Early Auditory Referral in Primary Care

The Best Practice Alert (BPA) was developed via an iterative process during a two year pilot
phase at one site at each health system. First, a "standard" BPA was developed to be launched
at each site during the pilot phase. Similarly, a pilot 10-minute education system was
developed to be presented just before the above BPA was launched. Pre and post surveys of
clinicians were conducted to evaluate the effectiveness of the education program. After
clinicians had experience with the BPA, Cognitive Task Analyses (CTAs) with clinicians were
conducted to identify ways to make the BPA more effective, and then the BPA was iteratively
improved. Similarly, the CTAs helped the investigators understand why clinicians do or do not
use BPAs in general. Using this process, a highly rated, easy to use BPA was created and will
be utilized in the actual study. The investigators also revamped the education program to a
10 minute video that focused on clinicians mental models of HL, to be used in the actual
study. The bigger study, i.e., the R33 phase, will launch at several Family Medicine
practices within each of the two different health systems. One of these systems is a
traditional academic institution with only academic faculty (physicians and audiologists),
midlevels and residents, and the other is a newer academic system, based within a private
health system, that includes non-academic physicians and private audiologists. Patients who
trigger the BPA will be 55 years or older, do not have an open referral in their chart to
audiology, and do not have a known hearing loss already on their problem summary list (PSL).
These patients are asked to complete a Hearing Handicap Inventory (HHI) at check-in, a common
hearing loss screening tool (score of 10+ indicates probable hearing loss); the results of
this will not be shared with clinicians. If the physician chooses to address the prompt
during the patient encounter, the BPA design allows them to, 1) Indicate that the patient
declines hearing screening (BPA is dismissed for 1 year), 2) Indicate that the patient
already has a known hearing loss (HL) and add HL to the PSL (The BPA will be permanently
dismissed), 3) Indicate that the patient does not have any HL at this time (The BPA is
dismissed for one year), or 4) refer the patient to audiology for hearing screening. The data
generated by the BPA is extracted from the electronic health record (EHR) and analyzed to
determine if HL screening rates improve when compared to baseline data, whether or not
providers are interacting with the BPA, and whether HL is being added to the PSL. The HHI
results are used as the "gold standard," i.e., when compared to the data generated by the
BPA, indicate whether or not patients with probable HL are getting appropriate care. When an
enrolled patient shows up in Audiology the audiologist is asked to complete a three question
survey to verify that 1) the referral was appropriate, 2) what is the severity of hearing
loss if any, and 3) were hearing aids recommended. This step is to study whether the BPA is
generating appropriate referrals. 20% of patients that score 10 or above on their HHI and/or
were referred to audiology are contacted by phone and researchers ask them questions about
any conversation they may recall related to HL at their appointment as well as their
experience in audiology. Iterative improvements will be made to the BPA based on Cognitive
Task Analysis (CTA) interviews with randomly selected providers (mostly family physicians).
Finally, the implementation of the BPA into clinical practice is observed using the
principles of Normalization Process Theory (NPT) to study whether there are other potential
issues that may impact whether patients at risk for HL are being screened and referred. The
revamped educational video will be shown a week prior to the BPA going live at each site, and
repeating the pre and post evaluations. The investigators will be studying whether the
education video increases identification and referral of patients at high risk for HL.

Inclusion Criteria:

-55 years or older, doesn't have a known hearing loss on their problem summary list (found
in the electronic health record), doesn't already have an open referral to audiology in
their chart, and has an encounter with a provider at a participating Family Medicine
clinic.

Exclusion Criteria:

- None