June 2020 The Hearing Journal
Safety measures due to the COVID-19 pandemic have compelled audiologists to incorporate telehealth services into their practices. Telehealth has the potential to improve various aspects of patient care, including patient and provider satisfaction, patient access, clinical efficiency, travel and clinical costs, and wait times. So, to what extent do data support positive outcomes of teleaudiology? To answer this question, we evaluated evidence supporting hearing assessment in Part 1 above. For Part 2 we explore evidence from teleaudiology procedures for intervention and auditory rehabilitation.
HEARING AID FITTING, PROGRAMMING, AND FINE-TUNING
The limitations in remote threshold assessment have, by necessity, curtailed work on fully remote hearing aid fittings. However, in-situ audiometry has permitted some studies to be conducted—specifically those by Convery and colleagues, who have examined factors associated with success with a self-fitting hearing aid. They determined that success with a fully self-fitting hearing aid is influenced by user characteristics, such as locus of control, cognitive status, cultural background, and health literacy, in combination with the availability of support from either a trained assistant or a partner, and the quality of the instructional materials provided to support the user. Of note, many companies now offer fully remote hearing aid fittings (e.g., Eargo, Lively Hearing Corp., Soundworld Solutions, iHear), some of which also provide ongoing support and auditory rehabilitation from a hearing professional after the purchase (e.g., Lively Hearing Corp., iHear).
A recent systematic review of teleaudiology services for the rehabilitation of adults with hearing aids concluded that of the 14 available studies, none demonstrated strong methodological or high-quality evidence. Individual studies, however, report that outcomes following remote hearing aid programming are equivalent to those obtained via face-to-face encounters, although in these studies, hearing aid adjustments were made by a technician in the same site as the patient with instructions from an audiologist who was at a remote location. A more recent study, however, has shown good outcomes for remote hearing aid programming conducted via a manufacturer-specific application. Indeed, most major hearing-aid manufacturers now have apps available that allow the audiologist to program hearing aids remotely, some of which are now available from the NHS. Despite the absence of high-quality evaluations of these apps, there is no reason to believe that outcomes will differ from programming conducted in the clinic. In fact, since the patient is in his or her home environment during the device programming, there is the possibility that outcomes will be better than that when programming the hearing aids in the audiology clinic.
COCHLEAR IMPLANT PROGRAMMING
The data regarding remote programming of cochlear implants is relatively comprehensive, with numerous studies showing that both performance and subjective outcomes are the same for face-to-face programming as for remote programming, with or without a facilitator present at the remote site. Further, remote testing did not compromise safety when the audiologist is managing the programming system and patient satisfaction with the remote programming was found to be high. Again, in these studies, programming adjustments were made by an audiologist. However, two other studies show good outcomes for patient-made adjustments via a remote assistant app.
AUDIOMETRIC REHABILITATION FOR CHILDREN
As mentioned in part 1 of this two-part review, audiologists have in the past been reluctant to use teleaudiology for management of children with hearing loss, although indications are, this is changing as a result of COVID-19 restrictions. In an ongoing survey by our laboratory, 60 percent of NHS paediatric audiologists (n=46) in the United Kingdom reported offering teleaudiology appointments to their patients, with 24 percent using teleaudiology with almost all of their caseload. Almost 90 percent of families accepted the form of care. Presumably, remote programming and fine-tuning are as effective in children as in adults. Cochlear implant programming in children as young as 6 months has been shown to be feasible and safe. Furthermore, the use of remote appointments to monitor hearing aid use and provide support to parents has been shown to be effective and appreciated by families.
In a slightly different vein, report the findings of a scoping review of telepractice, i.e. care provided using telemedicine, delivery of family-centred early intervention for children who are deaf or hard of hearing resulted in the conclusion that while challenges arose, telepractice can be effective.
Audiologist-guided internet-based tinnitus management has been shown to be effective in at least two randomised controlled trials (RCTs). One study found that after participating in an internet-based cognitive behavioural therapy (CBT) program, individuals randomised to the intervention group had a significantly greater reduction in tinnitus distress, insomnia, depression, hyperacusis, cognitive failures, and a greater improvement in the quality of life compared with those in the control group. The group differences were maintained at two months post-completion of the intervention. Similar results were found in an RCT that used the telephone to provide progressive tinnitus management (PTM) which consisted of a combination of CBT and therapeutic sound intervention. Individuals in the PTM group had significantly better outcomes than the waitlist control group in terms of reduced distress from their tinnitus, anxiety, and depression, as well as increased self-efficacy for managing their tinnitus. Finally, a review of literature examining the feasibility, advantages, and limitations of telaudiology for tinnitus concluded that telemedicine can be beneficial to supporting tinnitus management during screening and diagnosis, in providing therapies, and for long-term monitoring and support.
MOBILE HEALTH AND OTHER INTERVENTIONS
Multimedia online materials to provide instruction and education via telehealth are widely available from researchers and hearing aid manufacturers (via their websites) alike. At least some of these materials have shown benefits regarding patient knowledge of hearing aid handling skills, hearing aid use among suboptimal users, and self-efficacy for self-management. Presumably, but not yet evaluated, the online videos provided by most hearing aid manufacturers are valued equally valued by their clients. However, caution should be applied when using materials not developed with principles of health literacy in mind since much research has shown that many hearing aid education materials are written without regard to vocabulary, aspects of layout and typography, and reading grade level.
Online auditory rehabilitation programs have the possibility of providing remote support to new hearing aid users. A study using one such program reported decreased hearing handicap and increased hearing aid use in individuals who attended the five-week online rehabilitation program. The program consisted of self-study, training, and professional coaching in hearing physiology, hearing aids, communication strategies, and online contact with peers, relative to those in a control group.
Photo sharing is the use of patients' photos to facilitate communication, understand needs, and enhance audiological counselling. It is a novel way to provide remote support to patients who are struggling with aspects of their hearing aids. Photo sharing has been shown to facilitate highly tailored counselling and provision of evidence-based recommendations for hearing assistive technology, enhanced interaction between communication partners, provided insight into participants' lifestyle and communication needs, and seemed to generate rapport and trust. Recently, it has been suggested photo-sharing could be used to troubleshoot hearing aid insertion, fit and feedback problems by having a patient compare a photo taken of their (possibly mis-inserted) hearing aid in their ear with one taken by the audiologist of the correctly inserted hearing aid.
Auditory training (AT): the evidence for the efficacy and effectiveness of computer-based AT for hearing aid users is poor. Computer-based AT outcomes for cochlear implant users is better, with effects about 2 dB SNR for trained materials. It is also possible that AT may increase communication efficacy or decrease listening effort rather than improve speech scores, and that many individuals enjoy the training. Many computer-based AT programs are available, and since there is nothing to suggest that the costs of using AT outweigh the perceived benefits if a patient wants to engage in AT, there is probably no need to discourage it.
Limitations notwithstanding, teleaudiology for hearing assessment and audiological rehabilitation offers many reasons for optimism. While barriers to the use of teleaudiology for audiologic rehabilitation remain, the increased availability of communication technology and the gradually increasing trust in remote systems by clinicians and patients alike indicate that the acceptance and use of teleaudiology will remain even when COVID-1-related restrictions are decreased.