How private is your consultation? Acoustic and audiological measures of speech privacy in the otolaryngology clinic.

The right to confidentiality is a central tenet of the doctor-patient relationship. In the United Kingdom this right to confidentiality is recognised in published GMC guidance. In USA the Healthcare Insurance Portability and Accountability Act of 1996 (HIPAA) strengthened the legal requirement to protect patient information in all forms and failure to do so now constitutes a federal offence. The aims of this study are to assess the acoustic privacy of an otolaryngology outpatient consultation room. Acoustic privacy was measured using the articulation index (AI) and Bamford-Kowal-Bench (BKB) speech discrimination tests. BKB speech tests were calibrated to normal conversational volume (50 dB SPL). Both AI and BKB were calculated in four positions around the ENT clinic: within the consultation room, outside the consulting room door, in the nearest waiting area chair and in the farthest waiting area chair. Tests were undertaken with the clinic room door closed and open to assess the effect on privacy. With the clinic room door closed, mean BKB scores in nearest and farthest waiting area chairs were 51 and 41% respectively. AI scores in the waiting area chairs were 0.03 and 0.02. With the clinic room door open, privacy was lost in both AI and BKB testing, with almost 100% of word discernable at normal talking levels. The results of this study highlight the poor level of speech privacy within a standard ENT outpatient department. AI is a poor predictor or privacy.

Safety of audiology direct access for medicare patients complaining of impaired hearing.

BACKGROUND: Allowing Medicare beneficiaries to self-refer to audiologists for evaluation of hearing loss has been advocated as a cost-effective service delivery model. Resistance to audiology direct access is based, in part, on the concern that audiologists might miss significant otologic conditions. PURPOSE: To evaluate the relative safety of audiology direct access by comparing the treatment plans of audiologists and otolaryngologists in a large group of Medicare-eligible patients seeking hearing evaluation. RESEARCH DESIGN: Retrospective chart review study comparing assessment and treatment plans developed by audiologists and otolaryngologists. STUDY SAMPLE: 1550 records comprising all Medicare eligible patients referred to the Audiology Section of the Mayo Clinic Florida in 2007 with a primary complaint of hearing impairment. DATA COLLECTION AND ANALYSIS: Assessment and treatment plans were compiled from the electronic medical record and placed in a secured database. Records of patients seen jointly by audiology and otolaryngology practitioners (Group 1: 352 cases) were reviewed by four blinded reviewers, two otolaryngologists and two audiologists, who judged whether the audiologist treatment plan, if followed, would have missed conditions identified and addressed in the otolaryngologist's treatment plan. Records of patients seen by audiology but not otolaryngology (Group 2: 1198 cases) were evaluated by a neurotologist who judged whether the patient should have seen an otolaryngologist based on the audiologist's documentation and test results. Additionally, the audiologist and reviewing neurotologist judgments about hearing asymmetry were compared to two mathematical measures of hearing asymmetry (Charing Cross and AAO-HNS [American Academy of Otolaryngology-Head and Neck Surgery] calculations). RESULTS: In the analysis of Group 1 records, the jury of four judges found no audiology discrepant treatment plans in over 95% of cases. In no case where a judge identified a discrepancy in treatment plans did the audiologist plan risk missing conditions associated with significant mortality or morbidity that were subsequently identified by the otolaryngologist. In the analysis of Group 2 records, the neurotologist judged that audiology services alone were all that was required in 78% of cases. An additional 9% of cases were referred for subsequent medical evaluation. The majority of remaining patients had hearing asymmetries. Some were evaluated by otolaryngology for hearing asymmetry in the past with no interval changes, and others were consistent with noise exposure history. In 0.33% of cases, unexplained hearing asymmetry was potentially missed by the audiologist. Audiologists and the neurotologist demonstrated comparable accuracy in identifying Charing Cross and AAO-HNS pure-tone asymmetries. CONCLUSIONS: Of study patients evaluated for hearing problems in the one-year period of this study, the majority (95%) ultimately required audiological services, and in most of these cases, audiological services were the only hearing health-care services that were needed. Audiologist treatment plans did not differ substantially from otolaryngologist plans for the same condition; there was no convincing evidence that audiologists missed significant symptoms of otologic disease; and there was strong evidence that audiologists referred to otolaryngology when appropriate. These findings are consistent with the premise that audiology direct access would not pose a safety risk to Medicare beneficiaries complaining of hearing impairment.

Hearing rehabilitation in a patient with sudden sensorineural hearing loss in the only hearing ear.

A case report is presented of a 62-year-old software product manager who had normal hearing in one ear and a congenital profound hearing loss in the other ear and then sustained a sudden sensorineural hearing loss in the only hearing ear. The approach to amplification decisions, cochlear implant evaluation, and rehabilitation options are discussed. Providing aural rehabilitation and continually updating and providing new amplification options and accessories are described.

Hearing loss and speech privacy in the health care setting: a case study.

Ensuring speech privacy has become an important consideration in the design of health care environments. The Healthcare Insurance Portability and Accountability Act requirements include the establishment of reasonable technical and procedural methods to protect patient privacy. However, specific standards for meeting speech privacy requirements are not currently established. This article presents a case study of two clinical environments, one where speech privacy was judged by health care workers to be adequate and one where speech privacy was judged to be inadequate. Careful study of both environments revealed three factors that led to the perception of inadequate speech privacy. First, sound attenuation between adjacent rooms was slightly poorer by 5 dB in the inadequate environments. Second, ambient noise levels were lower by 9 dB in the inadequate environment. Finally, geriatric patients with hearing loss prompted health care workers to increase their speech intensity, decrease language complexity, and decrease the speed at which speech was articulated. These factors made it more probable that speech was overheard and understood. Existing methods to calculate speech privacy in health care settings need to consider the effect of hearing loss on the acoustics of the oral communication transaction.

The importance of audiologic red flags in patient management decisions.

BACKGROUND: It is essential that nonbenign forms of hearing impairment are recognized and addressed before audiological management is entertained. PURPOSE: To present an illustrative case and focused literature review of early red flag indicators for retrocochlear impairment, as might be discerned from a patient's history or physical examination. RESULTS: The presenting history and clinical course of a female patient with fatal adenocarcinoma presenting as a suspected retrocochlear mass is reviewed over the last four months of her life. Clinical signs, symptoms and test results pointing to the diagnosis of "acoustic neuroma" and then "metastatic neoplasm" are reviewed along with selected supporting reference literature. The ambiguous clinical pictures at various points in her history are analyzed, with an effort to point out how early audiological decisions may significantly impact patient's overall health. CONCLUSIONS: Clear communication with primary care physicians, vigilance when audiological results are ambiguous for active disease, and pre-established referral relationships with practitioners in the neurologic and otologic disciplines are stressed as important requirements for audiologists who serve as entry points into hearing healthcare.

Outcome measurement for patients receiving hearing aid services.

OBJECTIVE: The purpose of this paper is to describe a useful patient report outcome measure for a hearing aid program that can be completed annually, with limited staff resources, and can be used to document performance excellence. STUDY DESIGN AND METHODS: The International Outcome Inventory for Hearing Aids (IOI-HA) questionnaire was mailed to all patients receiving new hearing aids and rehabilitative services during a 1 year period at Mayo Clinic (Rochester, MN). The data were analyzed to assess outcomes. RESULTS: Overall, patients reported a high level of satisfaction and an improved quality of life. The results compared favorably with published norms and with the previous year's results. CONCLUSION: The IOI-HA was implemented easily with little incremental cost. An annual project such as the one described can be used to demonstrate to administrators, patients, and payers that the clinic's rehabilitative hearing aid services have positive outcomes and that program quality is being monitored.

Hearing loss and hearing aid treatment options.

Hearing loss is a common problem that impacts quality of life for the patient, family members, and caretakers. Unfortunately, hearing loss is often undiagnosed and untreated. This article summarizes symptoms of typical hearing loss associated with aging and simple screening procedures that can be Implemented into a primary care practice. In addition, hearing aid treatment options, Including monaural or binaural fitting, size and style, and circuitry and feature options, are reviewed.

Effectiveness of counseling-based adult group aural rehabilitation programs: a systematic review of the evidence.

A systematic evidence-based review was conducted to examine the effectiveness of counseling and communication strategy-oriented group adult aural rehabilitation (AR) programs. The literature search for relevant articles focused on studies that (1) employed adults with hearing impairment; (2) used a group aural rehabilitation program that emphasized counseling and communication strategies; (3) utilized a randomized controlled trial, quasi-experimental, or non-intervention cohort design; (4) employed an outcome measure that assessed some aspect of personal adjustment, perceived hearing handicap, or hearing aid benefit and/or satisfaction; and (5) were published in a refereed journal. Twelve articles were found that met these inclusion criteria. Analysis of the 12 studies led to the following conclusion: there is reasonably good evidence that participation in an adult AR program provides short-term reduction in self-perception of hearing handicap and potentially better use of communication strategies and hearing aids. It is less clear whether this advantage over provision of hearing aids alone persists over time.

The ability to pun may be retained in Alzheimer disease.

Although the deficits and difficulties of the patient with Alzheimer disease (AD) are well documented and discussed, less attention is paid to describing some of the interesting and unusual abilities that these patients can possess. This case report describes an 81-year-old female with moderately severe Alzheimer disease who, in spite of some severe cognitive deficits, is able to express impressive humor through the extensive use of puns. Acknowledging and focusing on the remaining positive attributes of a person with AD can be helpful to both family members and professionals.