Cochlear Implants
by Michaela Coon

3 essential Journal Clubs to keep on hand

April 30, 2020
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In today’s busy clinical environment, clinicians who value research-based practice often struggle to keep up with current literature. Our monthly Journal Club feature includes rotating guest authors who present current journal article summaries that provide clinical insights for a range of practice and patient demographics.

Here are three Journal Club articles to bookmark:

  1. Speech Recognition as a Function of the Number of Channels in Perimodiolar Electrode Recipients

Based on a Vanderbilt University Medical Center study, Speech Recognition as a Function of the Number of Channels in Perimodiolar Electrode Recipients, increasing the number of electrodes resulted in improved performance and sound quality. Findings were statistically significant in demonstrating that the subjects with the electrodes closest to the modiolus had the best performance.

Read now!

2. Pediatric Cochlear Implant Wear Time and Early Language Development

This Journal Club edition explores a study by the team at the University of North Carolina published in September 2019, Pediatric Cochlear Implant Wear Time and Early Language Development. The results of this study support the importance of consistent device use for language development in children and highlight device datalogging as a critical tool in measuring progress. The findings may also encourage professionals to consider how they counsel parents of young children who are using cochlear implants. 

Learn more!

3. Musical training improves the ability to understand speech-in-noise in older adults

Based on a Neurobiology of Aging study out of Canada, Musical Training Improves the Ability to Understand Speech-in-Noise in Older Adults, music-based auditory rehabilitation is likely to be successful in older adults in improving their hearing abilities.

Explore now!

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Journal Club: New trends in CI clinical service delivery – Improving clinic efficiency while maintaining recipient outcomes

November 18, 2019

By Dave Catlett, Au.D. – Principal Clinical Training Manager, Cochlear Americas

Presley, R. “Increasing Efficiency While Maintaining Patient Outcomes and Satisfaction: One Clinic’s Approach to a New Service Delivery Model.” Presented at ACIA’s CI2019: 16th Symposium on Cochlear Implants in Children, Hollywood, FL, July 2019

Slager, H. et al. “Artificial Intelligence-Assisted Cochlear Implant Mapping: Implications for Clinic Efficiency and Future Directions.” Poster at ACIA’s CI2019: 16th Symposium on Cochlear Implants in Children Hollywood, FL, July 2019

Zwolan, T. “The Benefits of Using Audiology Assistants in a Cochlear Implant Program.” Presented at ACIA’s CI2019: 16th Symposium on Cochlear Implants in Children Hollywood, FL, July 2019

In today’s busy clinical environment, clinicians who value research-based practice often struggle to keep up with current literature. To help, we’re excited to offer a new ProNews Blog monthly feature – Journal Club!  Each month, rotating guest authors will present a current research-based journal article summary.

This month’s Journal Club explores two podium presentations and one poster presented at the ACIA CI2019: 16th Symposium on Cochlear Implants in Children conference in Hollywood, Florida by audiologists from the University of Michigan and Greater Baltimore Medical Center (GBMC).

What did these clinics investigate?

Each of these investigations explored ways to improve patient access to cochlear implant technology and clinical care including:

  • Use of trained, non-audiologist clinical assistants to supplement provision of testing (particularly for pediatric recipients), counseling and troubleshooting
  • Reduction in audiologist non-billable time and procedures
  • Efficacy of reducing the number of clinical programming appointments in the first year post-activation while preserving recipient performance outcomes and patient satisfaction

Why is this important? 

Despite increased awareness of cochlear implants in the general population and growth in the number of clinics providing cochlear implant services, it has been estimated that only 5% of those who could benefit from a cochlear implant have received one.1,2

Ongoing efforts to educate professionals and the public on the benefits of cochlear implantation, coupled with an aging population and research showing that untreated hearing loss can lead to the acceleration of isolation in the elderly, are intended to increase consideration of CI and guide more potential candidates to clinics for assessment and, if indicated, implantation.3

Increasing clinic capacity to accommodate greater access without sacrificing quality of outcomes or overwhelming clinic schedules is an increasingly-discussed topic, as evidenced by dedicated sessions at recent ACIA meetings focused on service delivery. In light of this, clinics are exploring novel approaches to the provision of quality care for their patients, increasing clinic productivity and reducing non-billable time and services.

How did they do it?

Each presentation described similar challenges seen among CI centers looking to provide quality care in a sustainable way.

  • Access to sound booths for testing and, increasingly, real ear equipment to optimize contralateral hearing aids and/or verify acoustic CI components
  • Busy clinic schedules, particularly the number and length of post-operative programming appointments
  • Less-than-ideal reimbursement, especially given the needed provision of non-billable services like counseling, troubleshooting and email/phone responses
  • Increasing facility scrutiny of audiologist productivity and patient-focused quality of care metrics
  1. Dr. Presley described in detail several practice changes4 that have been implemented in recent years at GBMC including:
  • A pre-operative device counseling workshop to bring CI candidates together for a group session reviewing surgery and vaccination information, realistic expectations, device selection and ordering options. This would also allow candidates to connect with others in similar stages of their implant journey.
  • Development of increased webpage resource links for candidates, including a private Facebook group and manufacturer resources, as well as device counseling and surgical-consent videos to streamline the process and provide consistent information
  • Use of non-audiologist support staff to assist with non-billable activities
    • Use of a clinic-trained ‘CI technician’ for device review, equipment set-up and pairing, externals troubleshooting and to device counseling workshop facilitation
    • Aural rehab therapist who sees recipients two-weeks post-IA and takes on some equipment counseling responsibilities as part of their billable time
    • Administrative assistants trained to provide basic equipment troubleshooting by phone and in clinic
  • Ongoing review and evolution of clinic protocols with a focus on increasing patient empowerment and assessment-based outcomes
  • Reduction over time of programming appointments in the first year post-operatively from eight to five, with no reported impact in patient outcomes or satisfaction

2. Dr. Zwolan described the need for and initiation (in 2016) of a CI Audiology Assistant position at the University of Michigan (UM) implant program.5 The potential responsibilities include:

  • Management of processor upgrade requests and pre-authorizations
  • Maintenance of clinic test equipment, loaner speech processors and hearing aids
  • Assistance with pediatric testing and programming
  • Troubleshooting of hearing aids and CI processors for walk-ins or by telephone

She also detailed CPT coding and reimbursement fee schedules associated with common CI procedures and compared these with average hourly salaries of audiologists versus audiology assistants.

  • According to ZipRecruiter.com, audiology assistants typically make about $34,305 annually (range = $20-60K) 
    • Plus benefits at 31.7% = $45,179 annual, $21.72/hour
  • Average annual salary for audiologists = $75,000 
    • Plus benefits (31.7%) = $98,775 annual, $47.48/hour
  • In an “average” scenario, audiologists cost about $25/hour more than a typical audiology assistant

Dr. Zwolan also provides guidance for developing a return-on-investment (ROI) proposal that clinics can use to facilitate conversations with their facilities, such as tracking current non-billable time spent in clinic to highlight the potential need for audiology assistance and relating that to improvements in patient access, satisfaction and quality of care.

3. Dr. Slager and her colleagues at the UM CI program described their site’s participation in a study seeking to validate the evidence-based clinical tool to assist programming and featuring a streamlined post-operative mapping schedule for adults.6

The study protocol dictated just four programming sessions in the first six months (IA, 1-, 3- and 6-month intervals), compared to UM’s existing clinic protocol at study initiation of six visits in the first six months (two-day IA, 1 week, and 1-, 3- and 6-month intervals).

Performance at the 3- and 6-month intervals was also evaluated in soundfield using CNC words and AzBio sentences at +10 signal-to-noise ratio and then compared with pre-operative scores on those same tests.

Results

At GBMC, monthly group device counseling workshops have reduced non-billable services by 75% (Fig. 1)4, while provided (and billable) clinical services have almost doubled in the past three years (Fig. 2).4

Similarly, the use of audiology assistants at the UM resulted in increased productivity and improved patient access.

In addition, the UM poster noted improvements in CNC word scores for their eight subjects at the 3- and 6-month intervals compared with pre-operative performance. They also reported no subjective changes in clinician-patient relationship with the use of the study’s novel programming procedure and two fewer programming sessions in the first six months post-activation. Based on their study experience, the UM clinic protocol has since changed by removing the Day 2 programming appointment, resulting in increased patient access and improved audiologist productivity.

Discussion

Each of these presentations reveal examples of clinic efforts to increase both patient access and audiologist productivity while maintaining recipient outcomes. These are necessary goals for any-sized CI programming center to remain viable and sustainable providers of excellent clinical care. Individual clinic protocols should be reviewed regularly and, if evidence of potential improvements such as those noted here are seen or desired, adjusted over time to best accommodate the realities of scheduling, billable services and patient-centered outcomes.

Learn  more about this exciting clinical strategy by accessing the presentations and stay tuned for next month’s edition of Journal Club!

References

  1. Blanchfield, B.B., et. Al. (2001). The severely to profoundly hearing-impaired population in the United States: Prevalence estimates and demographics. JAAA. 12, 183-189.
  2. Cochlear internal estimate, recipients data.
  3. Lin FR et al (2013) Hearing loss and cognitive decline in older adults.  JAMA Intern Med, 174(4):293-299
  4. Presley, R. “Increasing Efficiency While Maintaining Patient Outcomes and Satisfaction: One Clinic’s Approach to a New Service Delivery Model.” Presented at ACIA meeting, Hollywood, FL, July 2019
  5. Zwolan, T. “The Benefits of Using Audiology Assistants in a Cochlear Implant Program.” Presented at ACIA meeting, Hollywood, FL, July 2019
  6. Slager, H. et al. “Artificial Intelligence-Assisted Cochlear Implant Mapping: Implications for Clinic Efficiency and Future Directions.” Poster at ACIA meeting, Hollywood, FL, July 2019
Elizabeth Preston, AuD

Pediatric wear time case study with Elizabeth Preston, AuD

January 18, 2022

By Elizabeth Preston, AuD, CCC-A

Background

The importance of consistent wear time has been drilled into me as a pediatric audiologist and it is important to have conversations with families about this regularly. Conversations around wear time are easier if the stage is set early. The sooner we stress the importance of device use and the impact it has on language outcomes for the child, the better.1-3 We use a co-treat model in our clinic, so a speech language pathologist (SLP) who is LSL certified is always seeing the family on the same day as the audiology appointments for young children especially during the first year after cochlear implantation. There are many advantages to having this model; one of those advantages is having both the audiologist and SLP  discussing device use and stressing the importance of wear time.

I was also always using the “10 hours a day” (children wear their device at least 10 hours per day) reference for getting a full day of use in. In our clinic, we now use “80% of the day” to take into consideration increase in awake time as a child gets older.4 A child quickly outgrows being awake 10-12 hours a day. To help providers start the conversation about wear time and its importance, we have posted the below figure in each treatment room. We feel it is an easy visual for families to read and understand and we are often asked about it.

Case study

I’d like to share the story of Gwen (name has been changed) to give an example of how taking the time to have hard conversations around wear time helped her outcomes in the long run. Gwen had an uneventful pregnancy/birth and she passed her newborn hearing screening in both ears.  However, her parents were concerned by two months of age about her lack of responses to sound, so they asked their pediatrician for a referral for a diagnostic auditory brainstem response (ABR).  Due to COVID, that testing was a bit delayed. A no-response ABR was obtained in both ears at 6 months of age and hearing aids were fit by seven months of age. There is a positive family history of hearing loss as her father has been diagnosed with Waardenburg Syndrome.

Gwen was referred for a cochlear implant (CI) evaluation and later she was bilaterally implanted. Gwen struggled to maintain consistent wear time from the very beginning. We had several conversations discussing strategies the family could use, discussing daily routines and where the family could improve upon their efforts. We also discussed different retention options to help keep the processors on. They tried wearing the Kanso® 2 Sound Processors and utilizing the HugFits™. To complicate our efforts, the family was also getting advice from a family member who is Deaf and encouraging them to focus more on sign language than on consistent device use . Our message remained consistent: If Gwen is going to talk, she needs to wear her devices consistently and be spoken to. We encouraged the family that they could choose to teach sign language along with spoken language if they wanted her to learn both languages.

Data also helped inform our counseling strategy. At initial activation, wear time started at 40-50% of her waking hours. Unfortunately, it reduced to 10% after three months of device use, which also meant she was not making much progress with her listening and her speech. Her parents were not seeing the benefit of keeping them on.

After many discussions with the family to find a solution that would work for them to keep the devices on, Gwen’s wear time has improved. This was a team effort including the parents, audiologist, speech language pathologist and early interventionist. She has begun to make great progress with her spoken language as well as learning a few signs and her parents are now seeing the benefits of having the devices on. There is still work to do; however, Gwen is on the right trajectory and we will continue to support her and her parents through this journey.

Results

By taking time to work as a team and talk through different strategies to address the struggles and celebrate the successes, Gwen’s wear time improved and she began to make quick progress with her listening and spoken language. These conversations were often hard and we didn’t always feel equipped to answer all the questions, but we did not shy away and we believe this is what has made the difference.

Helpful takeaways:

  1. Start the wear time conversation at the very beginning of discussions about the cochlear implant
  2. Discuss retention options early to have a plan and possibly start practicing that plan prior to surgery (e.g., wearing a headband to get used to having it on prior to activation)
  3. Celebrate the small successes
  4. Make sure everyone on the team is using the same messaging and working together
  5. Keep the conversations focused on the family coming up with strategies if possible (prompting may be necessary to start ideas flowing)
  6. Review datalogging so that timely conversations can happen with family and between appointments if needed
  7. Keep conversations as positive as possible and validate the family’s feelings

No matter how young infants are when implanted, they will not close the gap with their normal hearing peers without wearing their devices 80% or more of their awake time. If we meet the family where they are and offer our support, their child will be more likely to succeed.

To hear more from Dr. Preston, listen to her pediatric-focused AudiologyOnline course.

About the author: Dr. Elizabeth Preston just finished up as Pediatric Cochlear Implant Audiologist, Audiology Clinic Manager and Clinical Assistant Professor at The Children’s Cochlear Implant Center at UNC. She earned her degrees from Texas Tech Health Sciences Center and has over 16 years of clinical experience. Her career as an audiologist has focused on working with children who are deaf or hard of hearing gain access to spoken language through listening.  She began her career as a diagnostic audiologist, fitting hearing devices for children with varying degrees of hearing loss.  As the Audiology Clinic Manager with UNC’s Cochlear Implant Team, she helped children in her region gain access to cochlear implants and receives high-quality follow-up services.  This included participating in clinical research and working to broaden the number of children who have access to services. Dr. Preston also provides training to professionals and graduate students throughout the United States to improve the diagnosis and treatment of children who are deaf or hard of hearing.

References

  1. Gagnon EB, Eskridge H, Brown KD. (2020, March)Pediatric cochlear implant wear time and early language development. Cochlear Implants Int. 21(2):92-97. doi: 10.1080/14670100.2019.1670487. Epub 2019 Sep 29. PMID: 31566100.
  2. Gagnon EB, Eskridge H, Brown KD, Park LR. (2021, April). The impact of cumulative cochlear implant wear time on spoken language outcomes at age 3 Years. J Speech Lang Hear Res. 64(4):1369-1375. doi: 10.1044/2020_JSLHR-20-00567. Epub 2021 Mar 30. PMID: 33784469.
  3. Wiseman KB, Warner-Czyz AD, Kwon S, Fiorentino K, Sweeney M. (2021, Jul-Aug). Relationships between daily device use and early communication outcomes in young children with cochlear Implants. Ear Hear. 42(4):1042-1053. doi: 10.1097/AUD.0000000000000999. PMID: 33974791.
  4. Jenco, Melissa. (2016, June). AAP endorses new recommendations on sleep times. The official Newsmagazine of the American Academy of Pediatrics. https://www.aappublications.org/news/aapnewsmag/2016/06/13/Sleep061316.full.pdf

In the United States, the Cochlear Nucleus Implant System is approved for use in children 9 to 24 months of age who have profound sensorineural hearing loss in both ears and demonstrate limited benefit from appropriate hearing aids. Children 2 years of age or older may demonstrate severe to profound hearing loss in both ears.

 In the Canada, the Cochlear Nucleus Implant System (CI500 and CI600 Series) is approved for use in children 9 to 24 months of age who have profound sensorineural hearing loss in both ears and demonstrate limited benefit from appropriate hearing aids. Children 2 years of age or older may demonstrate severe to profound hearing loss in both ears.

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