July 2020 The Hearing Journal
Deaf adults looking to use cochlear implants (CIs) to help with their hearing often don't end up adopting these devices due to various barriers, including limited access to a CI centre in rural areas, the time investment needed for aural rehabilitation, and more, resulting in a low utilisation rate of 5.6 percent among U.S. adult CI candidates These factors, however, can be mitigated by telemedicine, a team of researchers at Yale University School of Medicine and the Veterans Affairs (VA) Connecticut Healthcare System found, not only for veterans in their local area but also for those facing similar challenges in the developing world.
The VA New England Healthcare System, of which the VA Connecticut Healthcare System is a part, compromises eight medical centres in Maine, New Hampshire, Vermont, Massachusetts, Rhode Island, and Connecticut, servicing a large geographic area that spans urban centres and rural areas. Because of this, however, Douglas Hildrew, MD, an assistant professor of surgery in the division of otolaryngology—head and neck surgery at the Yale School of Medicine who provides care to veterans at the VA Connecticut Healthcare System-West Haven, said they found that patients were often requesting to push out their follow-up visits longer than they were comfortable with. “The limiting factor was always time,” he said. “If a veteran lived in Maine and chose to stay within the VA system, a 90-minute clinic visit could easily turn into a two-day event. While they were happy to do it when necessary, my team always felt that we could do better, and the solution was telemedicine.”
Hildrew said they started their CI telemedicine services in 2017, which were limited to an education campaign and remote candidacy evaluations at first but quickly took off. “In 2018, we began expanding our services to also include pre-operative visits, post-operative visits, and remote cochlear implant programming,” he said. “By 2019, our efficiency, quality benchmarks, and patient satisfaction were such that telemedicine actually became our most common practice model, with only a minority of patients electing to pursue the traditional in-person pathway.”
A video telemedicine visit with the VA Connecticut Healthcare System is performed on a standard telemedicine platform. The company-specific hardware is connected to the receiver-stimulator and VA Connecticut's computer system, and the manufacturer-specific software is opened. A third-party software is then used to take control of the computer at the remote site where the patient is, and CI programming is done as usual. Since VA Connecticut is a two-implant centre, patients are always asked to bring both of their implants in case of a software or connection failure. After they finish programming, they also have each patient fill out an International Outcome Inventory for Hearing Aids questionnaire modified for CIs (IOI-CI), which measures satisfaction, improvement in hearing, and the degree of use for CIs, and undergo a new AZBio test when applicable.
Hildrew and his colleagues demonstrated the feasibility and non-inferiority of their telemedicine program compared with traditional in-person programming in a study (Otol Neurotol. 2020 Mar;41:e330-e333). Other researchers have explored remote CI mapping, but what makes his team's work unique is their efficiency and scale, said Hildrew. “With operating at the VA only once a month and having clinic just three times a month, we are able to work up, operate, treat, and manage approximately 40 new cochlear implants a year,” he said. “In addition to this, we also care for all of our prior cochlear implant recipients… I am aware of no other site in the world that has achieved such performance measures using remote telemedicine technologies.”
Their results showed that threshold, comfort, and impedance levels among the 20 patients who used CIs from different manufacturers (Advanced Bionics, Cochlear, and Med-EL) in the study were not significantly different between telehealth and live sessions. The AzBio scores and warble tone averages were also similar in both modalities. The most surprising finding to Hildrew was the positive response from patients: The average IOI-CI score was 27.99, when a score higher than 25.5 is typically considered successful (J Am Acad Audiol. 2003 Oct;14[8)]403-13). “We were very pleased when patients not only enjoyed the telemedicine visits but actually preferred them,” he said. “But remember to be careful what you wish for… as we have transitioned more and more to telehealth, we really do miss seeing our patients face to face.”
The most valuable take-home for audiologists from the success of their remote cochlear implant clinic is the collaborative approach they have embraced, Hildrew said. “Community audiologist should never feel worried about knowing the specific guidelines for cochlear implant candidacy,” he said. “If their patient is struggling, no matter what the numbers say, it is good practice to consider reaching out to the nearest cochlear implant centre. This advice works both ways, though, because if a cochlear implant centre receives a consult from a community audiologist, it is always good practice to follow up and involve them. Some referring audiologists may wish to be more involved, while others may wish to be less involved. There should be no competing interests, though, as patient care should always drive the conversation and partnership.”
The success of Hildrew's team also has significant implications for humanitarian missions in developing countries. “[The] developing world often has great medical infrastructure. Less and less is there a need for surgeons and physicians in the developing world, but more and more there is a need for making it easier for patients to get to see their providers,” Hildrew said. “Until telemedicine becomes mainstream, this geographic gap will always exist. The future of cochlear implants is closing the geographic gaps that exist, keeping patients from connecting with their providers. Everyone deserves the right to hear should they want to, but only by closing geographic barriers can we deliver.”