Potential barriers and facilitators for implementation of an integrated care pathway for hearing-impaired persons: an exploratory survey among patients and professionals

BACKGROUND: Because of the increasing costs and anticipated shortage of Ear Nose and Throat (ENT) specialists in the care for hearing-impaired persons, an integrated care pathway that includes direct hearing aid provision was developed. While this direct pathway is still under investigation, in a survey we examined expectations and potential barriers and facilitators towards this direct pathway, of patients and professionals involved in the pathway. METHODS: Two study populations were assessed: members of the health professions involved in the care pathway for hearing-impaired persons (general practitioners (GPs), hearing aid dispensers, ENT-specialists and clinical audiologists) and persons with hearing complaints. We developed a comprehensive semi-structured questionnaire for the professionals, regarding expectations, barriers, facilitators and conditions for implementation. We developed two questionnaires for persons with hearing complaints, both regarding evaluations and preferences, and administered them after they had experienced two key elements of the direct pathway: the triage and the hearing aid fitting. RESULTS: On average GPs and hearing aid dispensers had positive expectations towards the direct pathway, while ENT-specialists and clinical audiologists had negative expectations. Professionals stated both barriers and facilitators towards the direct pathway. Most professionals either supported implementation of the direct pathway, provided that a number of conditions were satisfied, or did not support implementation, unless roughly the same conditions were satisfied. Professionals generally agreed on which conditions need to be satisfied. Persons with hearing complaints evaluated the present referral pathway and the new direct pathway equally. Many, especially older, participants stated however that they would still visit the GP and ENT-specialist, even when this would not be necessary for reimbursement of the hearing aid, and found it important that the ENT-specialist or Audiological Centre evaluated their hearing aid. CONCLUSION: This study identified professional concerns about the direct pathway for hearing-impaired persons. Gaps exist in expectations amongst professions. Also gaps exist between users of the pathway, especially between age groups and regions. Professionals are united in the conditions that need to be fulfilled for a successful implementation of the direct pathway. Implementation on a regional level is recommended to best satisfy these conditions

Choosing between measures: comparison of EQ-5D, HUI2 and HUI3 in persons with hearing complaints

OBJECTIVES: To generate insight into the differences between utility measures EuroQol 5D (EQ-5D), Health Utilities Index Mark II (HUI2) and Mark III (HUI3) and their impact on the incremental cost-effectiveness ratio (ICER) for hearing aid fitting METHODS: Persons with hearing complaints completed EQ-5D, HUI2 and HUI3 at baseline and, when applicable, after hearing aid fitting. Practicality, construct validity, agreement, responsiveness and impact on the ICER were examined. RESULTS: All measures had high completion rates. HUI3 was capable of discriminating between clinically distinctive groups. Utility scores (n = 315) for EQ-5D UK and Dutch tariff (0.83; 0.86), HUI2 (0.77) and HUI3 (0.61) were significantly different, agreement was low to moderate. Change after hearing aid fitting (n = 70) for HUI2 (0.07) and HUI3 (0.12) was statistically significant, unlike the EQ-5D UK (0.01) and Dutch (0.00) tariff. ICERs varied from 647,209 euros/QALY for the EQ-5D Dutch tariff to 15,811 euros/QALY for HUI3. CONCLUSION: Utility scores, utility gain and ICERs heavily depend on the measure that is used to elicit them. This study indicates HUI3 as the instrument of first choice when measuring utility in a population with hearing complaints, but emphasizes the importance of a clear notion of what constitutes utility with regard to economic analyse

Molecular mechanisms involved in pulmonary arterial hypertension development

Pulmonary arterial hypertension (PAH) is an elevation in pulmonary arterial pressure, characterized by symptoms of dyspnea, chest pain, decrease in exercise tolerance-fatigue, syncope and, if untreated, PAH leads to right heart failure. In PAH, there is an imbalance between mediators of vasodilation and vasoconstriction (e.g. nitric oxide and prostacycline – potent vasodilators, platelet inhibitor and antimitogens are decreased in PAH, while thromboxane, vasoconstrictor and platelet activator is increased in PAH, resulting in smooth muscle hypertrophy of small vessels, adventitial and intimal proliferation, and plexiform vascular lesions with vascular thrombosis). Standard diagnostic procedures for PAH include physical examination, pulmonary function testing, radiographic imaging, transthoracic echocardiography, right heart catheterization. Current drugs include synthet c prostanoids (iloprost, epoprostenil, beraprost, treprostinil) – vasodilators and antiplatelet agents. Phosphodiesterase-5 inhibitors decrease the breakdown of cGMP, increasing its intracellular levels, leukotriene receptor antagonist, – zafirlukast, decreases pulmonary arterial and venous pressure. Endothelin receptor blockers, bosentan, decrease pulmonary vascular resistance and improve results of functional tests. Other treatments are: anticoagulants, calcium-channel blockers, positive airway pressure therapy for obstructive sleep apnea, or oxygen for hypoxemia, and surgery. In conclusion, although there are some promising drugs in therapy of PAH, there is a need to develop new ones, together with surgical approaches, in order to increase the survival of patients with PAH. Gene and cell therapy could be expected as future perspectives

Audiologist-Driven Versus Patient-Driven Fine Tuning of Hearing Instruments

Two methods of fine tuning the initial settings of hearing aids were compared: An audiologist-driven approach-using real ear measurements and a patient-driven fine-tuning approach-using feedback from real-life situations. The patient-driven fine tuning was conducted by employing the Amplifit (R) II system using audiovideo clips. The audiologist-driven fine tuning was based on the NAL-NL1 prescription rule. Both settings were compared using the same hearing aids in two 6-week trial periods following a randomized blinded cross-over design. After each trial period, the settings were evaluated by insertion-gain measurements. Performance was evaluated by speech tests in quiet, in noise, and in time-reversed speech, presented at 0 degrees and with spatially separated sound sources. Subjective results were evaluated using extensive questionnaires and audiovisual video clips. A total of 73 participants were included. On average, higher gain values were found for the audiologist-driven settings than for the patient-driven settings, especially at 1000 and 2000 Hz. Better objective performance was obtained for the audiologist-driven settings for speech perception in quiet and in time-reversed speech. This was supported by better scores on a number of subjective judgments and in the subjective ratings of video clips. The perception of loud sounds scored higher than when patient-driven, but the overall preference was in favor of the audiologist-driven settings for 67% of the participant

Optimization of the Dutch matrix test by random selection of sentences from a preselected subset

Matrix tests are available for speech recognition testing in many languages. For an accurate measurement, a steep psychometric function of the speech materials is required. For existing tests, it would be beneficial if it were possible to further optimize the available materials by increasing the function's steepness. The objective is to show if the steepness of the psychometric function of an existing matrix test can be increased by selecting a homogeneous subset of recordings with the steepest sentence-based psychometric functions. We took data from a previous multicenter evaluation of the Dutch matrix test (45 normal-hearing listeners). Based on half of the data set, first the sentences (140 out of 311) with a similar speech reception threshold and with the steepest psychometric function (≥9.7%/dB) were selected. Subsequently, the steepness of the psychometric function for this selection was calculated from the remaining (unused) second half of the data set. The calculation showed that the slope increased from 10.2%/dB to 13.7%/dB. The resulting subset did not allow the construction of enough balanced test lists. Therefore, the measurement procedure was changed to randomly select the sentences during testing. Random selection may interfere with a representative occurrence of phonemes. However, in our material, the median phonemic occurrence remained close to that of the original test. This finding indicates that phonemic occurrence is not a critical factor. The work highlights the possibility that existing speech tests might be improved by selecting sentences with a steep psychometric functio