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.
Key Words
Age-related hearing loss - audiology - delivery of health care - health-care policy
- hearing loss - Medicare - presbyacusis
