Diabetes Management and the Role of the Audiologist: Interview with Kathy Dowd, AuD

Amyn Amlani 0:10
So welcome to This Week in Hearing. My name is Amyn Amlani. I’m here today with Kathy Dowd of The Audiology Project. It’s great to have you.

Kathy Dowd 0:19
Thank you so much for having me.

Amyn Amlani 0:22
So Kathy, would you share a little bit about you and The Audiology Project for our viewers, please?

Kathy Dowd 0:30
Certainly, the audiology project started in 2016. Although I had been working, communicating with the Centers for Disease Control since 2011, trying to get them to recognize the link between diabetes and hearing loss. In 2016, it looked like they were going to make some, they were going to add this. And so I went ahead and got together ASHA, ADA, and AAA and we had a stakeholders meeting at Salus. And that’s when I started The Audiology Project that was to basically have some sort of structure and umbrella for this initiative. I was very surprised that CDC didn’t know about the link between hearing loss and diabetes. However, after three months back in 2011, Dr. Allweiss found some research that they had sponsored a few years earlier on that same topic. So I think it was just a matter of, you know, putting it in front of their face again. So

Amyn Amlani 1:44
No, and it’s wonderful that you’ve been able to highlight that relationship. Can you tell us a little bit about how that relationship has potentially helped change the face of audiology in the healthcare space?

Kathy Dowd 2:05
Well, I’m retired now, but for 35 years, I was in practice, in schools in ENT offices, and in private practice. And you know, the focus is always on trying to correct find the hearing loss, assess it, and then correct it with hearing aids. When you bill Medicare, you have to have medical necessity. So you have to have illness, injury, trauma, or complaint. Those were the four issues that they that Medicare had for saying that we’ll pay you for what you’re doing. So I learned early to look at those things and get a good case history on all the chronic diseases, all the medications, all the traumas, or infections that people had that could have contributed to what I was finding that day when I tested them. Yeah.

Amyn Amlani 3:06
So, you know, just for our audience that may not be aware, let’s talk a little bit about diabetes in hearing and balance care. So what is the prevalence of diabetes? And what’s the pathio- What’s the pathophysiology of it?

Kathy Dowd 3:22
Well, the I just was at a North Carolina diabetes Advisory Council, and they had the head of Medicaid, discussing the incidence of diabetes in our state of North Carolina. And it’s the incidence of diabetes in the population is between 9% and 12%. So it’s more prevalent in rural areas, obviously, because they showed the picture of the map. And so whether they have access to care, or you know, the physicians have access to diabetes education, it’s all relative. The incidence of hearing loss in diabetes is around 30%. Which is pretty significant. You consider we test every single baby at birth, and the incidence is 1% to 2%. And here we have one chronic disease that is 30% incidence for hearing loss – on the issue of balance, Dr. Gans has talked about the most prevalent type of issue with diabetes is BPPV, which we know is easily treatable and manageable if it’s diagnosed. But then again, the other issue is diabetes is almost a domino effect with chronic kidney disease or cardiovascular disease. So you usually don’t find diabetes in isolation. I’ve been worried that I’ve been so focused on diabetes and not trying to do the same thing with cardiovascular and chronic kidney. But doctor Allweiss says really starting with with diabetes was the best step forward because they are the most organized section of CDC. So she felt it was a good step.

Amyn Amlani 5:31
So that’s interesting, in we know, right that diabetes is typically treated through pharmaceuticals. But it would also be interesting for you to share with the audience, what is the audiological treatment or management for diabetes and hearing loss?

Kathy Dowd 5:50
Well, the main thing is, what CDC now has guidelines on their website is that the person with diabetes gets their hearing evaluated on diagnosis, and then annually thereafter to monitor it. I think it’s really up to the audiologist, though to set when they want to monitor the hearing, it might be within six months based on the whole case history or the medication that the person is taking. Or it might be two years if everything is perfect, and they’re managing their blood sugar level. But as far as an audiological evaluation, I would urge audiologists to do more than just air bone and speech, you want to find out is there any disruption in the auditory processing system. So you know, we test the peripheral system, but the signal has to travel up the eight nerve to the brainstem crossover to the auditory cortex and make its way up to the prefrontal and frontal lobe. So any microangiopathy in the brain, the disruption of small blood vessels can impede the signal and may be affecting the way that person processes. So that’s always good to know. And obviously, if they manage their blood sugar, well, then they’ll have less complications of hearing loss and risk of falls.

Amyn Amlani 7:24
So there are gaps in the management of diabetes. And those gaps sometimes linger either in policies or in the education of the the professional. And so do we want to start out by looking at the the gaps that might exist in the diabetes management? I believe there was a an example that you shared with a speech language pathologist, conducting cognitive evaluations without an audiological exam

Kathy Dowd 7:59
that is happening every day, multiple times a day in every city in the United States. And it it grieves me that they are doing and this is in skilled nursing facilities. They’re doing cognitive evaluations without ever screening for a hearing problem first. To me, it’s egregious. I’ve been talking to Medicare about it. The, I did work in nursing homes for 21 years, Medicare developed a CMS MDS hearing assessment, minimum data set hearing assessment, where the assessment nurse goes in to the residence room and says Hi, Mr. Jones, can you hear me okay? And Mr. Jones says, Yeah, I hear you pretty good. So she marks that his hearing is fine. Okay, which baffles me because, you know, she can, the resident can read our lips, and if he has low frequency hearing, he’s hearing the vowels. So it kind of combines to me and I hear you pretty good. But that’s not an assessment of hearing. And then speech therapists have it in their professional guidelines that they should if there’s chronic disease, infectious disease, ototoxic meds, trauma, head trauma, genetic issues, noise exposure, then they should do a hearing screening. However, rehab agencies don’t give them equipment, don’t give them an audiometer and they don’t seem to know about easy online validated, hearing screenings that takes three minutes to give. If it ever, if this ever came to light and change, I don’t know how audiology could deal with the numbers of people that need to have their hearing checked. Because just in North Carolina, there’s around 75,000 new admissions every year, in skilled nursing, you take an 80% incidence of hearing loss in skilled nursing. That’s over 60,000 Hearing evaluations every year that doesn’t include if you have if they’re on ototoxic meds, and they need to be monitored more frequently. So. So we have to figure out a system. And it’s great that we know this is an issue, and we can get prepared for it. But it’s really hard to change, you know, Medicare, and what they do. I met with six nurses on the CMS Division of Nursing Homes triage team last week. And they said, Yes, that is what we know. It’s a subjective evaluation. And I said, Well, that’s like, looking at somebody and saying, you know, I think your blood pressure’s doing pretty good, I’m going to take you off your medicine without putting a blood pressure cuff on them. Or saying, Oh, my God, your blood sugar’s way out of control, without ever doing a blood sample, you know, and then prescribing medications, it’s the same with hearing loss, you have to have a valid, objective tool to even say they have a problem or not. And then we have to do a very comprehensive evaluation to see what is it for the air and bone conduction, but then what is it for auditory processing speech, discrimination in noise, then in quiet, so we don’t overestimate you know, if they have really, really poor speech discrim in noise, that’s going to affect their cognitive score, even if they’re amplified, even if their hearing is corrected for quiet. So we need to know those things and let people know that maybe we need a visual means of communication when it gets noisy in the residence room. With a caption source or something.

Amyn Amlani 12:30
Yeah, yeah, no, no, absolutely. In you know, to to add, insult to injury, right. We also have a shortage of providers. And so you know, how do we overcome the fact that we have a shortage of audiologist, they’re not necessarily trained in this we have speech language pathologists who could potentially help us but they’re restricted because they can only screen. So how do we overcome these barriers is, is a huge problem that that is unfortunate, but exists in the marketplace today?

Kathy Dowd 13:05
Well, I really feel like interprofessional collaboration with speech therapists would be wonderful because they do have some training in the hearing screening and that sort of thing. If you’re doing telehealth, if we’re unable to go into facilities because of COVID. Having the speech therapists there to monitor when somebody is taking a hearing evaluation online or virtually would be very valuable. But for some reason, that’s not happening. I don’t understand why, you know, they look ASHA looks for other interprofessional collaboration with physical therapists and other professions. But why not? Audiology? We’re right in front of them. And we have to come before anything they do. Anything they do you have to know what the hearing and what the speech processing is, before you attempt to do speech, language or cognitive.

Amyn Amlani 14:10
No, no, absolutely. And, you know, I’m also thinking, you know, to kind of help the process along and you as you’re talking about interprofessional health, you know, is it possible to potentially get, you know, maybe nurses to participate in this as well and let the audiologist and be kind of the, the dentist, if you will, where you’ve got the hygienists feeding into the dentist could these other inter professionals then feed into the audiologist who could then make these higher level decisions on where to take the treatment? Is that something that your group might potentially be looking into? Or is that something that you would favor?

Kathy Dowd 14:49
Actually, it is something that we’re looking at and we have reached out to the North Carolina Family Physicians Group. Again, it all comes down to money, you know what’s in it for us. But they they are the boots on the ground. And they will say, well, we don’t have time for that. Unless there is a way that they see, they need to make time for that, if you understand what I’m saying, just in talking to the pharmaceutical pharmacy group in North Carolina, and I asked them about putting, you know, screeners in their consult rooms. And the first question was, well, what do we get paid? So everybody wants to know, but yes, I do think that that’s a great alliance, because you have a medical doctor, and then usually one or two nurse practitioners under that doctor, and they are there every single day, they have to sign all the orders in the charts, they have to do some examinations. So they’re there. And if they could be trained under the physician’s umbrella, then there’s no need for the licensing. Although, you know, as an audiologist, I would hope they be very, very well trained in everything that they would need to help audiology do. But yes, I think that might be a means of spreading our professional influence into rural areas or areas that don’t have an audiologist for one or two counties away.

Amyn Amlani 16:31
Yeah, yeah, no, absolutely. And then And then also, Kathy, you know, one of the things that I thought about, as I was preparing for our talk today, is, you know, when I was in graduate school, in this, you know, this was before the comorbidities really became more of a discussion. But a lot of audiologists are not trained in the fact that these comorbidities are affecting their hearing in some capacity. So what would you know, what advice would you have for the audiologist that’s now working that doesn’t have that information? Where can they become more educated on the effects of these comorbidities like diabetes on hearing loss?

Kathy Dowd 17:14
Well, we have a lot of educational material on our website, theaudiologyproject.com. We also have a referral form on there that can be downloaded and used. I was audited by Medicare back in 1995. And what I learned is, you – your order needs a test hearing for medical management purposes. If you put that at the bottom of a referral page, and the top is a checklist, you know, one of the things you could check is that they failed a hearing screening, that’s a valid reason for a valid medical reason. But then you can also check when you’re there with the person did they do they have high blood pressure, have they had a stroke, have they had a really bad accident in the last 10 or 20 years that they’ve been in the hospital for any MRSA, sepsis, anything that they would have been treated with aminoglycoside antibiotics, any hormone replacement treatment, any cancer chemo? Treatment, I mean, it’s just… I don’t know, I knew all this before. And that’s why I was so surprised in 2011, when my brother in law said he had and he was the head of diabetes for a state agency didn’t know anything about hearing loss being connected. But we always have to look, that’s the reason we do what we do is that’s why we’re audiologist and not hearing aid dealers or hearing aid specialist we, you know, we deal with the medical component of hearing loss and what we can anticipate is going to happen going forward. And then also making recommendations outside of our field to diabetes educators, because that’s one good way to make sure that the patient you have in front of you is going to be able to manage their diabetes, learn how to check their A1C, learn how to take their medicine, how to exercise, eat, right, etc. So

Amyn Amlani 19:30
yeah, it almost you know, it almost sounds like the audiologist has to essentially just expand the case history that they’re taking, do the assessment and do it in a way that’s that’s comprehensive, and then make the right kinds of relationships in order to co manage these individuals. And you know, one of the things that I’ve learned over the last several years is audiologists are are sometimes hesitant to do that. So what advice would you have for audiologists in saying, hey, you know what, in as the landscape is changing, and as there’s more opportunities to engage in these more medically kinds of issues that relate to hearing loss? What can you do? And what can you say that will then help you to push that agenda forward? That will push us away from being the hearing aid dealers and put us more in this healthcare arena that where we belong?

Kathy Dowd 20:33
Well, if you’re billing Medicare, if you’re billing insurance, you always want to have a really good case history and you want to, you know, and that includes what are their medications? Or what have they ever been on medications for, it takes a little bit of time, usually, the patient will fill it out, but then you have to look at it, I would spend time in front of my computer with them right next to me, looking at their medications to see what side effects there were. And then when you put them in the booth, do more than just a normal air bone in speech, put a hearing aid on them do auditory processing, you know, what, how is that contributing to their ability to hear and understand in the real world, when they get around noise and other issues. And then your recommendations. I’ve had people tell me, they don’t, they don’t make a recommendation anymore to see the person in a year, because that’s called routine audiometry. And I beg to differ with that strongly. If you have medical necessity, in your case history. And you put it into your report to the doctor that establishes your medical necessity for the next time you’re going to test them. So your recommendations should read retest in one year due to diabetes due to retest in three months due to chemo. I mean, there’s so many people that have chemo and you know, the doctors are not referring for they’re not doing ototoxic monitoring, they’re not referring to an audiologist. So you establish it in your in your records. And I wouldn’t even be concerned about what some audiologist called soliciting an order. In nursing homes, OTs write the order PTs write the order, speech therapist write the order, and the nurse practitioner or the doctor comes in and signs it. But they have medical necessity, because they did a screening and the person failed. And then they write the order and the doctor signs it. So I don’t know why we have as audiologists this knee jerk reaction against getting an order. If I have medical necessity, I would have no problem faxing that over to the doctor’s office for a signature. And if they have a problem, they can call me but I’ve very rarely would have usually they didn’t understand that this person could even have a hearing problem from those medical issues. So

Amyn Amlani 23:21
yeah, you bring up you bring up some really valid points here. And I think as a profession, we need to take the bull by the horns and say, you know, we’re gonna own this. And in order to own it, you know, we have to take, we have to take responsibility, and hopefully that will come with the next this this next generation. It’s got to start now. And, you know, Kathy, you’ve done so much to move this diabetes to the forefront as it relates to hearing loss. And we thank you for your service in doing that. Any last parting words that you might have for our viewers?

Kathy Dowd 24:01
Well, the only words because our you can only expect what you inspect. So if you don’t look at everything that could be contributing, if you don’t look at a full test that is outside of just the air bonus speech. And if you don’t write good recommendations, they’re going to educate the physician. So just do a deep dive on a lot of those things.

Amyn Amlani 24:35
Well, Kathy, you’ve you’ve educated so many of us on on again, on these various important issues. Thank you for being a champion for Audiology. It’s greatly greatly appreciated from all of us. And you know, for the viewers, I think this is an important component of what we need to do as we move forward particularly as disruption starts to increase. And you know, We want to move away from the product into the service realm, and helping these individuals who many of whom have diabetes and other comorbidities. It allows us to really embrace what audiology was meant to be when our forefathers put it together. And so, you know, thank you again for all that you do. And I’m hoping that we can get you back on here, you know, in due time, and we can have this discussion and hopefully the discussion is different in that more people are doing it and now we’re able to share other information with them. So, thank you again.

Kathy Dowd 25:38
Thank you so much Amyn