20Q: Interventional Audiology - Improving Patient Outcomes

From the Desk of Gus Mueller

Let’s start with reviewing a couple things about hearing loss that you probably already know. First, while as audiologists we commonly focus on speech understanding, we need to remember that hearing loss impacts a person’s life in many other areas: falls, fatigue, anxiety, depression, social isolation, and hospitalization, to name a few. And we’re all aware of the more recent publications related to the association between hearing loss and cognitive decline.

Related to this is the fact that the majority of hearing loss is untreated. Comparing the percent of the U.S. population (aged 20 to 80 years) who have hearing loss to those who use hearing aids, audiologist Larry Humes has come up with some numbers for us, which he refers to as “unmet hearing care needs.”

Using the audiogram findings from the National Health and Nutrition Examination Surveys (NHANES), he projects the unmet needs are about 38 million; 21 million males and 17 million females. If we look at those with self-report of hearing loss, rather than using audiometric findings, the value goes up to 42 million; 23 million males and 19 million females.

That’s a lot of people. What can we do to help? One approach that many believe can make a difference is “interventional audiology,” the topic of this month’s 20Q, and our guest author will tell you all about it.

Lori Zitelli, AuD, is an Audiology Manager at the University of Pittsburgh Medical Center, and an adjunct instructor at the University of Pittsburgh. Her special interests include evaluation and treatment of tinnitus/decreased sound tolerance, amplification, clinical education, clinical research, and interventional audiology. You are probably aware of her many presentations and publications. She’s quite famous here at AudiologyOnline, as her work has been honored with the Editors’ Picks in 2017, 2020, 2021 and 2023!

Dr Zitelli was selected as the recipient of the 2022 American Academy of Audiology Early Career Audiologist Award, and also was chosen as one of the Jerger Future Leaders of Audiology.

In her excellent 20Q, Lori explains how interventional audiology can be a routine part of our services, for the times when we need to manage hearing loss in order to positively impact other primary concerns of the patient. 

Gus Mueller, PhD
Contributing Editor

Browse the complete collection of 20Q with Gus Mueller CEU articles at www.audiologyonline.com/20Q

20Q: Interventional Audiology - Improving Patient Outcomes

Learning Outcomes 

After reading this article, professionals will be able to:

• Define the term “interventional audiology.”
• Describe what is considered impactful hearing loss.
• List 3 components of a successful interventional audiology program.

Lori Zitelli, AuD

1. I know educational audiology, pediatric audiology, clinical audiology…I’m not sure I’ve heard of interventional audiology?

The term “interventional audiology” refers to a method of providing care that focuses on successful communication.  It appears that the term was first introduced by audiologist Brian Taylor and colleagues, going back to 2013 (Taylor & Tysoe, 2013; Taylor & Tysoe, 2014a; Taylor et al, 2014) with a 2015 follow-up article by Catherine Palmer.

Essentially, we want to maximize a person’s ability to participate in their own care. However, we know that hearing loss (especially when untreated) can be a barrier that prevents participation and leads to less-than-optimal outcomes. Providers using an interventional strategy will focus on intervening to optimize communication, even when hearing is not the primary health concern of the patient or their care team.

2. By “less-than-optimal outcomes,” you’re referring to things like reduced audibility and poor speech intelligibility?

Yes, those are expected outcomes when hearing loss is untreated, but I’m really referring to some bigger-picture outcomes. In the literature, untreated hearing loss has been linked to a variety of poor health outcomes. A person with an untreated hearing loss is at risk for receiving ineffective medical care for a variety of reasons: poor adherence to treatment recommendations (Lawthers et al, 2003), increased likelihood of experiencing a preventable adverse event (Bartlett et al, 2008), and dissatisfaction with quality and accessibility of care (Hoffman et al, 2005) are just a few.

3. Those all sound like issues that we want to avoid. What other problems might a person with untreated hearing loss experience in a healthcare setting?

Consider all of the ways that a person’s untreated hearing loss may interfere with their ability to receive care: communicating with providers effectively to describe their complaints or symptoms, lack of lipreading cues due to masks worn for infection control, following test instructions for diagnostic procedures, understanding treatment options, scheduling appointments, hearing their name being called in the waiting room, communicating with office staff and providers for follow-up care… and the list goes on.

I’ll provide some examples:

• A patient leaves the hospital against medical advice despite having an increased heart rate when they do not understand their test results and the recommendations to stay for monitoring.
• A patient falls in their hospital room after they did not hear the nurse telling them to sit back down.
• A patient gets two x-rays instead of one because they did not understand the questions being asked by the technician.
• A patient feels their provider is being demeaning when they say, “I know you don’t have your hearing aids in. Can you hear me?”
• A patient is admitted to the hospital under the wrong name because they mis-heard the spelling.
• A provider is passing medications to the patient, who interrupts the instructions with multiple questions, leading to the provider becoming distracted and forgetting to cut the pill in half (providing too large of a dose).

And there are many more examples. As you can see, untreated hearing loss can cause a variety of problems.

4. Are there any long-term risks we need to be aware of, as well?

Absolutely. People with untreated hearing loss are more likely to suffer from depression (Golub et al, 2019) and social isolation (Mick, Kawachi, & Lin, 2014). They’re also at an increased risk for cognitive decline (Sarant et al, 2023) and falling (Agmon, Laive, & Doumas, 2017). On a larger scale, if we think of it from a public health approach, there are other issues to consider as well. These patients are more likely to be admitted to the hospital for inpatient care (Genther et al, 2013) – and readmitted after discharge (Genther et al, 2015). Other data have linked untreated hearing loss to $3.3 billion dollars in excess medical expenditures (Huddle et al, 2017).

5. Got it. Well, it should be easy to get all healthcare providers on board for this and look for signs of untreated hearing loss, right?

You’d hope so, and many healthcare providers often think that they will be able to recognize when an individual has a hearing loss. Unfortunately, research shows us that about half of healthcare professionals are not able to accurately recognize untreated hearing loss (Mormer et al, 2020). Furthermore, some may feel confident that they can recognize when a person has hearing loss because they assume that the person will be wearing hearing aids. However, we know that the hearing aid uptake rate in our country is only 38% (Powers & Carr, 2022), so by using this strategy, most individuals with untreated hearing loss will not be identified.

Many healthcare providers – if they screen for hearing loss at all – rely on non-standardized methods of hearing screenings with poor sensitivity (e.g., finger rub, watch tick, whispered voice tests) (Nuwer & Sigsbee, 1998; Boatman et al, 2007). Other providers will not see compelling reasons to screen for hearing loss in aging adults at all because, to them, age-related hearing loss is expected. Although it may be expected, as we’ve discussed, it is not benign.

6. Can’t we just ask these patients if they have hearing loss?

Generally, we expect adults to develop hearing loss over time and we expect adults with hearing loss to self-identify. This becomes problematic with age-related hearing loss, when the hearing loss has come on gradually over a span of 10 years or so. When the onset is gradual, it may be difficult for the patient to recognize because they may have developed ways of compensating for the hearing loss by limiting their activities in challenging listening situations. They will not necessarily say “yes” when asked if they have difficulty hearing because they may not realize that they do have hearing loss and are missing things. Research has shown that only 40% of people with age-related hearing loss recognize it (Mormer et al, 2020).

In my opinion, there are better strategies available, although they each have their own respective limitations. There are some questionnaires that could be administered which are designed to identify hearing difficulties — the HHIE/A is the most commonly recognized by audiologists. These may take some time to administer (may not be ideal in a clinical setting) and may not be ideal to identify a person who doesn’t recognize their own hearing difficulty.

Another option would be a pure-tone screening or speech-in-noise screening to identify deficits in sensitivity that may indicate they’d be at risk for poor communication in a healthcare setting. The equipment for these screenings can be expensive and require a person who has been trained to use the device to operate it. Additionally, it’s important to take into account that these types of screenings can be influenced by the effects of background noise in exam rooms.

Ultimately, the most sensitive and reliable way to know if someone has a hearing loss is to measure it. In the various health care clinics we support, we choose to use a portable audiometer that facilitates a brief pure-tone screening bilaterally.

7. You’re saying that we should be screening people in healthcare clinics to identify those with hearing loss – what screening protocol do you recommend?

First, let me point out that there are really two reasons to use a screening procedure to identify a problem: managing the hearing loss in real time to support the healthcare interaction (e.g., supplying an amplifier to be used during the appointment) and recommending appropriate follow-up care so that the person can pursue a long-term solution for their hearing loss.

I think the screening protocol that you select will depend on your goals. Are you trying to identify everyone with hearing loss? Then you’d want to screen selected frequencies (e.g., 500, 1000, and 2000 Hz) at a set level. Let’s say you decide to use ASHA criteria (ASHA, 2024) that classifies -10 to 15 dB HL thresholds as normal, 16 to 25 dB HL thresholds as slight hearing loss, and 26 to 40 dB HL thresholds as mild hearing loss. If you set your screening level at 15 dB HL, you’ll catch everyone with even the slightest degree of hearing loss, but you’ll also probably make some over-referrals as well.

I’d recommend avoiding over-referrals by setting the screening level to identify impactful hearing loss. Remember that these patients often have more pressing and concerning medical issues that need to be dealt with immediately and you only want to recommend follow-up care for the people who need it. Over-referrals don’t help anyone. If everyone needs immediate follow-up care, why bother to screen anyone?

8. What do you consider to be “impactful hearing loss?”

In this case, it’s actually what the World Health Organization (WHO) considers, not me! WHO (2024) states that hearing loss worse than 35 dB HL in the better hearing ear is disabling. Using this criterion and if it is your goal to identify individuals at risk for disabling hearing loss, a screening protocol that uses a set level of 35 dB HL for adults is appropriate. If you look at the American Academy of Audiology Guidelines for Childhood Hearing Screening (2011), there are a variety of screening protocols in use. Most use 1000, 2000, and 4000 Hz at a minimum. Some include additional frequencies such as 500 Hz (which can be affected by room noise) and 8000 Hz (which, arguably, many older adults could be expected to fail at 35 dB HL). Interestingly (and perhaps directly to my point), there are not widely accepted guidelines for screening older adults.

9. Didn’t I read somewhere that some group recommended against screening for hearing loss in older adults?

Thanks for bringing this up. Indeed, the U.S. Preventive Services Task Force (USPSTF) did release a recommendation statement in 2021 (Krist et al, 2021) indicating that there was not sufficient evidence to warrant a recommendation for screening at that time. Some people may have interpreted this as a statement against screening, but it is an indication that studies evaluating the impact of screening on intervention are needed! Remember, a lack of evidence FOR is not the same thing as evidence AGAINST. We know that children (newborns, school-age kids) benefit from hearing screenings because of the work that was done in this area by audiology pioneers to make it evident that these screenings lead to early intervention which leads to better outcomes. We need to develop the same level of evidence to support adult screenings, as well. To obtain the evidence we need, we must commit to putting boots to the ground and collecting the data that supports our involvement in identifying and mitigating disabling hearing loss in healthcare settings; thus, our interest in interventional audiology. As I mentioned before, we view this as a three-part activity: 1) identifying a person at risk for poor communication, 2) intervening to reduce the negative impacts in real time, and 3) providing recommendations for appropriate follow-up care, when indicated.

10. You’ve already made your case for item #1 on your list. Is there anything else I need to know about screening hearing in older adults?

I do have a few strategies to recommend. We’ve learned a thing or two over the past 10 years, as we’ve integrated interventional audiology components into a variety of health care settings. We started doing this in 2014 in UPMC’s Post-Trauma unit (see Zitelli & Palmer, 2017a for a description of how this inter-disciplinary clinic operates, if you’re interested). In that clinic, an interdisciplinary team of providers follows up in an outpatient setting with patients who were discharged from an inpatient trauma unit approximately 2 weeks earlier. Other providers include speech-language pathologists, physical therapists, occupational therapists, nutritionists, and advanced practice providers (APP) such as physician assistants and certified registered nurse practitioners. The team evaluates each patient, recommendations are consolidated into one flowsheet, and the APP facilitates the implementation of the care plan.

11. With at least 6 providers, I imagine it gets tricky to coordinate… How long are these appointments?

You’re right. In some of our interdisciplinary clinics, there are even more providers! It is not uncommon for a patient to spend a few hours in the clinic completing all their evaluations and receiving a comprehensive care plan. While this does help them to avoid multiple different appointments, it can be a long day. We’ve found that it’s very important to make our interactions as efficient as possible. Given the constraints of these situations, we acknowledge that we can’t complete full testing – and that this is okay. In these interactions, we want to identify the need for further follow-up care and provide immediate access to communication. Other, more comprehensive testing can be completed at another time. It really forced us to pare down our interactions to only the most essential components.

12. What are the essentials?

First, you must work with the other providers to ensure that you are the first provider in the room. Your ability to identify a patient’s impactful hearing loss and improve their communication in real time is not helpful to them during these appointments if they have already spoken with 6 other providers before you. Additionally, this strategy puts communication front and center in the minds of both the patient and the care team. Each provider on the team likely feels that their expertise is essential to the patient’s success. While this is true, it is arguably especially true for audiology! If the patient is unable to communicate effectively, they may mishear or miss instructions, results, or recommendations. It does sometimes help to frame your argument this way. In other words, you can tell other providers, “It’s important for me to be the first provider to see each patient so that they can benefit from the important information you’re going to provide them. If the patient has a hearing loss that will interfere with your communication, we’ll provide a solution that you can use to communicate effectively with them.” Don’t be afraid to be proactive and assert yourself. What you are doing is important!

Next, you need to be flexible and aware of your surroundings. We’ve found that sitting at a computer and waiting for a medical assistant to alert us that a patient is available is a risky strategy that often results in us “missing our window” to evaluate the patient first. Everyone on the team is trying to move as fast as they can. Mistakes are sometimes made. I joke with my students that interventional audiology has turned me into a “lurker.” I have become comfortable waiting in doorframes to pounce when opportunities arise. Additionally, using portable equipment is critical. We move in and out of rooms frequently and it’s unmanageable to carry heavy audiometers or try to find electrical outlets in each room. A handheld portable audiometer powered by a rechargeable battery is a nice option.

13. Isn’t it a little confusing when the patient scheduled an appointment to create a care plan for their cancer, and the first person to walk into their room is an audiologist?

We quickly found that patients were more likely to agree to a hearing screening if we framed our presence as such: “My name is Lori Zitelli. I’m here from audiology. You’ll be seeing several people today and it’s important that you can communicate with them so that you are able to participate in your care. To make sure you can, we’re going to do a quick hearing screening before the rest of your appointments. If we identify a hearing loss that might interfere with your communication, we have a solution to help with that.” Simple, quick, and to the point.

14. Let’s say I’ve convinced someone to let me screen their hearing and they fail. Now what?

Here’s the protocol we landed on after some trial and error: If the patient hears all the screening tones, or only misses one, this suggests that at least one ear can hear most frequencies at a 35 dB HL level (this should be sufficient for face-to-face communication in an exam room). If they miss two or more of the screening tones, this is considered a failed screening and we provide a non-custom amplifier for the remainder of the appointment, in addition to follow-up care.

15. What’s a non-custom amplifier?

You could use any one of many available amplifier devices (e.g., the SonicTechnology Super Ear or Williams Sound Pocketalker). The one we use has a headset (allowing the use of disposable earphone covers so that they can be used with multiple patients) and a volume wheel that affords patients the flexibility to find a volume level that is comfortable to them. It is simple to use and effective. Some patients find it so helpful that they choose to purchase one to take with them for use outside of the clinic!

16. It’s good that there’s a simple way to help them communicate more easily. What do you do for people who are already hearing aid owners?

First, let’s distinguish between hearing aid owners and hearing aid users. We all know that some patients who own hearing aids do not wear them regularly. Knowing that a patient owns hearing aids is helpful, though. If someone has hearing aids, they likely would not pass a 35 dB HL screening. In this case, even if they are not wearing the hearing aids at the appointment, I think it’s safe to say you can probably skip the screening and go right to the amplifier.

17. Do a lot of people use the amplifier when you offer it? I imagine some patients may say “I don’t need that!”

It is for this exact reason that we don’t offer the amplifier. When they fail the hearing screening (or if there is a known hearing loss), we put it on them and show them how to operate it, providing the expectation that they will use it for the remainder of their appointment. Some patients may choose to remove it after we leave the room, but we have found that offering the amplifier implies that it’s optional and makes it much more likely for patients to decline it (especially if they don’t recognize that they have hearing loss).

18. Once you’ve identified people and improved their communication, what’s next?

If they haven’t passed the hearing screening, follow-up care is recommended. I think we need to be a little careful here to not act as though an audiogram is an urgent referral need. These patients may be dealing with a life-altering diagnosis such as cancer or recovering from severe trauma. Understandably, an audiogram may be low on their list of priorities. Using language that is sensitive to this may be helpful:

“When you’re ready, the next step would be to get a hearing test. I know you have other things you are dealing with right now and it’s okay if this is not your priority. I’ll give you some information that tells you how to schedule that type of appointment and you can do it whenever you’re ready.”

By placing the focus on communication related to their health care, they may be more likely to react positively to the recommendation.

Something else to think about – making it as easy as possible for patients to follow your recommendations may make it more likely that they will obtain follow-up care. Recent data indicate that the opportunity to complete audiometric testing on the day of other medical appointments (thereby avoiding additional appointments) may increase the follow-up rate (Zitelli et al, 2023). Other strategies that may help include asking an office staff member to contact the patient to facilitate the appointment scheduling, providing opportunities for the patient to schedule follow-up care while they are in-office, creating a handout that lists all available office locations with contact information, etc.

19. This all sounds great, but I work in a small private practice. How does all this apply to me?

Much of what I have said here applies to audiologists working in larger clinics or hospital/ENT settings. But understand, interventional audiology also is important for smaller offices and audiologists in private practice. Partnering with non-audiology providers and educating them about the negative impacts of untreated hearing loss (both on their patients’ health as a whole and on their ability to effectively communicate with their patients) creates opportunities to forge long-lasting relationships. Brian Taylor and Bob Tysoe (2014b) outline a few key elements related to building effective relationships with other providers: authentically caring for your patients’ wellbeing, making yourself visible to care providers in your community, and positioning yourself as a credible source of up-to-date research that can be applied to clinical practice.

You can empower other non-audiology providers to provide interventional audiology services within their own clinics, as well. Screening activities (including distribution of amplifiers) can easily be completed by assistants, students, or technicians. Our goal as audiologists is to be the group overseeing all activities related to hearing (including screening and intervention), but the people carrying out the screenings and provision of amplifiers do not need to be audiologists. We oversee and organize these programs and make sure they are conducted accurately. Regarding your question, this organization easily can be a service provided by a small practice like yours.

20. What other clinical settings are appropriate for this?

We’ve employed interventional audiology strategies in a variety of settings. Some are multidisciplinary clinics involving several providers (Post-Trauma Clinic, ENT Survivorship [Head & Neck Cancer] Clinic, Center for Perioperative Care). Interventional services also have been provided in Senior Living Facilities (Palmer et al, 2017), outpatient clinics (geriatric clinics are perfect for this!), and inpatient settings (Zitelli & Palmer, 2017b).

We have partnered with other providers (for example, Home Health providers such as Speech-Language Pathologists, Occupational Therapists, or Physical Therapists). These individuals have unique opportunities to assess a person’s communication needs within their homes.

All team members who contribute to interventional services are valuable and can help patients to optimize their outcomes. We can all work together to collect the data needed to support this approach, with the goal of moving toward implementing interventional activities in more healthcare settings.

References

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Zitelli, L., Palmer, C., Mamula, E., Johnson, J., Rauterkus, G., & Nilsen, M. (2023). Hearing screening and amplifier uptake results in a multidisciplinary head and neck cancer survivorship clinic. Journal of Cancer Survivorship, 17(3), 720-728.