The Under-Treatment of Hearing Loss and Continuum of Care with Dr. Meredith Holcomb

under treatment of hearing loss holcomb interview
May 9, 2023

Meredith Holcomb, AuD, Associate Professor of Clinical Otolaryngology and Director of the Hearing Implant Program at the University of Miami Ear Institute discusses the under-treatment of hearing loss and new cochlear implant guidelines that support the continuum of care.

Links mentioned in this interview: 

Full Episode Transcript


and welcome to another episode

of this Week in Hearing.

I’m Brian Taylor,

and my guest today is Dr.

Meredith Holcomb,

who’s an associate professor of

clinical otolaryngology and the

director of the Hearing Implant

Program at the University of

Miami Ear Institute.

And today we’re tackling the

topic of under treatment of

hearing loss in adults. Dr.


I want to welcome you to

This Week in Hearing.

It’s great to have you with us.

Thank you for inviting me.

This is exciting,

that’s for sure.

This is a really important

topic, I think,

and one that kind of flies

under the radar.

And before we get into it,


I thought if we could if you

could share a little

bit about yourself,

where you practice your role

at the Miami Ear Institute,

that would be great. Great.

So as you mentioned,

I’m an audiologist.

I’ve been providing cochlear

implant care,

specifically in audiology,

for 16 years.

I trained at the University of

North Carolina in Chapel Hill

and I’m the hearing implant

program director here at the

University of Miami.

I’m very passionate about

improving access for patients

who need hearing loss treatment.

And that’s sort of how some of

these initiatives we’ll

talk about today,

that’s kind of how I got

involved with it.

One of my big passions is making

sure that communication is

available for as many patients

as possible. However, that is,

whether it’s captioning

for our appointments,

which we do that here,

or just making sure that we are

providing the best care possible

for all of our hearing

loss patients.

Very nice.

I guess my first question is,

from your perspective as a

cochlear implant expert,

just how big of a problem is the

undertreatment of hearing loss

in the adult population?


I think we’ve got an enormous

problem. And honestly, Brian,

it’s a big enough problem

that in 2021,

the World Health Organization

sort of used hearing and

untreated hearing loss as part

of their initiative.

We have millions and millions

of people in the US.

And in other countries who are

experiencing hearing loss,

and those numbers are expected

to grow exponentially by 2050.

What is expected is that there’s

going to be about 711 million

people who have a disabling

form of hearing loss.

And disabling means it’s

impacting their life

in some way.

I think when you think

about hearing loss,

it’s an invisible problem for a

lot of people. We can’t see it.

When had knee surgery,

I remember several years ago,

you could see the brace.

People got out of my way or

said, Can. Hold the door.

Help me do things with

hearing loss.

It’s not something that’s

easily visible.

And so we oftentimes don’t know

that our colleagues or our

friends or our family members

are suffering from this,

treating it.

The reason it’s really so

important and why is

such a big problem,

is that hearing loss can affect

so many other parts

of our health.

Cardiac concerns,

mental health concerns,

cognition concerns.

All of those things

have been linked.

Diabetes has been linked

to hearing loss.

And there’s sort of a story of

how that all works together.

But it’s an enormous problem.

And communication is one of the

main ways that we are able to

live our life with our family

members and our loved ones.

We saw that during the height

of COVID not being able to

communicate really was

destructive on a lot of

levels for people.

And so making sure that we can

provide care for patients who

need hearing loss is

a huge concern.

And the biggest problem is that

the vast majority of patients

who suffer from disabled hearing

loss are not getting in the door

and are not being treated well.

I want to get into that a little

bit more with more detail.

I know that you were involved

in some recently published

guidelines around referrals

for cochlear implants.

I was hoping you could tell us

a little bit about more about

these guidelines for adults and

cochlear implant candidacy. No?


It’s been a two year journey of

50 global task force members.

And when I say global,

I mean we on the map

of the globe,

are representing so many of the

areas that need to have

a voice in this topic.

And these people have

come together.

We’ve looked at the evidence,

the peer reviewed information,

what our researchers are

putting out there.

We’ve looked at what is lacking,

what’s necessary.

And what we’ve really found is

there’s a huge need for us to

better identify and standardize

the care that patients are

receiving even before they get

to the cochlear implant process.

So it’s getting the patients

in the door of a clinic,

getting patients identified with

a hearing loss, and then,

of course,

being treated appropriately with

a cochlear implant when

they need it.

So all of those steps are

highlighted in these living

practice guidelines.

What’s really cool about the

guidelines is because

they’re living,

they can change as the research

changes and as the needs change.

But if you can imagine getting

50 task members to vote and

agree on guidelines,

it wasn’t the easiest task that

we all undertook, of course.

But I think what came out of

this is a really lovely document

that providers, family members,

and even pay patients can look

at to help navigate this

very complex process.

Of getting the right treatment

for your hearing loss. Right.


I’m not expecting you to have

the website where you can find

those guidelines memorized,

but if you have it off

the top of your head,

could you share that with us?

I do not have it on the

top of my head,

but I can certainly look it up,

and I can get that information

either in this session,

or I can send it, Brian, to you,

and you can make sure that you

have it. That’s all right.

What we’ll do is we’ll put those

guidelines are posted

in the show notes,

and people will be able to click

on the link to the guidelines

that you just talked about.

So that’s good to know.

As a clinician myself,

based on my own experience,

I know that there are a lot of

adults out there with severe

hearing loss who really struggle

with traditional hearing AIDS.

And it seems like there’s maybe

a bit of reluctance,

or maybe it’s just a lack of

information that kind of gets in

the way of clinicians referring

those patients for cochlear


Could you tell us a little bit

more about some of the

guidelines around who might be a

cochlear implant candidate for

an adult hearing aid where what

would be an indication that they

should maybe go and seek a more

formal cochlear implant


Great question.

I think the top sort of I guess

maybe the number one thing that

patients should think about is

if they are wearing hearing aids

and those hearing aids are not

providing them with enough

audibility or enough opportunity

for them to hear and communicate

well with their loved ones.

That’s a huge red flag and

something that they should

certainly investigate

a little further.

And I would say that those

patients, a lot of times,

are the patients who need to be

seen for a cochlear implant

evaluation. Now,

from a provider perspective,

we have some cool sort of

metrics that we look at to try

to identify patients who are

potential cochlear implant


But from the patient

perspective, really,

the number one thing is,

if the patient or their loved

ones have concerns about how

they’re performing with

their hearing aids,

it’s probably time for them to

take the next step and get just

a little higher level


That’s pretty simple to do.

It’s just not done in all

audiology offices.

So I think sometimes patients

don’t know where to go,

which is part of what these

living practice guidelines

are hoping to address.

But there’s great information on

the Web for cochlear implant


also for an organization in

America called the American

Cochlear Implant Alliance.

There are maps on specific

centers that are in your area

that may be able to offer those

evaluations. So it’s out there.

We just need to make sure

patients know how to navigate

all of those,

I guess, media.

Outlets in order to find

the right place. Right.

And we’ll put some of those

links to the websites that you

mentioned in the show notes so

people can find you already kind

of alluded to it a little bit,

but could you give us a little

bit more information for any

consumers out there

that have severe,

profound hearing loss that might

be struggling with their

hearing aids?

What’s some good advice that you

might be able to share

with them? Yeah,

the one thing that I tell

patients is you have to be

your own best advocate.

And oftentimes we hear from many

patients who come in the door.

Here at University of Miami,

I’ve been getting new hearing

aids every five years.

My hearing has still been severe

to profound or I’ve been

struggling with every new

hearing aid that I’ve

been fit with.

I finally found a way to get

into the evaluation.

And so no disrespect at all to

any of us hearing healthcare


but we as audiologists really

don’t do the best job of sort of

nudging patients to go look for

a little bit more information

for their hearing loss.

But I think the best thing

patients can do is ask questions

if they’re unhappy with how

they’re hearing with

their hearing aids,

ask if there’s something else

that is available for them.

What we really want to see with

these guidelines as well is that

there’s a hearing health


I think up until recent years

there’s sort of been you have a

little bit of hearing loss

and then you have a lot.

If you have a lot,

then you do hearing aids.

And then maybe if hearing

aids don’t work,

the last resort is a

cochlear implant.

And the topic of conversation

around cochlear implants has

unfortunately almost been a

little bit negative. Like,

if you end up with an implant,

you’re almost failing with

your hearing. Right.

But what we know is that

candidacy is changing so much.

We see patients now who they can

still score around 60% or less

on some of their speech tests

that we do for their

hearing assessment.

Those patients are implant


Back when I first started,

you had to have like

0% understanding.

And now really implants are able

to help patients who hear 50%

with their hearing aids.


there’s always more information

and more education for patients,

but they’ve got to be their best

advocate and really ask the

right questions too. Yeah,

you brought up a couple of

really great points that I

wanted to kind of go back and

talk a little bit about.

One is you mentioned

the 60% criteria.

Could you tell us a little

bit about that?

60 x 60 criteria?

I know that’s kind of a new

thing and some of our hearing

care providers may not even

know about that yet. Yeah,

so the 60/60 was created,

I guess,

or discovered rather by Dr.

Zwolin and her colleagues at

the university of Michigan.

She’s a really good

friend of mine.

And I remember when she was

working on this project,

and they knew that there had to

be some tangible data that we

could use as audiologists

to say, hey,

this person needs to be.

Be sent for a cochlear

implant evaluation.

So what they found from their

research is that patients who

have a pure tone average,

which is

their kind of 500 Hz and 1000 Hz hearing

if that is 60 decibels or worse,

and then if they have scored 60%

or worse on their unaided

so no hearing aids,

unaided word recognition


Those patients should be sent

for a cochlear implant


And her research really

supported that.

There was like a 96%

detection rate.

Meaning if you applied that 60

60 rule to your patients,

the vast majority of them are

actually going to end up being

cochlear implant candidates if

they’re evaluated properly and

tested at a cochlear implant

center. Now,

that’s for English

speaking adults.

And I do want to mention that

because something that is

hopefully coming out pretty soon

from our clinic is looking at

our very large Spanish speaking

population down here, which,

as we all know,

is a rapidly growing

language in the US.

The 60% part doesn’t

hold for Spanish,

but the 60 pure tone average,

that just your hearing test.

The pure tone average,

it does hold for the Spanish

speaking patient.

So I think there’s a lot of good

that’s coming out in the

research even now to try to

identify as many of these

patients that we work with as

possible and put them in the

right hands of somebody who can

help them with their

hearing loss. Yeah,

that’s really great information.

And thanks for talking about

the 60-60 criteria.

I think that’s really important

for providers across the globe

to know about. Really?


You also mentioned something

else that I wanted

to ask you about,

and that is this concept of the

continuum of care and the fact

that cochlear implants are kind

of thought of as a last resort.

Can you speak a little bit more

about what you mean by the

continuum of care and maybe how

cochlear implants shouldn’t be

thought of as a last resort?

So anything about a continuum of

care in the medical field,

anytime you’re diagnosed with

something and hearing loss is

what we’re talking about today,

typically you look at the

longevity of that diagnosis and

what is available throughout the

patient’s experience or lifetime

with the diagnosis.

Thinking about hearing aids

and cochlear implants now,

because the candidacy has

rapidly changed and we’re

implanting people with

better hearing,

we can actually combine hearing

aids and cochlear implants

into one device.

And so they’re not even separate

for some patients,

which is amazing.

Also thinking about patients who

use a hearing aid on one side

and a cochlear implant

on the other,

which would work for about 80%

of the patients that we see in

our clinics here in the cochlear

implant centers.

Those patients are able to

make use of both of those

technologies on. Each ear.

But having the ability to use

both of those technologies on

one ear is something that

came out in about 2014,

and it’s really been a game

changer for those patients with

better hearing loss. And so,

with that being said,

it’s not necessarily one

or the other anymore.

It really is a combination,

and it’s looking at what devices

are most appropriate for this

patient, not necessarily device.

And then when they fail

at that device,

they go to the next device.

It really is a combined effort,

which is great.

And the hearing aid companies

and the cochlear implant

companies have recognized that

and have really given us as

providers a lot of tools and

resources to accommodate all of

the patients that we conceive

with hearing loss. Yeah, no,

that’s great.

We have hybrid devices,

bimodal fittings on one

end of the spectrum.

On the other end of

the spectrum,

we have over the counter


other kinds of assistant


even apps that can help people

definitely communicate

more effectively.

So a lot to kind of wrap your

head around if you’re a provider

these days, it is.

But you can see, Brian,

why it can be so confusing for

patients when they’re looking

online or at literature.

I think there are so many

options which are great,

but what’s right for one patient

may not be right for the other.

So the more we can do,

especially things like this

kind of interview,

I hope we’ll be able to guide

patients in the right direction.

Great. Well,

as we wrap things up here,

Meredith, any final thoughts,

any final suggestions that you

have for hearing care providers,


consumers that might be in the

market for these kind of devices

that we’ve talked about? Yeah,

so I think I’ll separate

those for consumers.

What I would say to consumers is

treat your hearing loss before

it becomes a really

bad situation.

Bad meaning you are

limited. Your socialization,

your quality of life

is getting poor.

It’s impacting your

mental health,

your communication

with your family.

Treat the hearing loss

as soon as you can.

There’s so many great benefits,

and we’ve seen from really huge

reputable journals that treating

hearing loss early can actually

mitigate some of the cognitive

problems that come about as we

age and get into the elderly

stages of life.

Ask questions of the providers

that you’re working with.

Seek answers,

and don’t take no for an answer.

If you feel like you need a

cochlear implant evaluation,

go get the cochlear implant


You don’t need a referral.

You can go find your center,

and we’ll see you.

For the providers,

what I would say is

we need to do a really good job

of sharing all of these

patients. Only about, you know,

less than 20% of patients who

need hearing aids or cochlear

implants, actually. Have them.

We have a large population of

patients who need to be served

with technology,

and so we need to work together

as a team and make sure that we

are offering all of these

hearing healthcare continuum

devices as an option when we

work with our patients.

And if providers,

if you guys have information or

need information about

Cochlear implants,

please reach out to any of us.

You can reach out to

me personally,

and I’m happy to assist with

connecting you with somebody

in your area.

That’s just super advice,

and we’ll make sure that those

links are in the show

notes here. Awesome.

As people watch this,

they’ll be able to access it.

Dr. Meredith Holcomb,

audiologist associate professor

of clinical otolaryngology and

the director of the hearing

implant program Graham at the

University of Miami

Ear Institute.

Thank you so much for taking

time out of your busy schedule

to spend some time with us.

Thank you, Brian.

And thank you to the listeners.

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About the Panel

Brian Taylor, AuD, is the senior director of audiology for Signia. He is also the editor of Audiology Practices, a quarterly journal of the Academy of Doctors of Audiology, editor-at-large for Hearing Health and Technology Matters and adjunct instructor at the University of Wisconsin.



Meredith Holcomb, AuD, is an Associate Professor and the Director of the Hearing Implant Program at the University of Miami Department of Otolaryngology. Dr. Holcomb received her Doctorate of Audiology from the University of North Carolina at Chapel Hill in 2006. She spent the first 13 years of her career at the Medical University of South Carolina as an Assistant Professor and the Clinical Director of the Cochlear Implant Program. She is a Past-Chair of the American Cochlear Implant Alliance Board of Directors. She is on the Audiology Advisory Council for Advanced Bionics, Med El, and Hemideina. Dr. Holcomb is a faculty member for the Institute for Cochlear Implant Training Advanced Audiology Course, and she serves as a consultant for Cochlear Corporation and ASHA.

Dr. Holcomb demonstrates a strong commitment to education, mentorship, and clinical research. She has published book chapters and peer reviewed journal articles and has given numerous invited presentations at national and international conferences on the subject of cochlear implantation and clinical efficiency.



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