on tinnitus, many ask for individualized, patient-centered care. Unfortunately, the current health care reimbursement landscape is a barrier to audiologists performing this type of patient-centered care.

               In the evolution of Tinnitus Activities Treatment (TAT), we saw the benefit of (and included) Progressive Muscle Relaxation and Guided Imagery.6 Audiologists ask patients to focus, at the moment, without judging. Our TAT includes helping patients to “accept," “own" their tinnitus. 

RECOGNIZING THE VALUE OF AUDIOLOGY SERVICES

Hearing loss is not just about hearing but also about how we use our hearing for communicating, interacting with friends, enjoying life, and planning for the future. Smoking cessation and weight management are reimbursed by government health care and insurance agencies—so why not hearing loss and tinnitus? Audiology services are valuable and should be reimbursed appropriately. Clinicians must make choices about how to spend their time and resources. Because of the limited reimbursement, many cannot justify helping tinnitus patients.

Our professional organizations need to work collaboratively with legislators and take this on as the most important focus of our profession. It is necessary to conduct solid research not only on the effectiveness of counseling but also its cost-benefit analysis compared to other reimbursable procedures. We need the help of audiology professional organizations to speak up—as well as the help of people with tinnitus, including those committees and legislatures, since they can appreciate the consequences and be helpful.

               Audiologists can provide counseling to help with the psychological consequences of hearing loss and tinnitus (and hyperacusis). A reasonable, driving force, behind our ability to help these patients depends on reimbursement for our audiological services.

ABOUT THE AUTHORS: Richard Tyler, PhD, is a professor of otolaryngology–head and neck surgery and of communication sciences and disorders at the University of Iowa. Najlla O. Burle is a speech therapist affiliated with the Post-Graduate Program in Speech Therapy Sciences at the Universidade Federal de Minas Gerais in Brazil, where Patricia C. Mancini, PhD, is an associate professor in the university's department of speech-language pathology and audiology.

REFERENCES:
1. Tyler, R., Perreau, A., Mohr, A. M., Ji, H., & Mancini, P. C. (2020). An Exploratory Step Toward Measuring the 'Meaning of Life' in Patients with Tinnitus and in Cochlear Implant Users. Journal of the American Academy of Audiology, 31(4), 277-285. doi: 10.3766/jaaa.19022.
2. Sweetow, R. W. (1984). Cognitive-behavioral modification in tinnitus management. Hearing Instruments, 35, 14-52.
3. Tyler, R. S., & Erlandsson, S.  (2003). Management of the tinnitus patient.  In L.M. Luxon, J.M. Furman, A. Martini, and D. Stephens. (Eds.), Textbook of Audiological Medicine (pp. 571-578).  London, England: Taylor & Francis Group.
4. Henry, J., & Wilson, P. (2001). The Psychological Management of Chronic Tinnitus: A Cognitive-Behavioral Approach. Needham Heights, MA: Allyn & Bacon.
5. Mohr, A. M., & Hedelund, U.  (2006). Tinnitus Person-Centered Therapy. In R.S.Tyler (Ed.), Tinnitus Treatment: Clinical Protocols (pp. 198-216).  New York: Thieme.
6. Tyler, R. S., Gehringer, A. K., Noble, W., Dunn, C. C., Witt, S. A., & Bardia, A. (2006). Tinnitus activities treatment. In R. S. Tyler (Ed.), Tinnitus treatment: Clinical protocols. (pp. 116-132). New York, NY: Thieme.
7. Tyler, R. S., Gogel, S. A., & Gehringer, A. K. (2007) Tinnitus activities treatment. Progress in Brain Research, 166, 425-434.
8. Tyler, R., Jilla, A. M., & Von Dollen, S. (2020) Coding and Reimbursement Specialty Series:  Tinnitus. Audiology Today,  March/April.
9. Johnsen, T.J., & Friborg, O. (2015) The effects of cognitive behavioral therapy as an anti-depressive treatment is falling: A meta-analysis. Psychological Bulletin, 141(4), 747-768.
10. Tyler, R. S., & Mohr, A. M. (2017). Is CBT for tinnitus overemphasized? The Hearing Journal, 70(2), 8-10.
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