Barbara Weinstein PhD

Barbara Weinstein’s “Downstream Consequences of Aging” appears bi-monthly at HearingHealthMatters.org. Today’s post is part 2 of a series on reframing the clinical conversation with older adults.

 

The hearing healthcare delivery landscape is in transition with the emphasis being placed on affordability and access.  President Trump’s signing of the 2017 Food and Drug Reauthorization Act, guarantees that a new category of OTC hearing aids will be forthcoming within the next few years.

 

Hearing Loss as a Social Construct with Consequences

 

The top-down changes are an opportunity for audiologists to revisit and reframe our approach to clinical practice with the emphasis on the patient rather than on the technology.  

We must engage with persons with hearing loss in new and better ways with a focus on the environmental and psychosocial underpinnings of age related hearing loss, I have posed five myths held by held by stakeholders in hearing health care. I follow each myth by my thoughts about how audiologists might broaden our framework for addressing the experiences of persons with hearing loss. 

Perhaps approaching hearing loss as a social construct with consequences in large part depending on the interaction between the persons with hearing loss and their physical and social environments might help us to optimize outcomes associated with their clinical encounter.

 

Myth I. Audiologist=Hearing Aid Salesperson

 

I recently conducted an informal survey of members of the local HLAA Chapter regarding their perceptions of the hearing health care services which they received. The consensus was that audiologists sell hearing aids and are not educated or skilled at assisting persons with hearing loss self manage the communication challenges posed by hearing loss.

To put it mildly, I was shocked by these very strong convictions.  We need to position ourselves as hearing/communication ambassadors whose primary focus is to help parsons with hearing loss overcome the communication barriers caused by their loss of hearing. We are the experts who can help persons with hearing loss self manage the social and physical environments in which they live and interact, thereby enhancing the quality of their interactions and enabling them to remain socially engaged.

Bottom line, social engagement is the key to long life and adds to life expectancy. The most important outcome of our clinical encounters should be to help our patients maintain their participation in meaningful social and intellectual activities and the technology we dispense is a means to this end.

 

Myth 2. Hearing Aids Prevent or Forestall the Onset of Senile Dementia

 

The evidence to date is clear……hearing aids DO NOT prevent dementia. BUT, hearing aids, when fit correctly in the context of a rehabilitation program, can optimize communication function thereby facilitating social engagement (measured in terms of contact with family and friends participation in social activities, and quality of interactions).

Hearing assistance may reduce the burden on cognitive processing, especially in challenging listening environment. Further, by helping persons maintain social enagement and social connectedness, hearing aids may in fact have a protective effect thereby reducing the risk of developing dementia (Fratiglioni, Wang, Ericsson, Maytan, and Winblad, 2000).

Consider the argument that hearing aids are a cognitive reserve enhancing and lifestyle intervention which when fit and used properly will help persons with hearing loss remain intellectually stimulated and socially engaged.

 

Myth 3. The Audiologist Knows Best and Told Me I am a Candidate for Hearing Aids

 

Shared decision making (SDM) and preference based treatment should guide clinical practice. A bidirectional process between a clinician and a patient suffering from a preference-sensitive condition (e.g. hearing loss), SDM helps the patient decide among multiple acceptable intervention choices in accordance with their lifestyle preferences (Spatz, Krumholz & Moulton, 2017).

Since persons with hearing loss often opine that they would like to be offered a range of options, SDM using patient decision aids (PDAs) is an ideal approach to engaging patients in a transparent manner when there are multiple treatment options from which to choose, High quality evidence based patient decision aids delineating the options, their risks and benefits can help facilitate patient course of action especially when there is more than one reasonable option (Stacey, Bennett, Barry, et al., 2011).

To date, patients are told that hearing aids have a clear advantage in terms of health outcomes but with the availability of hearables, self fitting hearing aids, PSAPs, to name a few a more broad based conversation may be in order. The majority of respondents to my survey lamented the fact that it took an average of three different audiologist visits before they were convinced that they were receiving high quality care.  It is noteworthy that the factors associated with patient judgments of high quality health care include participation in decision making, self management support, and involvement in care processes (Maskrey & Gordon, 2017).

 

Myth 4. Clinical Encounters are Patient Focused and Centered

 

Respondents to my survey overwhelmingly commented that their audiologist did not take the time to learn about them; they rarely inquired about their “hearing loss journey.”  We must take the time to learn more about our patients.

To ensure that we are meeting our patient’s needs we should understand the motivations, priorities, and preferences of our patients. Engagement means ensuring that our patients are active participants in their care and that our patient’s lifestyle informs the discussion of treatment options. Make sure to:

  1.  inquire about the availability of social support network so critical to hearing aid satisfaction; 
  2. understand your patient’s activity levels-whether they are socially active;
  3. gain insight in to their satisfaction with the quality and quantify of their social contacts.

The latter information must inform counseling, It goes without saying that understanding our patients’ hearing challenges in communicative environments (e.g at home, with family members, in large group meetings) is key, and understanding how they self manage their hearing problems can help optimize outcomes. Table 1 lists some sample questions which you may pose.

Table 1. Sample Questions Regarding Self-Management of Hearing Loss

  • Do you inform and/or remind family and friends of their hearing?
  • Do you ask others to remove their hands from in front of their mouth when speaking?
  • Do you tell your primary care physician that you have a hearing loss and some difficulty communicating and suggest ways to optimize the clinical encounter?
  • If you are in a noisy room, how do you manage the situation?
  • Do you ever use hearing apps on your smartphone?
  • Do you find yourself putting in more and more effort to understand others when they are speaking?
  • Do you find yourself decreasing your engagement in social activities because of communication challenges?

 

Myth 5. The Focus of Clinical Encounters is on Helping Patient to Self Manage their Hearing Loss

 

Audiologists and persons with hearing loss differ on this point as respondents were uniform in their comments that “it is all about the technology,” and they learned about self management through “trial and error.”  Self-management is a critical component of hearing health care delivery (Powers, Bardsley, Cypress., et al.,2015).  According to Hogan, et al.,(2015) physical stress is higher and wellbeing is lower when the fit between the person’s hearing related coping ability is mismatched with the demands or social ability to self manage in challenging social or physical environments (Hogan, Reynolds, & Byrne, 2012).

Stated differently, low self-confidence due to hearing impairment combined with poor perceived self-rated capacity to manage hearing and listening impairments were closely associated with lower quality of life ratings. In short, anxiety seems to increase and self confidence decreases as self management skills decline. Note also that Hogan, et al., (2015) found that “objective” measures of hearing status (i.e. the audiogram) did not correlate with self-reported physical and mental health outcomes.

To support and optimize self-management skill development and maintenance it is important to take advantage of opportunities before, during, and after the clinical encounter. That is, it is critical that we assess our patient’s self-management skill set, availability of support mechanisms (e.g. family members, HLAA) and factors that may serve as barriers to self-management including stigma or “fear of being found out!’

Table 2 lists some self management intervention strategies for promoting and optimizing hearing aid use (Barker, Mackenzie, Elliott., et al., (2016).

Table 2. Self-management Strategies  (Barker, Mackenzie, Elliott, et al. (2016)

  • Assess-self management skill set including impact of hearing loss, difficulties, facilitators and obstacles
  • Activate and educate your patients and their family members about behaviors they can adopt to overcome communication challenges and barriers
  • Make sure to encourage your patients to practice the new skills they have acquired
  • Refer patients to a local chapter of HLAA for support
  • Discuss the importance of sharing information about hearing status during all health care encounters including acute and primary care settings

 

Concluding Remarks

 

Audiologists must remain part of the solution to communication challenges posed by hearing loss and should be the go to professional for persons with hearing loss. Our patients must understand and experience the value added of working with an audiologist for ALL of their hearing health care needs.

In anticipation of top down changes in the hearing health care delivery system, we must reflect and prepare to initiate bottom up changes including a re-envisioning of the audiology Scope of Practice, our approach to the clinical encounter and associated outcomes. We should renew our focus on rehabilitation in support of helping patients to self-manage the stress and challenges associated with hearing loss. The latter was the foundation for the birth of the Profession of Audiology.

In closing, I concur with Alhanbali, et al. (2017) who underscored the import of educating persons with hearing loss about how to minimize the communication challenges posed by hearing loss and to make every effort to include social/psychological factors in our work with persons with hearing loss.

 

References

 

Alhanbali, S., Dawes, P., Lloyd, S. & Munro, K. (2017). Hearing handicap and speech recognition correlate with self reported listening effort and fatigue. Ear and Hearing. Oct 31 2017 published ahead of print.

Barker, F., Mackenzie, E., Elliott, L., et al., (2016). Interventions to improve hearing aid use in adult auditory rehabilitation. Cochrane Database of Systematic Reviews. Cochrane Database of Systematic Reviews. No 8. 

Hogan, A., Phillips, R., Brumby, S., et al., (2015). Higher social distress and lower psycho-social wellbeing: Examining the coping capacity and health of people with hearing impairment. Disability and Rehabilitation. Jan 5 2015, published online.

Hogan A, Reynolds K, Byrne D. (2012). Identity, social position, wellbeing and health: insights from Australians living with hearing loss. In: Banwell C, Ulijaszek S, Dixon J, eds. When culture impacts health. United States: Academic Press: pp. 95–104.

Maskrey, N., & Gordon, A. (2017). Shared understanding with patients. JAMA Internal Medicine.177: 1247-1248.

Spatz, E., Krumholz, H. & Moulton, B. (2017). Prime Time for Shared Decision Making. JAMA. 317: 1309-1310.

Powers, M., Bardsley, J., Cypress, M., et al. (2015). Diabetes self-management education and support in type 2 diabetes: A joint position statement of the American Diabetes Association, the American Association of Diabetes Educators, and the Academy of Nutrition and Dietetics . Diabetes Care. 38:1372-82.

Stacey D, Bennett CL, Barry MJ, Col NF, Eden KB, Holmes-Rovner M, et al. (2011). Decision aids for people facing health treatment or screening decisionsCochrane Database of Systematic Reviews. 2011; (10).

 

 

 

 

 Barbara E. Weinstein, Ph.D. earned her doctorate from Columbia University, where she continued on as a faculty member and developed the Hearing Handicap Inventory with her mentor, Dr. Ira Ventry. Dr. Weinstein’s research interests range from screening, quantification of psychosocial effects of hearing loss, senile dementia, and patient reported outcomes assessment. Her passion is educating health professionals and the public about the trajectory of untreated age-related hearing loss and the importance of referral and management. The author of both editions of Geriatric Audiology, Dr. Weinstein has written numerous manuscripts and spoken worldwide on hearing loss in the elderly.  Dr. Weinstein is the founding Executive Officer of Health Sciences Doctoral Programs at the Graduate Center, CUNY which included doctoral programs in public health, audiology, nursing sciences and physical therapy. She was the first Executive Officer the CUNY AuD program and is a Professor in the Doctor of Audiology program and the Ph.D. program in Speech, Language and Hearing Sciences at the Graduate Center, CUNY.

feature photo courtesy of shannon christy

 

“Peeling the Onion” is a monthly column by Harvey Abrams, PhD.

 

About 18 months ago, I came across an interesting letter to the editor in the Journal of the American Medical Association (JAMA). The author was Donald Berwick.For those of you unfamiliar with this distinguished health care policy expert, Dr. Berwick is a former administrator of the Centers for Medicare and Medicaid Services (CMS) but is probably better known as the President and CEO of the Institute for Healthcare Improvement.

His work has focused on improving the quality of health care, including the reduction in medical errors, through the aggressive and judicious use of evidence-based medicine. He is the author of several books on health care quality improvement, the latest being Promising Care: How We Can Rescue Health Care by Improving It.

 

Changing the Audiology Regime

 

The title of Dr. Berwick’s letter to JAMA was “Era 3 for Medicine and Health Care” in which he argues for the need to move beyond the past and current approaches to health care into a new era characterized by 9 fundamental changes to the current regime. At the time I read the letter, I was struck by how many of these changes could, and should, apply to the audiology profession.

Given the recent developments brought about by the PCAST and NASEM reports, recent legislation leading to a new class of OTC hearing aids and, what many consider, an existential crisis facing the profession, I re-read Dr. Berwick’s letter with a renewed sense of urgency.  

 

The 2 Eras of Health Care

 

Berwick describes era 1 as the ascendancy of the medical profession with roots going back to Hippocrates. It is characterized by beneficence, self-regulation and, with society’s full blessing, the authority of the profession to judge the quality of its own work.

Era 2 was born out of emerging evidence that demonstrated large and disturbing unexplained variations in practice, growing numbers of costly medical errors, profiteering, and documented injustices in the delivery and quality of health care related to race and social class. This current era is characterized by a tension between the medical establishment which desires to maintain the privileges it enjoyed in era 1 and the payer, governments, and consumer groups which advocate for more inspection and control.

Berwick maintains that “the tactics of eras 1 and 2 reflect deeply held beliefs” and that this “clash will continue unless and until those beliefs change and stakeholders act differently as result.” He advocates for a new era in health care, era 3, “guided by updated beliefs that reject both the protectionism of era 1 and the reductionism of era 2”  and suggests 9 changes that must characterize this new era.

 

Era 3 – 9 Changes Are Required

 

  1. Reduce Mandatory Measurement: Those of us working in hospital-based clinics are all too aware of the requirements associated with measuring just about everything we do. This era 2 reaction to era 1 shortcomings has, according to Berwick, resulted in excessive measurement and reporting leading to unnecessary waste and inefficiencies. Berwick suggests that CMS, insurers and regulators should commit to reducing the volume and cost of measurement by 50% in 3 years and 75% in 6 years.
  2. Stop Complex Individual Incentives: Berwick argues for a moratorium on complex incentive programs for individual clinicians which, he claims, are “confusing, unstable, and invite gaming.” He supports an approach characterized by a simple salaried practice as part of a patient-focused organization.
  3. Shift the Business Strategy from Revenue to Quality: Berwick argues that the current focus on maximizing revenue dominates the business model of most health care organizations. He maintains that a commitment to quality health care improvement, as opposed to maximizing revenue, is a better strategy for long-term sustainability.
  4. Give Up Professional Prerogative When It Hurts the Whole: A feature of era 1 health care is the belief that the clinician’s prerogative supersedes the needs and interests of others. Are our patients best served when we maintain that “Only an audiologist can…” “A hearing instrument specialist should only …” “An audiology assistant can never …”?
  5. Use Improvement Science: Despite decades of quality improvement implementation in other organizations, health care has still not fully mastered the tools of quality improvement such as process control charts and the “plan-do-study-act” cycle of testing. When was the last time we evaluated a clinical process to determine if it yields the best outcome at the lowest cost?
  6. Ensure Complete Transparency: Berwick maintains the best rule for transparency is, “Anything professionals know about their work, the people and communities they serve can know, too, without delay, cost, or smokescreens.” Naturally, the issues associated with bundling vs. itemizing our hearing aid related fees and services immediately come to mind.
  7. Protect Civility: ASHA vs. AAA vs. ADA vs. HIS. Berwick quotes Robert Waller, M.D., former president and CEO of Mayo Clinic who said, “Everything possible begins in civility.
  8. Hear the Voices of the People Served: Most of us would agree with Dr. Berwick’s assertion that “The more patients and families become empowered, shaping their care, the better that care becomes, and the lower the costs.” We often talk about the importance of a patient-centered focus to our care but how many of us fully engage our patients and their families as part of the clinical encounter?
  9. Reject Greed: Berwick observes that health care has “slipped into tolerance of greed” fueled by “rapacious pharmaceutical pricing, hospitals’ exploiting market leverage…, profiteering physicians, and billing processes that deteriorate into games…” He argues that professional organizations and academic medical centers should “articulate, model, and fiercely protect moral values intolerant of individual or institutional greed in health care.”

As we begin to explore and seek our way through a dramatically changing hearing healthcare landscape, let’s adopt the principles of the 3rd era of health care –  what Berwick describes as the “moral era.” Without a moral ethos, Berwick argues, there will be no winners.

 

Harvey Abrams PhD

Harvey Abrams, PhD, is a consulting research audiologist in the hearing aid industry. Dr. Abrams has served in various clinical, research, and administrative capacities in the industry, the Department of Veterans Affairs and the Department of Defense. Dr. Abrams received his master’s and doctoral degrees from the University of Florida. His research has focused on treatment efficacy and improved quality of life associated with audiologic intervention. He has authored and co-authored several recent papers and book chapters and frequently lectures on post-fitting audiologic rehabilitation, outcome measures, health-related quality of life, and evidence-based audiologic practice.  Dr. Abrams can be reached atharvey_abrams@starkey.com

Images from Ross Land/Getty and askideas