Journal Logo

Online Only

Access online-exclusive articles and updates published ahead of print.

Tuesday, April 21, 2020

Making Audiology Work During COVID-19 and Beyond
Editor's note: This article is published ahead of print. Send comments to hj@wolterskluwer.com. 

By De Wet Swanepoel, PhD, and James W. Hall III, PhD

The COVID-19 crisis has ushered in a new era in hearing health care that requires a radical rethinking of service delivery in audiology. Low- and no-touch services are now necessary for audiology patients—who are typically at the highest risk for COVID-19 morbidity and mortality due to their age—to access care. Fortunately, audiology is a technology-driven profession in terms of providing assessment and intervention, allowing unique opportunities to leverage remote and telehealth hearing care solutions. While traditional diagnostic assessment to confirm suspected ear disease, which has a very low prevalence, requires a sound-treated environment and a comprehensive test battery, a less controlled environment with fewer tests could suffice for hearing aid fittings. This means that more than 95 percent of adults with hearing loss could be served using alternative low- or no-touch models of audiological care. While the ongoing pandemic is very real, it also offers a unique opportunity to redefine and innovate how hearing health care professionals reach and serve patients in more responsive, efficient, and person-centered ways. Exploring alternative patient journeys is crucial to evolve audiology during COVID-19 and beyond.

A NEW ERA OF HEARING HEALTH CARE

The COVID-19 crisis has ushered in a new era in hearing health care that requires a radical rethinking of service delivery in audiology. According to the Centers for Disease Control and Prevention (CDC) guidelines, audiological services pose a medium to high risk for COVID-19 infection considering the proximity, test setup, and length of appointments.1 The fact that the majority of people who require audiology services (those over 65 years of age) are also the ones at the highest risk of COVID-19-related mortality and morbidity underscores the importance of reassessing how hearing care is delivered.

Traditionally, audiological care has been a high-touch service with several face-to-face appointments in confined sound-treated spaces for initial assessments, hearing aid fittings, follow-up troubleshooting, and counseling. In this respect, how audiologists have been providing services to adults with hearing loss has remained very much the same over the past five decades. The sudden requirement for physical distancing and even long-term lockdown recommendations for older adults render this traditional audiological care pathway untenable at present.

CHANGING TIMES REQUIRE CHANGES IN CARE DELIVERY

In the era of COVID-19, wherein low- or even no-touch services are necessary, audiological care needs to be responsive with alternative modes of service delivery. In our technology-driven field, there are unique opportunities to leverage connected solutions for remote and telehealth services. Over the past several years, we've witnessed tremendous growth in digital hearing health care solutions from web- and app-based screening to mobile audiometry that has made decentralized community-based hearing care services possible.2-6 These assessment options have typically relied on facilitators or assistants to guide patients through the testing. Also, hearing aid manufacturers have been particularly good at including telehealth tools for remote device troubleshooting, counseling, fine-tuning and tracking usage.

The challenge to audiologists is that tools for telehealth or remote care have been typically available in more expensive device options and, most importantly, serve existing patients only. While it is important to remotely support existing patients, the current situation requires urgent action to find alternative low- or no-touch mode to provide hearing assessments and hearing aids to new patients. This is important not only to ensure patients' access to audiology services but also, from a global perspective, to keep audiology practice doors open and sustainable.

LOW- OR NO-TOUCH AUDIOLOGY OPTIONS

The risks posed by traditional audiology services to a population cohort that is most vulnerable to COVID-19 infection necessitate alternative low- or no-touch options for delivering audiological care.1 In rethinking audiological care, it is important to differentiate the category and assessment purposes of the different adult patients we serve (Table 1). Audiological care for adults is generally directed to either (1) diagnostic assessments requiring a conventional sound-treated room to detect possible ear disease and (2) assessments for hearing aid fittings for which alternative point of care services may be suitable and, in the case of COVID-19, required.


Audiological assessments, regardless of the purpose, have traditionally occurred in the same clinical sound-treated environment (Table 2). The reality, however, is that whereas a diagnostic assessment to confirm suspected ear disease requires a sound-treated environment and comprehensive test battery, a less controlled environment with fewer tests could suffice for hearing aid fittings. The diagnostic assessment for a patient with suspected ear disease requires air and bone conduction audiometry performed in a sound-treated room to ensure that reliable thresholds can be measured down to -10 dB HL. Unoccluded bone conduction audiometry requires a maximum sound attenuation of at least a single-walled sound booth, and occluded testing leads to unreliable thresholds due to the occlusion effect. A patient with hearing loss who has no ear disease assessed for a hearing aid fitting may only require air conduction audiometry down to 20 dB HL, which could occur without a sound booth.


The prevalence of ear disease or conductive loss in adult populations with hearing loss is very low, with reports varying between two to five.7,8 Using conservative estimates, Zapala, et al.,9 estimated that the odds are 20:1 against encountering an ear condition that should be treated medically or surgically. This means that more than 95 percent of adults with hearing loss could be served using alternative low- and no-touch models of audiological care.

MAKING LOW- AND NO-TOUCH AUDIOLOGY WORK

The challenge in using low- and no-touch options is differentiating patients who require traditional clinic-based services, i.e., cases with suspected ear disease or conductive hearing loss, from those with sensorineural hearing loss who are likely candidates for hearing aids. Fortunately, some recent developments provide alternatives to conventional audiological testing, such as bone conduction audiometry and tympanometry, to identify the risk of ear disease. If a risk is detected for conductive hearing loss or ear disease, this small sub-group of patients can then be directed for high-touch audiology services in traditional settings where stringent COVID-19 guidelines must be employed to minimize infection risks (Table 1).

The Consumer Ear Disease Risk Assessment (CEDRA) is a validated questionnaire with a sensitivity of greater than 90 percent to detect ear disease.7 Initially developed for consumer-based over-the-counter (OTC) and direct-to-consumer services it is a valuable tool for making low- and no-touch audiology models work. The FDA also has a prescribed list of questions to screen for possible ear disease that can be used to direct referrals.10 There are also simple and quick test procedures that can support the differentiation of patients at-risk for conductive losses or ear disease. Recent work on antiphasic and diotic digits-in-noise testing has demonstrated the potential to differentiate conductive hearing loss by comparing the speech-recognition thresholds.2 Furthermore, air conduction audiometry can flag asymmetrical hearing losses that could infer referral for traditional high-touch audiological assessments.11 Other options include audiologist inspection of the patient’s external ear via close-up photographs by a family member in the home setting using a smartphone video-otoscope as part of a self-test kit.12,13

A combination of these questionnaire-based and simple test procedures can provide a reliable triage directing patients to either traditional high-touch audiology services or low- or no-touch audiology alternatives (Table 2). A medical waiver option by the FDA for hearing aids could also serve as a way to mitigate risks when limited test results are available.14  

EXAMPLES OF LOW- AND NO-TOUCH AUDIOLOGY

Moving outside of a conventional audiology clinic setting, at least outside of sound-treated rooms, could take the form of low-touch counter-side or drive-through services or even no-touch versions provided in patients’ homes (Tables 1 and 2). These home-based and counter-side services can come in the form of self-testing or facilitated assessments on digital devices with user-friendly step-by-step guidance and the option of real-time telehealth support from an audiologist. Figures 1 and 2 provide examples of possible no- and low-touch patient journeys.


Figure 1. Example of a no-touch audiology service journey.

A recent example of a digital self-test kit released in response to the COVID-19 crises aims to enable low- and no-touch audiological care.12 The self-test kit allows self-guided tablet-based pure tone audiometry, speech-in-noise testing, ear risk assessment, and optional digital AI otoscopy. These types of solutions could facilitate initial assessments and triage adult patients assessed for hearing aid fittings with minimal face-to-face contact. Supported by teleconsultations throughout the assessment process (Figs. 1 and 2) and hearing aid support and fine-tuning process enable alternative low-touch models of care. While technology and connectivity are essential to these modes of care, they should only support person-centered care fostering mutual trust. Telecare tools like those provided by the Ida institute15 offer an easy way to strengthen this partnership, along with information on a low- or no-touch patient journey.


Figure 2. Example of a low-touch audiology service journey.

To ensure the responsible use of low- and no-touch audiology options, audiologists must consider several aspects include test setting, infection risk, contraindications, and infection control measures (Table 1). Digital proficiency levels is another possible factor that may prohibit no-touch and even low-touch options. Interestingly, a recent study suggests that digital proficiency may not limit people accessing alternative models of remote care.16 It may, however, be valuable in determining the minimum levels of digital proficiency to determine whether no- or low-touch care options are appropriate. Fortunately, there are well-validated and brief questionnaires that clinicians can use to quickly screen for mobile device and computer proficiency.16-18

THE WAY FORWARD

The COVID-19 crisis is likely to continue as a pervasive global influence persisting well into 2021 and beyond until a vaccine becomes available.19,20 While it is posing a tremendous threat to the viability of traditional audiological services, it also creates the impetus to rapidly deploy and scale innovative digital and telehealth approaches in response to a changing landscape.

There are always challenges when expanding existing ways of service provision including, in this case, including restrictions in several U.S. states that still require bone conduction audiometry, speech reception thresholds and disrimination testing for hearing aid dispensing. The urgency to have audiological care in low- and no-touch settings, the pending OTC regulations, and the FDA medical waivers for hearing aid provision make a strong case for regulatory bodies to adjust such requirements. Precedence exists for making allowances during the COVID-19 crisis as seen by the U.S. Department of Health & Human Services,21 making special allowance for the use of several videoconferencing platforms that were not previously authorized. It is up to us as audiologists, professional associations including AAA, ADA, and ASHA, industry and even patient organizations like HLAA to drive lobbying and advocacy efforts for required allowances by legislators, third-party payers and healthcare insurers. Ultimately for the sake of our patients and the continuation of our profession under current circumstances.

As is the case in many other industries, the COVID-19 crisis is a watershed moment for audiology. While the threat is very real, it offers a unique opportunity to redefine and innovate how we reach and serve our patients in more responsive, efficient, and person-centered ways. As a profession reliant on technology, and as the world enters the fourth industrial revolution, timing has never been better for audiology to have its revolution in the provision of care.

ABOUT THE AUTHORS: De Wet Swanepoel, PhD, is a professor of audiology at UP and the editor-in-chief of the International Journal of Audiology. His research capitalizes on digital health technologies to explore, develop, and evaluate innovative hearing services for greater access and affordability. He is also a co-founder and scientific advisor to the hearX group. James W. Hall III, PhD, is an audiologist with over 40 years of clinical, teaching, research, and administrative experience. He is a professor of audiology at Salus University and the University of Hawaii.

REFERENCES:

  1. Centers for Disease Control and Prevention. (2020). Interim U.S. Guidance for Risk Assessment and Public Health Management of Healthcare Personnel with Potential Exposure in a Healthcare Setting to Patients with Coronavirus Disease 2019 (COVID-19). https://www.cdc.gov/coronavirus/2019-ncov/hcp/guidance-risk-assesment-hcp.html
  2. De Sousa, K., Swanepoel, D., Moore, D., Myburgh, H., & Smits, C. (2020). Improving sensitivity of the digits-in-noise test using antiphasic stimuli. Ear and Hearing, 41(2), 442–450.
  3. Ratanjee-Vanmali, H., Swanepoel, D., & Laplante-Lévesque, A. (2020). Patient uptake, experience and satisfaction using web-based and face-to-face hearing health services: Process evaluation study. Journal of Medical Internet Research, 22(3), e15875.
  4. Swanepoel, D. (2020). eHealth technologies enable more accessible hearing care. Seminars in Hearing, 41(02), 133–140.
  5. Swanepoel, D., Smits, C., De Sousa, K., & Moore, D. (2019). Mobile apps to screen for hearing loss: Opportunities and challenges. Bulletin of the World Health Organization, 97(10), 717–718.
  6. Van Wyk, T., Mahomed-Asmail, F., & Swanepoel, D. (2019). Supporting hearing health in vulnerable populations through community care workers using mHealth technologies. International Journal of Audiology, 58(11), 790–797.
  7. Klyn, N., Kleindienst Rober, S., Bogle, J., Alfakir, R., Nielsen, D., Griffith, J., Carlson, D., Lundy, L., Dhar, S., & Zapala, D. (2019). CEDRA: A tool to help consumers assess risk for ear disease. Ear and Hearing, 40(6), 1261–1266.
  8. Hoff, M., Tengstrand, T., Sadeghi, A., Skoog, I., & Rosenhall, U. (2020). Auditory function and prevalence of specific ear and hearing related pathologies in the general population at age 70. International Journal of Audiology, 1–12.
  9. Zapala, D. A., Dhar, S., Nielsen, D., Griffith, J. W., & Kleindienst, S. J. (2015). Managing disease risk in hearing healthcare delivery [PowerPoint]. https://phhp-slhs.sites.medinfo.ufl.edu/files/2012/11/UF-IOM-DISEASE-RISK-PRESENTATION-.pdf
  10. U.S. Food and Drug Administration. (2019). CFR - Code of Federal Regulations Title 21. https://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfCFR/CFRSearch.cfm?fr=801.420
  11. Kesser, B. W. (2010). Clinical thresholds for when to test for retrocochlear lesions: Con. Archives of Otolaryngology-Head & Neck Surgery, 136(7), 727–729.
  12. hearX group. (2020). COVID-19 hearing care solution, hearX self-test kit. https://www.hearxgroup.com/blog/hearX-self-test-kit.html
  13. Yancey, K. L., Cheromei, L. J., Muhando, J., Reppart, J., Netterville, J. L., & Jayawardena, A. D. L. (2019). Pediatric hearing screening in low-resource settings: Incorporation of video-otoscopy and an electronic medical record. International Journal of Pediatric Otorhinolaryngology, 126, 109633.
  14. U.S. Food and Drug Administration. (2016). FDA takes steps to improve hearing aid accessibility. https://www.fda.gov/news-events/press-announcements/fda-takes-steps-improve-hearing-aid-accessibility
  15. Ida institute (2020). Telecare tools. https://idainstitute.com/tools/telecare/
  16. Ratanjee-Vanmali, H., Swanepoel, D., & LaPlante-Levesque, A. (Submitted). Digital proficiency is not a significant barrier for acquiring hearing aids and support services with an online and face-to-face model. American Journal of Audiology, (Submitted).
  17. Boot, W. R., Charness, N., Czaja, S. J., Sharit, J., Rogers, W. A., Fisk, A. D., Mitzner, T., Lee, C. C., & Nair, S. (2015). Computer proficiency questionnaire: Assessing low and high computer proficient seniors. Gerontologist, 55(3), 404–411.
  18. Roque, N. A., & Boot, W. R. (2018). A new tool for assessing mobile device proficiency in older adults: The mobile device proficiency questionnaire. Journal of Applied Gerontology: The Official Journal of the Southern Gerontological Society, 37(2), 131–156.
  19. Adam, D. (2020). Special report: The simulations driving the world’s response to COVID-19. Nature, 580(7803), 316–318.
  20. World Health Organization. (2020). Public statement for collaboration on COVID-19 vaccine development. https://www.who.int/news-room/detail/13-04-2020-public-statement-for-collaboration-on-covid-19-vaccine-development
  21. U.S. Department of Health & Human Services. (2020). Slow the spread of the coronavirus. https://www.hhs.gov