Evidence gaps in ENT surgery - a qualitative survey.

Introduction: As in other disciplines, the burgeoning knowledge in ENT medicine long ago surpassed our ability to adequately absorb it and maintain a proper overview. This can give rise to actual or assumed evidence gaps that can impede the progress of the discipline and evidence-based treatment of patients. Clinics and medical practices also hold to traditional doctrines that shape day-to-day medicine, without these schools being challenged based on evidence. Methods: Between February and June 2015, 160 ENT clinics, including 34 university hospitals, and 2,670 ENT practices took part in a two-arm online survey on existing or perceived evidentiary gaps in ENT medicine using a previously developed questionnaire. The survey used for half of the participants was open in form; the other half were given a closed survey with systematics of the field for orientation. The survey was augmented with additional data such as the number of publications and focus areas in the clinics and the age and type of practice of the established physicians. Results: The return rate from the clinics was 39.7%; the return rate of the closed surveys was 29.3%. Of the physicians in medical practice, 14.6% responded to the closed and 18.6% to the open survey. There were no major differences between the two forms of survey. Otological and oncological issues comprised approximately 30% of the list of answers from clinics. Corresponding questions were formulated regarding the current diagnostic and therapeutic problems, such as with stage-related tumor treatment or implantable hearing aids. Diagnostic procedures, e.g., special new procedures in audiology and vestibulogy, dominated the surveys from the practices. However clinics and practices alike cited marginal areas of the discipline that are of daily relevance. Discussion: The cited evidence gaps then needed to be verified or refuted and clarified based on research of the literature as to whether the existing evidence actually reached healthcare providers in the form of guidelines, publications, conferences, or continuing training for application in daily practice. Other steps would include prioritizing future research, evidence mapping, deciding on further systematic reviews, and targeted studies in conjunction with procuring third-party funding and in cooperation with patient associations. The knowledge thus gained should ultimately be transferred in improved form for application in daily clinical practice. Ten questions of key importance each needed to be formulated for the hospitals and practices.

[The Influence of Hearing Loss Represented by Standard Audiogram Types to Unaided APHAB Scores]. / Die Abhängigkeit von APHABu-Scores von Hörverlusten in Standardaudiogrammen.

BACKGROUND: Questionnaires as the APHAB (Abbreviated Profile of Hearing Aid Benefit) are besides pure-tone and speech-audiometry the third method of diagnostics in audiology. Up to now there has been no research on the influence of individual hearing loss, represented by standard audiograms, on the scores of the unaided APHAB (APHABu) done with a big number of subjects. This study will investigate whether there does exist such a relationship or not. METHODS: A total of 2 745 records provided by a database were analysed. First, the subjects' audiograms (air conduction) were allocated to 7 standardised audiogram types. By using a multivariant mixed linear model a potential connection was examined between these standard audiograms and particular APHABu scores for its four subscales: EC - ease of communication, BN - background noise, RV - reverberation, AV - aversiveness of sounds. RESULTS: There was no evidence for a dependency between any type of hearing loss dependence and unaided APHAB-scores. The values on the EC-scale vary between 49.8 and 58.0, on the BN-scale between 45.3 and 46.6, on the RV-scale between 44.4 and 52.4, and on the AV-scale between 47.6 and 50.1. DISCUSSION: This result confirms earlier studies with other questionnaires. Therefore, the APHABu can be used as an initial instrument for the diagnostics of individual hearing loss independently on whether hearing aids will be fitted subsequently or not.

[Gaps of Evidence in ENT-Surgery - a Qualitative Survey]. / Qualitative Umfrage zur Identifizierung von Evidenzlücken in der HNO-Heilkunde.

INTRODUCTION: As in other disciplines, the burgeoning knowledge in ENT medicine long ago surpassed our ability to adequately absorb it and maintain a proper overview. This can give rise to actual or assumed knowledge gaps that can impede the progress of the discipline and evidence-based treatment of patients. Clinics and medical practices also hold to traditional doctrines that shape day-to-day medicine, without these schools being challenged based on evidence. METHODS: Between February and June 2015, 160 ENT clinics, including 34 university hospitals, and 2,670 ENT practices took part in a two-arm online survey on existing or perceived evidentiary gaps in ENT medicine using a previously development questionnaire. The survey used for half the participants was open in form; the other half were given a closed survey with systematics of the field for orientation. The survey was augmented with additional data such as the number of publications and focus areas in the clinics and the age and type of practice of the established physicians. RESULTS: The return rate from the clinics was 39.7%; the return rate of the closed surveys was 29.3%. Of the physicians in medical practice, 14.6% responded to the closed and 18.6% to the open survey. There were no major differences between the two forms of survey. Otological and oncological issues comprised approximately 30% of the list of answers from clinics. Corresponding questions were formulated regarding the current diagnostic and therapeutic problems, such as with stage-related tumor treatment or implantable hearing aids. Diagnostic procedures, e.g., special new procedures in audiology and vestibulogy, dominated the surveys from the practices. However clinics and practices alike cited marginal areas of the discipline that are of daily relevance. DISCUSSION: The cited knowledge gaps then needed to be verified or refuted and clarified based on research of the literature as to whether the existing evidence actually reached healthcare providers in the form of guidelines, publications, conferences or continuing training for application in daily practice. Other steps would include prioritizing future research, evidence mapping, deciding on further systematic reviews, and targeted studies in conjunction with procuring third-party funding and in cooperation with patient associations. The knowledge thus gained should ultimately be transferred in improved form for application in daily clinical practice. Ten questions of key importance each needed to be formulated for the hospitals and practices.

The influence of frequency-dependent hearing loss to unaided APHAB scores.

Hearing loss can be measured by pure-tone and speech audiometry. The subjective hearing impairment can be assessed using questionnaires. The APHAB determines this for four typical hearing situations. It has not been researched previously whether a particular frequency-specific hearing loss leads to a particular unaided APHAB score in one of the subscales or not. Clarification could be helpful using the unaided APHAB as an instrument for primary diagnostics of hearing loss independently of whether hearing aids were subsequently fitted or not. A total of 4546 records from a database were analysed; the average age of the subjects was 69.3 years. Using a multivariant mixed linear model, a possible correlation was examined between a frequency-specific hearing loss (0.5-8.0 kHz) and particular unaided APHAB scores for its subscales. Furthermore, it was determined whether the subject's gender has a corresponding impact. There was no evidence of gender-specific dependence of the unaided APHAB scores. For the EC scale frequencies above 0.5 kHz, for the RV scale all frequencies and for the AV scale the frequencies at 1.0 and 2.0 kHz showed a significant correlation between hearing loss and the APHAB score. For each decibel of hearing loss there was an average rise in the APHAB score for the EC and RV scale of approximately 0.2 percentage points and an average decrease in the AV scale of 0.1 percentage points for each frequency. For the BN scale there was no evidence of this kind of correlation. The very varied possibility between individuals compensating for hearing loss in situations with background noises could be that there is no correlation between frequency-specific hearing loss and an associated unaided APHAB score. The described frequency-specific influence of hearing loss to the EC and RV score could be explained by fewer compensating possibilities for the patients in these specific hearing situations than for the BN scale described. Using the unaided APHAB form in primary diagnostics of hearing impairment is helpful for understanding individual problems.

[Distribution and Scattering of APHAB Answers Before and After Hearing Aid Fitting]. / Die Verteilung und Streuung von APHAB-Antworten vor und nach einer Hörgeräteversorgung.

Objective: Questionnaires are an important diagnostic elements in audiology. In Germany the APHAB is regularly used for hearing aid fitting. This study is investigating whether there are any specific questions which are answered more rarely by the subjects than other and whether inverted questions have any influence to this. Methods: Between April 2013 and August 2015 the number of 23 557 APHAB forms by 10 associations of statutory health insurance registered physicians have been collected and evaluated. For all questions the frequency of answers before and after hearing aid fitting have been determined. Results: For the EC scale there was one group of patients without hearing aid which a lot of problems of hearing and a second without. For the BN and RV subscale the majority of the patients addresses problems of understanding. For the AV scale no specific kind of problems found has been found. After successful hearing aid fitting problems of understanding for EC, BN, and RV subscale were reduced on average, for the AV scale no relevant change could be observed. Except for the numbers 11, 18, and 21 all APHAB questions were answered by 93-94% by all subjects. The questions number 11 and 18 were answered by 92%, question number 21 by 87%. Some questions have a similar tendency in deviation from the average (1, 3, 13, 16, and 17). Conclusions: Inverted questions have no influence to the frequency of answers in APHAB questions. The 3 questions which are answered more rarely are describing hearing situations in cinemas, theatres, and at church. Presumably, this hearing situations are not so common for most patients than the other described by the APHAB.

[Hearing aid fitting: Effect of doubling the standard rate on compliance, quality of results, and excess payments]. / Hörgeräteversorgung: Folgen der Festbetragsverdoppelung auf Compliance, Ergebnisqualität und Zuzahlungen.

BACKGROUND: This study investigates the effect that doubling the standard rate for hearing aid fitting which is covered by statutory insurance has had on the size of excess payments and compliance, as well as on benefits for patients and their satisfaction. METHODS: In April 2014, 859 members of a statutory insurance scheme (hkk) who received hearing aids in the 6 months prior to the reform were questioned on the timing and financial details of their hearing aid fitting, as well as on treatment compliance and quality of the results using a standardized questionnaire. In October 2014, the same questionnaire was used to collect these data from a further 622 insurance holders who had received hearing aids in the 8 months following introduction of the new regulation. Most of the questions concerning hearing quality corresponded to those of the Abbreviated Profile of Hearing Aid Benefit (APHAB) questionnaire. RESULTS: The project revealed a statistically significant decrease of 6 percent points in the proportion of hearing aid users who had to pay any excess whatsoever; from 80.6% to 74.1%. However, 40% of the insured persons continued to pay an excess of 1000 euros and more. The subjective hearing quality remained practically unimproved by the reform and was statistically, almost without exception, independent of whether hearing aid users wore expensive devices associated with a large excess, or devices available at the standard rate. Finally, the study confirmed a previously recognized usage pattern characterized by noncompliance. For example, approximately 40% of hearing aid users did not wear their device in the everyday environment. This observation was independent of the size of the excess and the timing of the most recent visit to the hearing aid acoustician. CONCLUSION: Despite doubling of the standard rate, three quarters of patients pay an excess--sometimes a substantial one. The subjective hearing quality was not improved by doubling the standard rate; the majority of patients continue to complain of considerable problems with hearing in difficult situations (environments with background or reverberant noise). Satisfaction with hearing quality is neither dependent on the doubling of the standard rate, nor on whether or not an excess was paid. Compliance may possibly be improved by structured follow-up, which should involve the prescribing otorhinolaryngologists, as well as phoniatrists, pedaudiologists, and hearing aid acousticians.

Results in using the Freiburger monosyllabic speech test in noise without and with hearing aids.

The Freiburger Speech Test (FST) has been the gold standard in speech testing by word recognition score in Germany for many years. Recently, it has been demonstrated that for an amount of 104 test-persons there is no significant deviation within the lists. The objective of this study was to determine the percentiles of the distinct measuring situations in quiet and with noise (e.g. applied in hearing aid fitting) and the average benefit using hearing aids. In this prospective study, 623 patients with SNHL and equipped with hearing aids for at least 3 months have been investigated by means of the Freiburger monosyllabic test (FBE) without and with hearing aids and in quiet or with noise (CCITT noise, 65/60 dB signal-noise ratio) in free field conditions at 65 dB to determine the ratio of intelligibility. To investigate the different diagnostic conditions a linear mixed model was applied. The dependent binary variable corresponds to the number of understood syllables. The average age of all subjects was about 72.6 years. The average rate of understanding in the FBE without hearing aids and in quiet was 38.5 %, with hearing aids and in quiet 67.7 %, without hearing aids and with noise 22.4 %, and with hearing aids and with noise 39.8 %. All results were presented with the depending confidence intervals. The extent of hearing loss and the quality of hearing aid fitting can be successfully measured using the FST in quiet and with background noise (CCITT noise). In quiet, an average hearing improving gain of 29.2 % points and with noise a gain of 17.4 % points could be estimated with a successful hearing aid fitting.

[Development and use of an APHAB database]. / Entwicklung und Anwendung einer APHAB-Datenbank.

A specific quality assurance questionnaire concerned with the provision of hearing aids was introduced that assesses elements of patient satisfaction within Germany's statutory healthcare system. A questionnaire-based assessment is now relevant for all physicians involved in the care of statutorily insured patients in Germany. The APHAB (Abbreviated Profile of Hearing Aid Benefit) questionnaire is the most widely used. The APHAB assesses several different situations: the normal hearing situation, hearing in noise, comprehension of speech in situations of echo or reverberation and hearing in loud situations. The APHAB questionnaire-based patient evaluation of the benefit of hearing aids represents the third pillar of audiological diagnostics, alongside classical pure-tone and speech audiometry. The objective of the APHAB database is to allow evaluation of individual patient data on the basis of a larger volume of data.

[Implementation of the new quality assurance agreement for the fitting of hearing aids in daily practice. Part 2: New diagnostic aspects of speech audiometry]. / Umsetzung der neuen Qualitätssicherungsvereinbarung zur Hörgeräteversorgung im Praxisalltag. Teil 2: Diagnostische Neuerungen in der Sprachaudiometrie.

Upon review of the statutory health insurance reimbursement guidelines, a specific quality assurance questionnaire concerned with the provision of hearing aids was introduced that assesses elements of patient satisfaction within Germany's public healthcare system. APHAB questionnaire-based patient evaluation of the benefit of hearing aids represents the third pillar of audiological diagnostics, alongside classical pure-tone and speech audiometry. Another new aspect of the national guidelines is inclusion of free-field measurements in noise with and without hearing aids. Part 2 of this review describes new diagnostic aspects of speech audiometry. In addition to adaptive speech audiometry, a proposed method for applying the gold standard of speech audiometry - the Freiburg monosyllabic speech test - in noise is described. Finally, the quality assurance questionnaire will be explained as an appendix to template 15 of the regulations governing hearing aids.

[Implementation of the new quality assurance agreement for the fitting of hearing aids in daily practice. Part 1: New regulations pertaining to hearing aid fitting]. / Umsetzung der neuen Qualitätssicherungsvereinbarung zur Hörgeräteversorgung im Praxisalltag. Teil 1: Neue Regeln der Hörgeräteverordnung.

Alongside evidence-based medicine, quality assurance has becoming increasingly important in daily medical practice during the last decade. The introduction of a specific quality assurance questionnaire in connection with hearing aid fitting represents the first large-scale assessment of certain elements of patient satisfaction within Germany's public healthcare system. Part 1 of this review describes the most important new regulations pertaining to hearing aid fitting in the context of statutory health insurance. Since the vast majority of diagnostic and therapeutic procedures constituting the treatment of hearing loss patients--particularly the subsequent rehabilitation of hearing aid wearers in cooperation with hearing aid acousticians--occur outside the clinic, this review concentrates on the rules relevant to this area. After studying this part of the overview, readers should be able to understand and apply the sections of the statutory health insurance reimbursement guidelines relating to ambulant hearing aid fitting; furthermore, they should be able to understand and apply the standard evaluation criteria (Einheitlicher Bewertungsmaßstab, EBM).

[Complications in hearing aid fitting without otolaryngologist expertise]. / Komplikationen bei der Hörgeräteversorgung ohne HNO-Arzt.

BACKGROUND: Hearing loss is a symptom. The underlying disease must be investigated by an otolaryngologist, in order to ensure timely identification of alterations in disease course, complications and newly occurring secondary disease. METHODS: During the course of 1 year, 484 case studies in which treatment errors had arisen due to lack of otolaryngologist involvement during hearing aid fitting were collected from 115 practices and 7 ENT clinics, as well as from the patient representatives of the Federal Joint Committee. Depending on the type and cause of the individual complications, these were classified into five groups and described cumulatively. RESULTS: A total of 484 cases in which results had been incorrectly interpreted or charged to the wrong payer organization were presented in the form of a systematic overview. Furthermore, serious technical deficits, as well as unnecessary temporary and inappropriate fittings were observed. CONCLUSION: The aforementioned cases are interpreted on the basis of regulations governing hearing aid fitting and current legal practices. These case reports clearly demonstrate that otolaryngologist expertise are required not only at the first hearing aid fitting, but also for subsequent fittings, in order to appropriately treat the underlying disease. Only so can the patient be protected from damage to their health and financial complications, and health insurance providers avoid wasting resources.

[Evaluation of the Freiburg monosyllabic speech test in background noise]. / Evaluation des Freiburger Einsilbertests im Störschall.

BACKGROUND: The Freiburg speech test has been the gold standard in speech audiometry in Germany for many years. Previously, however, this test had not been evaluated in assessing the effectiveness of a hearing aid in background noise. Furthermore, the validity of particular word lists used in the test has been questioned repeatedly in the past, due to a suspected higher variation within these lists as compared to the other word list used. PATIENTS AND METHODS: In this prospective study, two groups of subjects [normal hearing control subjects and patients with SNHL (sensorineural hearing loss) that had been fitted with hearing aid] were examined. In a first group, 113 control subjects with normal age- and gender-related pure tone thresholds were assessed by means of the Freiburg monosyllabic test under free-field conditions at 65 dB. The second group comprised 104 patients that had been fitted with hearing aids at least 3 months previously to treat their SNHL. Members of the SNHL group were assessed by means of the Freiburg monosyllabic test both with and without hearing aids, and in the presence or absence of background noise (CCITT-noise; 65/60 dB signal-noise ratio, in accordance with the Comité Consultatif International Téléphonique et Télégraphique), under free-field conditions at 65 dB. RESULTS: The first (control) group exhibited no gender-related differences in the Freiburg test results. In a few instances, inter-individual variability of responses was observed, although the reasons for this remain to be clarified. Within the second (patient) group, the Freiburg test results under the four different measurement conditions differed significantly from each other (p>0.05). This group exhibited a high degree of inter-individual variability between responses. In light of this, no significant differences in outcome could be assigned to the different word lists employed in the Freiburg speech test. CONCLUSION: The Freiburg monosyllabic test is able to assess the extent of hearing loss, as well as the effectiveness of a fitted hearing aid, in the presence or absence of background-noise (CCITT-noise). The present study could not evidence statistically significant differences in outcome when using the different word lists in this test battery.