Carrie L. Nieman

Effects of Community-Based Health Worker Interventions to Improve Chronic Disease Management and Care Among Vulnerable Populations: A Systematic Review

BACKGROUND Community-based health workers (CBHWs) are frontline public health workers who are trusted members of the community they serve. Recently, considerable attention has been drawn to CBHWs in promoting healthy behaviors and health outcomes among vulnerable populations who often face health inequities. OBJECTIVES We performed a systematic review to synthesize evidence concerning the types of CBHW interventions, the qualification and characteristics of CBHWs, and patient outcomes and cost-effectiveness of such interventions in vulnerable populations with chronic, noncommunicable conditions. SEARCH METHODS We undertook 4 electronic database searches-PubMed, EMBASE, Cumulative Index to Nursing and Allied Health Literature, and Cochrane-and hand searched reference collections to identify randomized controlled trials published in English before August 2014. SELECTION We screened a total of 934 unique citations initially for titles and abstracts. Two reviewers then independently evaluated 166 full-text articles that were passed onto review processes. Sixty-one studies and 6 companion articles (e.g., cost-effectiveness analysis) met eligibility criteria for inclusion. DATA COLLECTION AND ANALYSIS Four trained research assistants extracted data by using a standardized data extraction form developed by the authors. Subsequently, an independent research assistant reviewed extracted data to check accuracy. Discrepancies were resolved through discussions among the study team members. Each study was evaluated for its quality by 2 research assistants who extracted relevant study information. Interrater agreement rates ranged from 61% to 91% (average 86%). Any discrepancies in terms of quality rating were resolved through team discussions. MAIN RESULTS All but 4 studies were conducted in the United States. The 2 most common areas for CBHW interventions were cancer prevention (n = 30) and cardiovascular disease risk reduction (n = 26). The roles assumed by CBHWs included health education (n = 48), counseling (n = 36), navigation assistance (n = 21), case management (n = 4), social services (n = 7), and social support (n = 18). Fifty-three studies provided information regarding CBHW training, yet CBHW competency evaluation (n = 9) and supervision procedures (n = 24) were largely underreported. The length and duration of CBHW training ranged from 4 hours to 240 hours with an average of 41.3 hours (median: 16.5 hours) in 24 studies that reported length of training. Eight studies reported the frequency of supervision, which ranged from weekly to monthly. There was a trend toward improvements in cancer prevention (n = 21) and cardiovascular risk reduction (n = 16). Eight articles documented cost analyses and found that integrating CBHWs into the health care delivery system was associated with cost-effective and sustainable care. CONCLUSIONS Interventions by CBHWs appear to be effective when compared with alternatives and also cost-effective for certain health conditions, particularly when partnering with low-income, underserved, and racial and ethnic minority communities. Future research is warranted to fully incorporate CBHWs into the health care system to promote noncommunicable health outcomes among vulnerable populations.

Racial/Ethnic and Socioeconomic Disparities in Hearing Health Care Among Older Americans

Objective: Hearing impairment is highly prevalent, but little is known about hearing health care among older minority adults. Method: We analyzed nationally representative, cross-sectional data from 1,544 older adults ≥70 years with audiometry and hearing care data from the 2005-2006 and 2009-2010 National Health and Nutritional Examination Surveys. Results: After adjusting for age and speech frequency pure tone average, Blacks (odds ratio [OR] = 1.68, vs. Whites) and those with greater education (OR = 1.63, ≥college vs. <high school) were more likely to report recent hearing testing, while White older adults and those with greater socioeconomic status were more likely to report regular hearing aid use (all ps < .05). Based on a multivariate analysis, Blacks were not more likely than Whites to use hearing aids despite being more likely to have had recent hearing testing. Discussion: Racial/ethnic and socioeconomic disparities exist in hearing health care and represent critical areas for research and intervention.

Personal Sound Amplifiers for Adults with Hearing Loss

Age-related hearing loss is highly prevalent and often untreated. Use of hearing aids has been associated with improvements in communication and quality of life, but such treatment is unaffordable or inaccessible for many adults. The purpose of this review is to provide a practical guide for physicians who work with older adults who are experiencing hearing and communication difficulties. Specifically, we review direct-to-consumer amplification products that can be used to address hearing loss in adults. Helping adults with hearing loss navigate hearing loss treatment options ranging from being professionally fitted with hearing aids to using direct-to-consumer amplification options is important for primary care clinicians to understand given our increasing understanding of the impact of hearing loss on cognitive, social, and physical functioning.

Hearing Care Intervention for Persons with Dementia: A Pilot Study

OBJECTIVE Hearing loss is a commonly unmet need among adults with dementia that may exacerbate common dementia-related behavioral symptoms. Accessing traditional audiology services for hearing loss is a challenge because of high cost and time commitment. To improve accessibility and affordability of hearing treatment for persons with dementia, there is a need for unique service delivery models. The purpose of this study is to test a novel hearing intervention for persons with dementia and family caregivers delivered in outpatient settings. METHODS The Memory-HEARS pilot study delivered a 2-hour in-person intervention in an outpatient setting. A trained interventionist provided hearing screening, communication strategies, and provision of and instruction using a simple over-the-counter amplification device. Caregivers (N = 20) responded to questionnaires related to depression, neuropsychiatric symptoms, and caregiver burden at baseline and 1-month postintervention. RESULTS Overall, caregivers believed the intervention was beneficial, and most participants with dementia wore the amplification device daily. For the depression and neuropsychiatric outcome measures, participants with high symptom burden at baseline showed improvement at 1-month postintervention. The intervention had no effect on caregiver burden. Qualitative responses from caregivers described improved engagement for their loved ones, such as laughing more, telling more stories, asking more questions, and having more patience. CONCLUSION The Memory-HEARS intervention is a low-cost, low-risk, nonpharmacologic approach to addressing hearing loss and behavioral symptoms in patients with dementia. Improved communication has the potential to reduce symptom burden and improve quality of life.

Whose experience is measured? A pilot study of patient satisfaction demographics in pediatric otolaryngology.

Despite a national emphasis on patient‐centered care and cultural competency, minority and low‐income children continue to experience disparities in health care quality. Patient satisfaction scores are a core quality indicator. The objective of this study was to evaluate race and insurance‐related disparities in parent participation with pediatric otolaryngology satisfaction surveys.

Age-related hearing loss in older adults with cognitive impairment

BACKGROUND Hearing loss can impair effective communication between caregivers and individuals with cognitive impairment. However, hearing loss is not often measured or addressed in care plans for these individuals. The aim of this study is to measure the prevalence of hearing loss and the utilization of hearing aids in a sample of individuals with cognitive impairment in a tertiary care memory clinic. METHODS A retrospective review of 133 charts of individuals >50 years who underwent hearing assessment at a tertiary care memory clinic over a 12-month period (June 2014-June 2015) was undertaken. Using descriptive statistics, the prevalence of hearing loss was determined and associations with demographic variables, relevant medical history, cognitive status, and hearing aid utilization were investigated. RESULTS Results indicate that hearing loss is highly prevalent among this sample of cognitively impaired older adults. Sixty percent of the sample had at least a mild hearing loss in the better hearing ear. Among variables examined, age, MMSE, and medical history of diabetes were strongly associated with hearing impairment. Hearing aid utilization increased in concordance with severity of hearing loss, from 9% to 54% of individuals with a mild or moderate/severe hearing loss, respectively. CONCLUSIONS Hearing loss is highly prevalent among older adults with cognitive impairment. Despite high prevalence of hearing loss, hearing aid utilization remains low. Our study highlights the importance of hearing evaluation and rehabilitation as part of the cognitive assessment and care management plan in this vulnerable population.

The Baltimore HEARS Pilot Study: An Affordable, Accessible, Community-Delivered Hearing Care Intervention

Purpose of the Study Age-related hearing loss negatively affects health outcomes, yet disparities in hearing care, such as hearing aid use, exist based on race/ethnicity and socioeconomic position. Recent national efforts highlight reduction of hearing care disparities as a public health imperative. This study a) describes a community engagement approach to addressing disparities, b) reports preliminary outcomes of a novel intervention, and c) discusses implementation processes and potential for wide-scale testing and use. Design and Methods This was a prospective, randomized control pilot, with a 3-month delayed treatment group as a waitlist control, that assessed feasibility, acceptability, and preliminary efficacy of a community-delivered, affordable, and accessible intervention for older adults with hearing loss. Outcomes were assessed at 3 months, comparing immediate and delayed groups, and pooled to compare the cohorts pre- and 3-month post-intervention results. Results All participants completed the study (n = 15). The program was highly acceptable: 93% benefited, 100% would recommend the program, and 67% wanted to serve as future program trainers. At 3 months, the treated group (n = 8) experienced fewer social and emotional effects of hearing loss and fewer depressive symptoms as compared to the delayed treatment group (n = 7). Pooling 3-month post-intervention scores (n = 15), participants reported fewer negative hearing-related effects (effect size = -0.96) and reduced depressive symptoms (effect size = -0.43). Implications The HEARS (Hearing Equality through Accessible Research & Solutions) intervention is feasible, acceptable, low risk, and demonstrates preliminary efficacy. HEARS offers a novel, low-cost, and readily scalable solution to reduce hearing care disparities and highlights how a community-engaged approach to intervention development can address disparities.

Physician screening and recommendations on secondhand smoke in chronic rhinosinusitis patients

Chronic rhinosinusitis (CRS) is a prevalent and costly disease that adversely impacts quality of life. As with other chronic diseases, individual and environmental factors impact the disease process. Smoking and secondhand tobacco (SHS) exposures are important risk factors for CRS. However, little is known about the role that physicians play in educating sinusitis patients about this preventable risk. The objective of this study was to characterize physician participation in SHS exposure screening and education.

The effect of frailty on short-term outcomes after head and neck cancer surgery: Frailty and Outcomes in Head and Neck Surgery

To determine the relationship between frailty and comorbidity, in‐hospital mortality, postoperative complications, length of hospital stay (LOS), and costs in head and neck cancer (HNCA) surgery.

Use of Pericranial Flap Coverage in Cochlear Implantation of the Radical Cavity Rationale, Technique, and Experience

Cochlear implant (CI) surgery in the setting of an open mastoid cavity is evolving. Two strategies are commonly pursued: a staged approach, clearing the disease, closing the meatus or the external auditory canal (EAC), and reevaluating in 3 to 6 months prior to implantation, or a single-stage procedure with mastoid obliteration without EAC closure. Meatal closure is often employed in the setting of an open mastoid cavity to reduce the risk of electrode extrusion and infection. An open cavity offers the advantages of being a single-stage procedure, permitting direct surveillance for recurrent cholesteatoma, and reducing the need for repeat computed tomography scans. We describe an approach to the coverage of a CI within a dry, open mastoid cavity using an anteriorly-based postauricular pericranial flap.