BackTable / ENT / Podcast / Transcript #29

Podcast Transcript: Improving Access to Hearing Care Services

with Dr. Carrie Nieman

We talk with Dr. Carrie Nieman about improving hearing health disparities among older adults, particularly among vulnerable populations. Her practice and research focuses on an innovative, community-delivered approach to affordable, accessible hearing care. You can read the full transcript below and listen to this episode here on BackTable.com.

Table of Contents

(1) Statistics in Age-Related Hearing Loss and Hearing Care

(2) Inequities and Disparities in Age-Related Hearing Loss

(3) Improving Access to Community Hearing Care

(4) Community Health Workers: Structure, Training, and Implementation

(5) HEARS Program for Community Health Workers and Hearing Care

(6) Over-the-Counter Hearing Devices Implemented through the HEARS program

(7) The Role of Audiologists in Community-Based Hearing Care

(8) Controversies in Community-Based Hearing Care

(9) Goals of a Community-Based Hearing Care System

(10) Tips for Practitioners to Improve Hearing Care Access

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Ep 29 Improving Access to Hearing Care Services with Dr. Carrie Nieman
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[Gopi Shah MD]
Hello, everyone and welcome to the BackTable ENT Podcast, where we discuss all things ENT. We bring you the best and brightest in our field with the hope that you can take something from our show to your practice. My name is Gopi Shah, and I'm a pediatric otolaryngologist at UT Southwestern here in Dallas, Texas.

[Ashley Agan MD]
And I'm Ashley Agan, and I'm a general ENT practicing in an academic setting at UT Southwestern in Dallas, Texas. We are your hosts and we're so glad you stopped by to check out the podcast today. How's it going, Gopi?

[Gopi Shah MD]
It's going good. I got the sinus a little bit today, but I did a rinse and I feel like I'm prepared and less nasally, so I'm ready.

[Ashley Agan MD]
Awesome. It's podcast Saturday. It's always good.

[Gopi Shah MD]
It's always good.

[Ashley Agan MD]
We have a great guest today. I'll go ahead and introduce Dr. Carrie Nieman. She is an otologist at Johns Hopkins, a core faculty member at the Johns Hopkins Bloomberg School of Public Health Cochlear Center for Hearing and Public Health, and a founding member of Access HEARS, which is a social enterprise that provides affordable, accessible hearing care through a sustainable community delivered model. She's here today to talk to us about improving access to hearing care services. Welcome to the show, Dr. Carrie Nieman.

[Carrie Nieman MD]
Yeah. Thank you. Good to be here.

[Gopi Shah MD]
We're super excited. We would love for you to just start by telling us a little bit about yourself and your practice.

(1) Statistics in Age-Related Hearing Loss and Hearing Care

[Carrie Nieman MD]
So, like you said, I'm an otologist at Johns Hopkins. I practice at the East Baltimore Campus, the main campus of Hopkins, but I'm also practicing at the Bethesda location. I see patients for the full spectrum of medical and surgical needs related to hearing loss with a particular emphasis on age-related hearing loss and also a little bit of a focus on eustachian tube dysfunction, which is I know not we'll be talking about today but just to put that out there too.

[Ashley Agan MD]
Awesome. Your research, you have some interesting background as far as working in the world of disparities to access to hearing care services. Can you set the stage to talk about that for us? What are the statistics? Why do we need to know and care?

[Carrie Nieman MD]
Yeah, so a lot of my work is focused in the space of age-related hearing loss. And a lot of it really comes from a public health perspective, and I think that's something that will come up time and time again, is trying to think through things from that public health perspective versus from that medical one-on-one perspective that we may use in a clinical setting day in, day out. So, when we think about hearing loss overall, when we are thinking about the US, we know that there's around 38 million individuals who have some degree of hearing loss.

And when we think about who in particular has hearing loss, we know that the vast majority of individuals are older adults, and that the vast majority have a mild to moderate degree of hearing loss. So, among those 38 million older... I should say 38 million Americans, we know that 29 million are older Americans. So, 60 years and older. So, a vast majority again, of those who have hearing loss are older adults and the vast majority is a mild to moderate hearing loss.

[Ashley Agan MD]
And so, can we go further back in terms of setting the stage? We said 28 million of those-

[Carrie Nieman MD]
Thirty-eight million, yeah.

[Ashley Agan MD]
But 28 of those are older.

[Carrie Nieman MD]
Twenty-nine, twenty-nine.

[Ashley Agan MD]
Twenty-nine million.

[Carrie Nieman MD]
Yeah, yeah, I'm sorry.

[Ashley Agan MD]
Okay. All right. All right. All right. So, that's a large percentage of older Americans. And when you say mild to moderate hearing loss, can you tell us what that means or the impact of that in an older individual?

[Carrie Nieman MD]
So, mild to moderate, we're thinking about individuals who may only notice their hearing loss when they're in a loud background noise, at a restaurant, a party and they're struggling, or as we all encounter in a clinical setting, "I don't have hearing loss, everybody else is mumbling." Solidly, those individuals who may or may not even recognize that they have a hearing loss.

And I think that's what's really important to... and make what I think we all struggle with in terms of talking with people about their hearing loss, particularly age-related hearing loss, when it's this slow gradual process, "It's others, it's not me." There's a lot that goes into getting people to recognize and think about themselves having a hearing loss. The thing that goes alongside that is what we have really spent on the research side of things in the past decade or so, and thinking about, "Does this age-related hearing loss, this mild to moderate hearing loss really matter?"

And so, in the past, we've always thought, "It doesn't really matter that much. It's this frustrating thing. We all deal with it, whether individually or with family, friends." But more and more we're starting to understand and think about age-related hearing loss in the context of healthy aging. And so, in the past decade, it's really shifted how we think about it. So, time and time again through study after study, I think what's gotten the most attention is thinking about hearing loss and its association with things like accelerated cognitive decline, dementia.

And I think study after study shows this association that for individuals with mild hearing loss, they have a two times increased risk of incident dementia, when it's a moderate loss, about a three times increased risk, and severe loss, five times increased risk. Obviously, there's a lot that we still need to learn and understand about that particular association. But when I'm counseling and talking to a loved one about the potential impact of hearing loss, when we're talking about solutions like hearing aids, things that are low-risk, non-pharmacologic, non-surgical, the risk benefit ratio is low.

So, we have a lot of work to do obviously on the research side of things to really help fully understand those associations. But I think more and more we're beginning to think that this isn't just this benign part of the aging process.

[Gopi Shah MD]
Wow. Those are not small numbers when thinking about risk, when thinking about something as significant as cognitive decline and dementia and things like that. So, we're thinking about this 29 million that have mild to moderate hearing loss. I mean, what are your thoughts as far as how many of those people would benefit from some amplification? They all?

[Carrie Nieman MD]
Yes, yep. And I will say just for the many individuals thinking and working in the space of the potential connection between hearing loss and cognitive decline. I will say the big thing that we don't have yet is, we don't know for sure whether giving somebody hearing aids or amplification, or whether that can slow the process. We don't know that yet. So, that work is ongoing in terms of a larger randomized control trial that's now ongoing at five sites across the country, the ACHIEVE trial based in part out of Hopkins.

We won't have those results till 2022, 2023. So, everything that we're talking about right now, we have a guess and a direction, but we don't know for sure. Specifically on the cognitive impairment connection side of things. I think there's also differences in thinking about who can benefit from amplification. And so, whether or not, do we start talking about amplification at a moderate level, or does it really depend on how much it's impacting them.

We know that it takes on average seven to nine, seven to 10 years for people when they actually first become aware of their hearing loss to actually start using a hearing aid. So, I will say for even the patients who have a mild degree, I touch them and say, "It's never too early to start at least thinking about it." Especially as we think about over-the-counter devices and if we think about, "Oh, maybe you're just getting a little bit of a boost when you're out at a restaurant because you need that little bit extra amplification in that particular setting."

Just starting to think about amplification in some targeted areas I think can be helpful and can be useful as people start to say, "Oh, maybe it is helping me." And then, go along the way as they're hearing may change over time and may hopefully be a little bit more open to thinking about using amplification devices, hearing aids, things like that.

(2) Inequities and Disparities in Age-Related Hearing Loss

[Gopi Shah MD]
Yeah, and that makes a lot of sense. And to me there's one conversation about a candidate and you could probably benefit, but then obviously, there's that gap of who's actually then able to attain those services. And that's why you're here. To talk through us so that we can understand the disparities that exist in access to hearing aids. Before we get into that-

[Carrie Nieman MD]
Sure.

[Gopi Shah MD]
There's a lot of terminology that we use. Can you just define or explain, is there a difference between when we say equity versus equality disparity? What are we thinking about?

[Carrie Nieman MD]
Yeah, yeah.

[Ashley Agan MD]
Because it's easy to think you know what you're talking about, but are all these words interchangeable?

[Carrie Nieman MD]
Yeah. So, if we channel what terminology is used within social epidemiology, so the specific field that really thinks about and tries to understand what are the drivers behind differences in outcomes or differences in care, we can think about these terms very specifically. And so, when first, when we think about disparities and we use the term disparities, we are talking about things that are differences along potentially different lines like race, ethnicity or socioeconomic status or socioeconomic position.

When we use the term disparities, we are not implying that we know or understand the driver or the cause behind those differences. When we use the term like inequity, inequity implies that we do believe that there is a reason or a cause behind those differences or disparities that we are seeing by race, ethnicity, socioeconomic status. And that it has to do with unequal access, injustices, social injustices that are the drivers.

So, when we use disparities again, overall discussion of differences by things like race, ethnicity, socio socioeconomic status, but when we say something like there's an inequity, there is some judgment and some moral judgment that you are making or implying when you use that term in particular.

[Ashley Agan MD]
Do you have a sense of what percentage of these 29 million older Americans that have hearing loss are actually getting some services for that?

[Carrie Nieman MD]
Yeah, yeah. So, based on some numbers from a few years back before that 29 million number came out, the working numbers when we thought just about older adults with hearing loss was around 26 million at that time, a few years back, had a clinically significant degree of hearing loss. And only about three million of those or so would actually use hearing aids. So around 23 million older Americans go untreated.

And again, we're talking about in that particular statistic, counting individuals who do have a mild degree of hearing loss or greater. So, those are some of the numbers that we've used in the past. So, overall, only around 15 to 20% of older Americans actually use hearing aids. When we start to look at things by race, ethnicity or socioeconomic status, when we look at African American older adults in the US who have a clinically significant hearing loss, only around 10% use hearing aids versus around 20% among White older adults with hearing loss.

[Gopi Shah MD]
And what do you think are some of the factors that make these disparities happen?

[Carrie Nieman MD]
So, I think one of the places that we often go as physicians in that medical model, that medical approach is I think we often think about these types of things from an individual perspective, we think about these things as individual health behaviors. And we certainly know that there is a lot that goes into somebody's ability and willingness to use hearing aids or to engage in some health behavior on an individual level. But I think that we also need to be thinking about and recognizing that these health behaviors happen within a context in terms of a social structural context.

So, thinking at a societal level and community level as well. So, I certainly think for our individuals who are thinking about hearing aids, yes, it is things like, "How many trips back and forth to the doctor does it take, how many co-payments?" Yes, obviously the financial realities of hearing aids in this day and age, I think certainly is part of it as well as things like, what's the health literacy involved in terms of thinking about being able to read and navigate hearing aid manuals. We know on average hearing aid manuals are written at around a 10th grade reading level, far above the recommended sixth grade reading level.

Again, these are individual level factors, and there's plenty of them in addition to things like, "Where is your local audiologist or your local ENT in your community? How many of your friends and family members have hearing aids?" These are all some of the varied things. And I think that while we all want a single explanation for why differences exist, I think it's one of those things we're just starting to have more and more understanding of the fact first that these differences exist much less getting into and digging in of what are all of the different drivers that go into to what we're seeing in terms of disparities.

[Ashley Agan MD]
Right, which makes a lot of sense. Because if it was one reason, then we probably would've solved it by now.

[Carrie Nieman MD]
Yeah, yeah, for sure. Or yeah, we wouldn't even be, for things like diabetes or hypertension or cancer, where millions and millions of dollars have gone into not only understanding and addressing these differences much less things like hearing care disparities, which in terms of just the number of individual, nobody has figured out, but I think there's a lot we can learn from these other disciplines and other fields to try to help move us along as well.

(3) Improving Access to Community Hearing Care

[Ashley Agan MD]
In moving through this and trying to help address the, number one, the disparities and then also just overall helping everyone to have more access to these cares, what's the way forward, what are some things that you're maybe doing or things you've seen in your research, what can we do?

[Carrie Nieman MD]
Yeah, for sure. So, a lot of what I do in my work is just one piece of it is trying to think about how can we develop an additional model of care. Because if we look and say, "Only 15 to 20% of our older adults in general are using hearing aids," we are not even scratching the surface. And the thing that I think many people it's very easy to say, "If it was just covered by insurance, we'd be fine. We would figure it out." If we look at places like the UK and the national health service there, where they do cover hearing aids, their rates of hearing aid use are higher, certainly, but they're not that much higher. There may be around 25%, 35%, right? So, it's not the magic bullet either. And just like we know that there's many factors that go into reasons why people are willing or not willing to use a device on a regular basis, we need to be thinking about models of care that maybe get at some of those things beyond just the potential costs.

I think a lot of us are thinking about stigma and ageism, and all of these complex factors that are going into people's decision-making processes. And so, one of the things I was thinking about more models of care is if we have only so many ENTs and only so many audiologists that we have in the United States to be able to reach all of these individuals.

We also need to be thinking about what other ways, especially thinking in other fields like public health, one of the things has been thinking through community health worker models of care, where community health workers is a term very broadly that is paraprofessionals individuals who share some lived experience, some aspect of whether same cultural backgrounds, same age, same educational background, same community, and community health workers can be really powerful.

And addition to all of these additional models of care in terms of clinic-based care to thinking about, how do we reach communities or reach populations that we haven't always been able to reach through this traditional clinic-based approach, because community health workers have a lot more insights into the nuances than I may have when I'm sitting and talking in counseling a patient about all the different reasons why they may or may not want to think about hearing aids, that community health workers can have particular insight and power in having conversations that we're not always as equipped to have.

[Gopi Shah MD]
So, in terms of community health workers, sounds like that's like your front-line troop. So, what are they responsible for? Is that hearing literacy? What is the role? How do you get them in?

(4) Community Health Workers: Structure, Training, and Implementation

[Carrie Nieman MD]
Yep, great question. So, community health workers can play lots of different roles, and they've played lots of different roles in many different settings for many different chronic disease, whether it's thinking about and talking about diabetes management or high blood pressure management in terms of diet changes, lifestyle changes, all the way to thinking about emergency care provision in low resource settings.

So, what I'm talking about in terms of community health workers and what we do in the Baltimore area is thinking about training old adult peer mentors. So, individuals who have shared lived experiences in terms of their older adults themselves, they may or may not have hearing loss themselves.

And so, they then are able to step through and provide not only counseling around what is age-related hearing loss, some of the basic oral rehabilitation, things like communication strategies, expectation management, about what you can expect from an amplification device, and then actually go through a step by step fitting an orientation to an over-the-counter amplification device.

So that's some of the work that we've been working on, I will say others have partnered with community health workers in that model in different ways. One of my colleagues and collaborators, Nicole Marrone at the University of Arizona, has trained a team of community health workers who work in federally qualified health centers to provide group oral rehabilitation to primarily Spanish speaking, older adults along the US Mexico border.

So, there's a lot of different ways in which to partner with, but it's just been an area that has been very much untapped in the space of thinking about how do we address age-related hearing loss when we will never have enough ENTs, enough audiologists to really get at and be able to help individuals connect with the technology that they need.

[Ashley Agan MD]
What does that look like with a group rehab situation? How would you set a patient's expectations for what that's going to be like?

[Carrie Nieman MD]
So, Dr. Marrone's work, they have a team... I want to say maybe like five, six older adults, like promotoras who have a very structured curriculum that they go through. I want to say it's five to six weeks or so, her program is called Oyendo Bien. And they are overseen by an audiologist. But a lot of that is very focused on just oral rehabilitation.

So, thinking about how you live well with hearing loss. And we certainly know education and counseling is a big part of managing hearing loss. But the other part of that in terms of actually connecting people with devices, that is something that differentiates our program in Baltimore in terms of the HEARS Program and the HEARS Study is that it does have that element of education and counseling, but then more importantly, older adult peer mentors are fitting other older adults with over-the-counter hearing technology.

[Gopi Shah MD]
Can you actually, this is probably a good time to tell us about the research and then the nonprofit side of HEARS because they're different.

[Carrie Nieman MD]
Yeah, yeah.

[Gopi Shah MD]
Okay.

(5) HEARS Program for Community Health Workers and Hearing Care

[Carrie Nieman MD]
For sure. HEARS is, I want to use the term HEARS. HEARS stands for Hearing Health Equity through Accessible Research and Solutions. That's the acronym. And so, HEARS is a structured program around one and a half, two hours that was developed by myself and team at Hopkins, a number of years back is this structured way in which it's designed for community health workers.

Again, that term used broadly where now we're working primarily with older adult peer mentors who then go through that one and a half, two hours of, "Here's some basics around age-related hearing loss. Here's some basic communication strategies. Let's get you set up with an over-the-counter device." And so, that one and a half, two-hour program is a structured program that we've completed initial pilot study a few years back.

And what we've found in that pilot study was for those individuals who went through the study in three months afterward as compared to a wait list control had about the same improvements in communication function that we would see with gold standard hearing aids fit by an audiologist. And that's compared using over-the-counter devices in a two-hour structured program. And so, we are now at the tail end of finishing a larger randomized control trial.

We had 13 sites throughout Baltimore city and county, eight older adult peer mentors who are overseen by two audiologists. And those eight older adult peer mentors talked with fit 151 older adults with hearing loss and took them through the HEARS program. So, we are anxiously awaiting the results for the randomized control trial. But we are really excited to be able to continue building the evidence for not only over-the-counter technology, but really the power of paraprofessionals and community health workers in partnering with us to reach communities that we haven't always been able to reach.

[Gopi Shah MD]
That's awesome.

[Ashley Agan MD]
And then, there's Access HEARS which you were one of the founding members of. Tell us about that, and what led you to get that going?

[Carrie Nieman MD]
Yeah. So, when I was initially designing and forming the HEARS intervention or HEARS program in the research context, I was thinking and looking around, and the reality is, again, this is a low risk intervention, we're using over-the-counter technology, things that are already readily available to any consumer out there. And why does it need to take as long as it does to get into wider practice?

We know on average that it takes 17 years to go from bench to bedside in terms of, from that initial discovery to getting something into widespread practice. And 17 years, I feel like is pretty unacceptable when we're talking about, again, this low risk type of intervention. And we know that these differences in care exist that we know are beginning to understand that hearing loss really matters for older adults. So, why not try and move that needle a little bit faster?

And was accepted through the Johns Hopkins incubator program, which was called the Social Innovation Lab. And so, during that time, I'm sitting around with... at that time I was a resident and sitting with undergraduates and graduate students, and other people who knew far less about the area that they were thinking about making this big change and thinking through like, "How am I going to change X, Y, or Z?" And I was like, "Oh my gosh. Why not?

If they can do it, I could do it too." So, we started the nonprofit at that point with the idea of like, "How can we have some experience with the realities of what does sustainability and scalability need to look like in that setting?" Obviously, it's important to build the evidence and we're continuing to do that, but how can we jump in a little bit sooner and get some experience and try to answer some of these?

So, the first thing that we did, we are really the founder in terms of our grant and support is the ARP foundation, which has been with us throughout this time. And then, has really been able to help us grow into providing services to older adults throughout Baltimore and throughout Maryland. We were a contractor with the department of Aging within Maryland as just an example, to really think about how we get more models of care out to older adults.

(6) Over-the-Counter Hearing Devices Implemented through the HEARS program

[Gopi Shah MD]
Carrie, can we back up just a little bit and dig into the over-the-counter devices? Are you talking like an FM system? What exactly is the community health worker "fitting" them with and how are they doing it?

[Carrie Nieman MD]
Yep. So, the devices that we use currently are PSAPs apps, personal sound amplifiers products, which are this gray area of devices that as soon as we have the over-the-counter hearing aids legislation designation move all the way through, we'll see what happens, but right now in this space, we are using personal sound amplifier products.

So, I will say from the beginning, all the HEARS and the Access HEARS approach has really been while we do use specific devices right now, it really is not meant to be these specific devices, but can grow and adapt with the changing market and insert whatever are the latest, greatest devices.

So, we always offer two different devices, because we try to make this as person centered and person driven as possible, it is very much the choice of the individual which device do they want. And so, we always offer a larger device, something like a Pocketalker or something, we also use a SuperEar SE9000. Both of those devices are a handheld device that then has headphones, wired headphones that go into that palm-sized device.

The beauty of that device is that it can be very easy for an individual or care partner to put that device on and off. There's no small buttons, there's just a dial. So, in terms of channeling, how do we make it as older adult friendly as possible for older adults who have manual dexterity issues or some limitations in terms of cognitive impairment, that larger device can be very... or at least more user-friendly than a smaller ear-level device. So, that's always one option.

And then, the second option we always offer is an ear-level device that does look very similar to a hearing aid when we've done studies on these devices, because we only use devices that we have studied, looked at in terms of their quality. So, we use the Sound World Solutions Sidekick or HD100 as that device is a Bluetooth device that does some basic insights, fitting in verification.

Meaning that it's tailored to some degree the loss an individual has, and that device our team has done studies on and shows that they're very comparable to gold standard hearing aids out there. I think one of the things that we're all anxiously waiting for, for over-the-counter hearing aids, is to provide some regulation in this space to ensure quality, which hasn't always been the case in this PSAPs area. But I will say the devices that we have worked with, we have gone through these testing and things like that.

So, in terms of the question about, "Well, what did the peer mentors actually do," so they helped say for the older adult they're working with, they go through the different options and say, "What do you feel comfortable with? You want to try it on?" They talk through the different options. And for the ear-level device, they do need to go through a process of pairing the device via Bluetooth.

There is just a little app, like a little program that goes through the... it's an automated program that goes through that fitting process, the beauty and why we chose those devices is that you don't need a smartphone on ongoing basis in order to use the device, that there's ways to interact with the device without having a smartphone for those who do have a smartphone, that's great. We help them get them paired and set up, but you don't have to rely on those technologies. And I think that's another barrier for many of our older adults.

When we're thinking about individuals particularly in low-income populations who may have different ways in which they interact with technology or comfortable with technology, how do we get over that technological jump or gap and ensure people can still have access to some of these over-the-counter devices, which a lot of them do rely on smartphones and things like that.

[Ashley Agan MD]
So, with the bigger models, like the Pocketalker, it's basically just amplification simple, the microphone speaker, it makes things louder. And then, you have your other ones that you can tailor a little bit-

[Carrie Nieman MD]
Exactly.

[Ashley Agan MD]
... more exactly more similar to a hearing aid, but not quite this sophistication.

[Carrie Nieman MD]
Yeah. I think some of the ways in which they are different, at least currently, and I think the lines are going to continue to blur certainly more and more some of the things like the ability to automatically switch between types of settings. So, for example, the devices that we use are great in that they have directional microphones, they have different settings.

So, if you're in a noisy setting, it shuts off the side microphone and just allows you to use the microphone for things in front of you. So, it has some of those same standard features and functionalities that a lot of hearing aids, but agreed, the sophistication is different in terms of it. It may not be automatically judging and gaining and things like that. So, there's certainly differences.

But I think at the end of the day, when we're talking about, how do we get more people connected with at least some basic amplification, because we know not everybody is going to want or need $8,000, $10,000 hearing aids, there is still something we can and should be doing.

(7) The Role of Audiologists in Community-Based Hearing Care

[Gopi Shah MD]
As the lines blur between, I think you're saying between the devices maybe and what it may be like, what the hearing aid, how has audiology been a part of your team? Do they help train the community health workers? I would imagine everybody's got the same goal and their expertise is very helpful in terms of, how do you know when the FM system is at the right setting or how does it all work?

[Carrie Nieman MD]
So, for the HEARS side of things, the peer mentors are overseen by a team of audiologists. So, the audiologists are the individuals who first trained the older adult peer mentors, that training process involves about eight sessions, hour and a half each that goes through basics of hearing loss, basics of over-the-counter devices, basics of working with other individuals in a teaching fashion. And then, a practicum session where they're certified.

And so, at the start of the program, all the peer mentors report back to their audiologist supervisor after each encounter that they have. So, they talk about things that they encountered, questions that they had. And then, that is generally spaced out to maybe once a week that they're checking in. And then, because in terms of when we were partnering with community health workers, paraprofessionals, a big part of that is continuing education and support.

But we do have monthly gatherings where all the peer mentors get together, we talk about different cases, different things that they wanted to learn more about. And so, we have this ongoing support and communication between the team of audiologists and the peer mentors. And I think one of the things that we're just starting to go through some of the data and things that we've found is that I would say many of these older adult peer mentors, they take their job very seriously and they definitely view themselves as... I don't want to say professionals, but they definitely view themselves as hearing paraprofessionals.

And I think that has a lot to do with making sure they feel empowered, the skills that they need. But then, also that they feel like they have the support of a team of audiologists to make them feel comfortable. So, I think none of these things, when we talk about alternative models of care, are we talking about excluding ENTs, excluding audiologists? And I think that's one of the biggest things that we need to be thinking about is recognizing our role in supporting these models of care as important gatekeepers, because the more that we partner, the more that we can ensure the safety and quality of what's going on.

(8) Controversies in Community-Based Hearing Care

[Ashley Agan MD]
Yeah. I think that's a good segue into just the discussion of the controversy around just having patients be fitted with over-the-counter hearing aids by their peers and things like that. Can you dive into some of the things that have come up for you as you've been upping this?

[Carrie Nieman MD]
Sure. I will say, I think it is certainly controversial in terms of, I think people have a lot of different reactions both when we use over-the-counter devices or even when I'm counseling my patients in clinic, I talk about over-the-counter devices and their role. I think there is a lot of hesitation within otolaryngology. I think there's even more with audiology.

So, not necessarily being an audiologist, I don't know if I've had to bear the brunt of it as much as my audiology colleagues who have. I think that's when it does go back to thinking in terms of as a medical professional, as a physician, yes, my job is to provide the best care possible to that individual in front of me, who is in my clinic. But then, we also have this parallel part of thinking from a public health perspective that we know that there are millions of older adults who are not getting care and who have not gotten care for decades now.

And we have not moved the needle there, and we need both of these perspectives. So, the medical perspective, certainly we need, and it is part of it, but we also need that public health perspective to understand how we are going to reach those older adults. Because the reality is, that no matter what, there are resource constraints. And so, how do we extend resources as far as they can go to reach as many individuals? So, I think balancing that tension is part of it.

I think over-the-counter hearing aids are coming. I still don't know exactly when, but the beauty of that is that they will at least now be regulated in terms of ensuring a quality so that our team's ability is not so much focused on ensuring that we're giving quality devices, but that will at least be something that's out there and standardized.

So then, let's just make sure, what is that process of connecting every older adult with that device that fits their needs? Not everybody wants to come see an audiologist or an ENT for their hearing care needs. So, how are we going to meet them where they are in their hearing care journey? So, it's not about competing in terms of one model versus the other model. We just need more models.

It's not about stealing one patient from an audiologist or stealing one patient from an ENT, there are plenty of patients out there who are not getting help and we're just trying to give more options. And starting with one device, using that for maybe a few years or so, and being like, "Yeah, no, I think I need something more," I think we'll hopefully go right into that. But yeah, those are some other thoughts. Yeah, if you want me to get further or not into it.

[Ashley Agan MD]
I think that's beautifully put, and I agree with you. I've noticed patients who on their own were like, "Yeah, I actually got these over-the-counter devices for a couple hundred dollars." And it became like a gateway to them getting actual hearing aids because it allowed them to try something for a lower initial upfront cost. And so, I think that it is important for us to get outside of our little boxes and think about different ways to take care of patients.

[Carrie Nieman MD]
Yeah. I think the healthy thing that is needed is the reality that we've had five hearing aid manufacturers now, and that the model has been high quality, low quantity in terms of... and that there needs I think pressures for that because we need more affordable devices that are also good quality. And I think there is a very healthy pressure. And I think the other side of it is that, really for the first time for over-the-counter hearing aids, it is going to be putting the user, the consumer in the driver's seat of what are the things that you need or want.

I will say, not all of my older adults want invisible things that they can't interact and touch the buttons with. Not everybody shares that. And I think putting the consumer, the user in that driver's seat at least more than we are currently doing, I think is a very important pressure. Because I will say, one of the things that our older adult peer mentors spend more time than you would want to is just helping the older adults actually feel the buttons on their device.

And one of them is like, "Oh, I know how to use a tablet. I have a stylist." So, they actually trained their client to use a stylist to be able to change the buttons on their device. And that type of design is not, but it's the kind of thing that I'm hoping with these types of pressures are the things that will change in terms of just more options and more high-quality options out there.

(9) Goals of a Community-Based Hearing Care System

[Gopi Shah MD]
So, just to go back to the basic terminology of equitable health. So, with this new model, that's like, "Hey, it's more access to higher numbers because we have people that are getting into the community." It's not, "Oh, how are we going to help you pay for hearing aid?" It's, "How do I get more people to get out there, spread the word and try something that might help? Is that the equitable solution?

[Carrie Nieman MD]
When I think about what is equitable, I am thinking about it as a gerontologist in terms of what are those big picture things that matter in terms of, "Am I helping older adults engage in their life or stay engaged, and do what they want and need to do on a daily basis? Is the device the most perfect setting and fit for them? Maybe, maybe not, but if it is a tool that enables them to stay connected, to stay engaged, to do those big picture things that matter to them and matter to aging well, then I think that is the success.

And I think that's what equitable hearing care needs to look like. And so, I think that's also the tension between thinking about things from a two-medical perspective versus a public health and person driven perspective. We do not, for example, in the HEARS randomized controlled trial, our primary endpoint is not number of devices fit or number of how much they gained from their devices, they are things like communication function, social isolation, depression, those are the outcomes that we're looking at that matter.

So, I think that shift and perspective and focus of, "What is the big picture? Why do we do what we do? Why do we want to provide the care we think everybody should and have access to?" So, I think that's a big part of it as well.

[Gopi Shah MD]
I think that's great.

[Ashley Agan MD]
And I think in medicine, we might let perfection get in the way of progress a little bit because that's just how our brains work. We want to fix things to the most perfect degree so that we can make things better. And so, it's hard to shift that way of thinking.

[Carrie Nieman MD]
We need both thinking. We need that attention and we need that back and forth. Yeah. But we also need progress for sure.

(10) Tips for Practitioners to Improve Hearing Care Access

[Gopi Shah MD]
So, as practitioners, what are things that we can do on our day to day? Because the majority of us are just seeing patients in clinic. Is it more maybe getting our own hearing literacy up to speed in terms of options, taking more time to counsel our patients? How do we help our patients in a one-to-one setting?

[Carrie Nieman MD]
Yeah. So, when somebody is seeing us in the office, they're already a different group than others, right? They have taken the time, effort. They obviously see the value in seeing an audiologist and seeing an ENT. So, it is a little bit of a difference, but I will say, every single time I see a patient, I always talk about multiple options. It is not just a discussion about, "Okay, now go back to see the audiologist for hearing aids."

I do talk about over-the-counter devices and I say, "Yes, there are not so great options out there, but there are definitely good options, and there's more options that are coming." So, I always do that. And then, I also do... I always talk about Costco as well. But I do give the same spiel to every patient, regardless of how they may be presenting in terms of their socioeconomic status, their background, their culture, whatnot.

I do give the same spiel to every patient because I say... and I tell them, "I just don't want costs or wherever you are in thinking about things to be the reason why you don't get help in terms of thinking about your hearing." So, I always talk about that. And so, I think getting comfortable with the idea that over-the-counter options exist and I think talking about them, I think is an important part of that because they are here to stay, they are part of the process.

And I think it also helps convey to your patients that your big picture goal is their hearing health, that it's not selling a hearing aid, that it's not in terms of your benefit. So, I think it is part of making sure they have the tools that they need, and wherever they may start, some people are like, "Definitely, oh my gosh, no, I never want to think about an over-the-counter device." But some may be a little bit more ready or willing to try something out for a little bit, and then come back and say, "Yeah, I want more. I want it to be able to do this X, Y, or Z or whatnot."

The other thing that I think is a big part of it is the education and the resources. I try to regularly talk about the Hearing Loss Association of America and the wealth of resources out there from a consumer perspective. Because I think that is one of the things that is difficult for many patients, especially for so many of them who have that mild to moderate degree of hearing loss is that they're not necessarily first and foremost, identifying as somebody with hearing loss, but they could still benefit from the communication strategies, the supports, the network and things like that, that exists out there.

So, I think raising those types of things as resources I think are an important part of it as well. And just for full disclosure, I do sit on the board of the Hearing Loss Association of America.

[Gopi Shah MD]
Well, I think this has been amazing. So, thank you for taking the time. Any final thoughts, parting words, things that you... we just want to make sure that we hit?

[Carrie Nieman MD]
Yeah. I think for all of us, I think it's very easy to respond and be like, "Oh my gosh, things are changing. It's not comfortable." And I think the more we can try to help remind ourselves that this is our goal, yes, it owes to provide high quality one-on-one care to the patients that we see, but to also recognize and think about a powerful role that we have as otolaryngologists, as gatekeepers, and as the source of high-quality information that we need to think about that power that that has, and to not necessarily shut down different avenues that are needed, but to say, "How can we partner and how can we support these things?"

Because that shared goal of how we get help to more people is something that I think we can all think about identifying, and I think is very, just that we have that commitment to that patient in front of us, we had that commitment to those 38 million individuals with hearing loss as well. So, I think it's both of those things and it doesn't have to be one or the other.

[Gopi Shah MD]
Thank you so much, Carrie. I feel like I've learned so much. And also, just opened my eyes and my mind on how to view things and how to practice medicine more holistically. Thank you for taking the time to come on the show.

[Carrie Nieman MD]
No, it's been a pleasure. Thank you again.

[Ashley Agan MD]
Carrie, you are on Twitter, right?

[Carrie Nieman MD]
Yes. Yes, I am.

[Ashley Agan MD]
If our listeners want to find you, what's your handle?

[Carrie Nieman MD]
Carrie Neiman. N-I-E-M-A-N-M-D.

[Ashley Agan MD]
Awesome. So, follow Carrie. And big thank you to our listeners. Thanks for checking out the show today. Everyone, please take a moment to subscribe, rate and share the podcast. It's a big help for us. It helps us grow, it helps us to bring you more of these podcasts, and you can follow us on social media. We're on Instagram and Twitter @_backtableENT.

Podcast Contributors

Dr. Carrie Nieman discusses Improving Access to Hearing Care Services on the BackTable 29 Podcast

Dr. Carrie Nieman

Dr. Nieman is an Associate Professor in the Division of Otology, Neurotology and Skull Base surgery in the Johns Hopkins Department of Otolaryngology-Head and Neck Surgery.

Dr. Gopi Shah discusses Improving Access to Hearing Care Services on the BackTable 29 Podcast

Dr. Gopi Shah

Dr. Gopi Shah is a practicing ENT at UT Southwestern Medical Center in Dallas, TX.

Dr. Ashley Agan discusses Improving Access to Hearing Care Services on the BackTable 29 Podcast

Dr. Ashley Agan

Dr. Ashley Agan is a practicing ENT and assistant professor at UT Southwestern Medical Center in Dallas, TX.

Cite This Podcast

BackTable, LLC (Producer). (2021, August 17). Ep. 29 – Improving Access to Hearing Care Services [Audio podcast]. Retrieved from https://www.backtable.com

Disclaimer: The Materials available on BackTable.com are for informational and educational purposes only and are not a substitute for the professional judgment of a healthcare professional in diagnosing and treating patients. The opinions expressed by participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.

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