Editor's Message: The Promise of Patient Centered Care

Author: Brian Taylor, Au.D.

Although we may not be intimately familiar with the statistics, a minuscule percentage of adults with hearing loss use hearing aids. For example, Chien & Lin (2012) analyzed data from the National Health And Nutritional Examination Surveys (NHANES) and estimated that among Americans over the age of 50 with a 25 dB HL hearing loss or greater, prevalence of hearing aid use is consistently low, ranging from 4.3% in individuals age 50-59 to 22% for those over the age of 80 years. In a separate study, Laplante-Levesque, et al (2012a) presented 153 adult participants with hearing loss several intervention options, including hearing aids, communication programs and no intervention. Although all participants were considered hearing aid candidates, when offered a wider range of treatment options, more than half of the participants seeking help for the first time did not obtain hearing aids. This finding suggests that offering patients a broader range of treatment options, especially those seeking help for the first time, may result in greater uptake of audiological services.

Among the multiple factors reported to influence hearing aid uptake and use are the patient’s degree of hearing loss, motivation level and support system. In addition, the financial cost of hearing aids and stigma associated with use are undeniable challenges related to uptake and use of hearing aids by adults. One factor, often misunderstood and underappreciated, contributing to poor hearing aid acceptance, is the clinician’s communication style and ability to foster a trusting relationship. As Clausen & Pryce (2012) suggest, a patient’s presence at an initial consultation with an audiologist does not automatically imply that the individual is seeking a hearing aid solution for a handicapping condition. Rather, patients may be seeking education, reassurance or support of their condition. By providing a full range of habilitation choices, patients are more likely to trust the provider and maintain control of the decision-making process – both germane to patient-centric care.

There are two recent veins of clinical research that may help audiologists better understand the critical role of effective communication and how it can be leveraged in the practice of patient-centric care. At their core, both veins of research indicate that non-technical factors, such as empathy, trust, active listening and the ability maintain effective dialogue with help seeking individuals are often more critical to the long term success of patients, than specific product offerings.

Dr. Jill Preminger at the University of Louisville School Of Medicine recently published a thought-provoking study on trust and how it impacts the patient-provider relationship. Her interview in this issue, which is our lead article in this issue of Audiology Practices, provides plenty of insights on how her team’s research can be clinically applied. Trust appears to be the elixir of effective, long-term professional relationships and Dr. Preminger’s research helps us better understand trusts impact on patient care. In another article devoted to trust, Dr. Peter Marincovich provides us with a practical, real world example of how office culture, and ultimately, patient satisfaction can be improved when a manager fosters trust among its staff. Finally, Dr. Raymond Hull of Wichita State University provides expert analysis of the art and science of effective communication.

The skills needed to promote and foster trust are valued by audiologists and patients alike, and the articles in this issue of Audiology Practices barely scratches the surface of some of the recent research in these areas. Laplante-Levesque, et al (2013) conducted four focus groups with patients and audiologists. The objective of their focus groups was to gather information about the elements and meaning of an optimized hearing aid fitting from the perspective of both audiologists and patients. In general, patients and audiologists shared the same thoughts about the importance of patient-centered communication, as each group highlighted the importance of patient access to information. Their results indicated that audiologists were aware of the need to provide the appropriate type of information to optimize benefits, without overwhelming patients with too much information, and that the information had to be conveyed in the right tone. Indeed, we walk a fine line between flooding our patients with too much information and starving them of the details they need to make informed decisions with respect to their treatment choices, goals and outcomes.

Taken one step further, it is apparent an audiologist’s knowledge of affective communication skills does not equate to the application of these skills in the clinic. Grenness et al (2015) examined the nature of audiologist-patient communication during the initial consultation process. A total of 62 consultations were filmed and analyzed. Communication was placed into one of four categories: education & counseling, data gathering, relationship building and facilitation & patient activation. Forty-eight percent of the audiologists' utterances were classified as education and counseling in nature. Within this category, 83% of education and counseling utterances were biomedical in content, which included an explanation of the audiogram and the possible cause of the hearing loss. Results of this study strongly indicate that the patient-provider dialogue is dominated by the audiologist with rapid movement from talk about test results to hearing aid options commonly occurring, and more than 75% of the educational and counseling time revolving around hearing aids.

If research indicates we spent too much precious clinical time talking about arcane technological details, what is a better use of our time? We can look to more recent research to address this important question. Poost-Faroosh, et al (2015) evaluated the quality of the professional relationship by comparing patient and clinician ratings of the importance of several factors that contribute to effective communication. Interview data was collected and placed into one of eight categories that may influence hearing aid purchasing decisions. Much like other patient-centered models of care used in other realms of healthcare, Poost-Faroosh et al (2015) determined that the following five components, shown in the outer ring of Figure 1, are an essential part of patient-centered communication.
Figure 1

At the core of patient-centered communication is participatory care. Participatory care is a model of healthcare in which patients take a more active role in the generation and implementation of treatment options. In today’s consumer era of healthcare, participatory care appears to be popular among Baby Boomers. It requires a relatively high degree of healthcare literacy on the part of the patient (Gilligan & Weinstein, 2014) and involves the use of shared decision making. Shared decision making, which is an essential component of patient-centric communication, is the process in which the patient and the audiologist exchange information about the scale and scope of the patient’s condition, express the preferences of intervention options and collaborate on the implementation and evaluation of a solution. Shared decision making and participatory care cannot be supported without adequate information provision (Poost-Faroosh, et al 2015).

One of the most critical factors in the patient-professional relationship is the ability of the audiologist to advise patients on their treatment decisions. Recommendations from audiologists have been shown to be predictive of actions taken by the hearing impaired patient. In other words, when the only treatment option offered patients are hearing aids, a likely result is for patients to do nothing. For example, Laplante-Levesque, et al (2012) found that one of five individuals with hearing loss will choose an alternative rehabilitation option when they have opted not to obtain hearing aids.

Structured tools, such as a decision aid, are a novel approach to improving knowledge transfer and patient engagement in their treatment choices. Decision aids and other tools that promote informed decisions are not substitutes or face-to-face communication between the audiologist and patient. Rather, they are intended to improve the patient’s knowledge and familiarity with various treatment options. Visit www.mayo.edu/center-for-innovation/projects/decision-aids to learn more about the advantages of decision aids in the fostering better communication with patients. Alternatives to traditional hearing aids that can be placed on your own decision aid include directed audio systems (e.g., Hypersound), hearing management groups (e.g., Active Communication Enhancement group from Louise Hickson), and various assistive listening devices. Offering more alternatives to patients, especially those with milder losses may be a potential gateway to increasing traditional hearing aid uptake.

Audiologists tend to believe that the hearing aid is the solution for all shape and manner of hearing problems encountered in their clinic. Historically, it is our hammer – the only tool in our bag that reliably addresses the needs of patients with hearing loss – the tool we seem to talk too much about. As recent research indicates, however, enlisting the help of an audiologist does not automatically mean patients are seeking help for hearing aids. Improving the daily living of patients requires tools, such as decision aids, and technology like directed audio and even high quality PSAPs that will expand the appeal of audiology care to new heights. It all starts with our ability to foster trust and utilize better communication skills. We need more tools and implementation strategies that help us with three key elements of the patient-provider relationship: Decision making, uptake of an agreed upon treatment plan and final outcome of that treatment. Systematically improving trust and communication in each of these areas promises to enhance our standing as professionals worthy of the title of doctor.

Chien, W. & Lin, F. (2012). Prevalence of hearing aid use among older adults in the United States. Archives of Internal Medicine. 172, 292-203.

Claesen, E. & Pryce, H. (2012) An exploration of the perspective of help-seekers prescribed hearing aids. Primary Health Care Research & Development. 13, 3, 279-284.

Gilligan, J. & Weinstein, BE (2014) Health literacy and patient-centered care in audiology –implications for adult aural rehabilitation. Commun Disord Deaf Stud Hearing Aids. 2, 110. Grenness, C, et al (2015) The nature of communication throughout diagnosis and management planning in initial audiologic rehabilitation consultations. JAAA. 26, 36-50.

Laplante-Levesque, A., Hickson, L., & Worrall, L. (2012a). What makes adults with hearing impairment take up hearing aids or communication programs and achieve successful outcomes? Ear and Hearing. 33, 79-93.

Laplante-Lévesque A., Knudsen L.V., Preminger J.E., Jones L., Nielsen C., et al. (2012b) Hearing help-seeking and rehabilitation: perspectives of adults with hearing impairment. Int. J. Audiol., 51, 93-102.

Laplante-Levesque, A. et al (2013) Optimal hearing aid use: Focus groups with hearing aid clients and audiologists. Ear and Hearing. 34, 2, 193-202.

Poost-Faroosh, et al (2015) Comparions of client and clinician views of the importance of factors in client-clinician interaction in hearing aid purchase decisions. JAAA. 26, 247-259.

Preminger J.E., Oxenbøll M., Barnett M.B., Jensen L.D. & Laplante-Levesque A. 2015. Perceptions of adults with hearing impairment regarding the promotion of trust in hearing healthcare service delivery. Int. J. Audiol., 54, 20-28.