Applied tele-audiology research in clinical practice during the past decade: a scoping review

Abstract

Objective

The purpose of this scoping review was two-fold, (1) to provide information about the characteristics, type of service delivery, participant information and outcomes related to tele-audiology in clinical popluations, and (2) to describe documented facilitators and barriers to tele-audiology delivery from the perspectives of practitioners and service recipients. Knowledge of these findings can assist audiologists in considering remote service delivery options for their practices.

Design

A scoping review was conducted in November 2019 to identify English-language peer-reviewed journal articles published from 1 January 2010 to 30 October 2019 related to remote clinical service delivery in audiology.

Results

Thirty-six published research articles were included. Research studies were classified into four broad areas with some articles including more than one area within the scope of their article: Screening (n = 5), Diagnostic (n = 5), Intervention (n = 18), and Perspectives (n = 22).

Conclusion

Hearing healthcare service delivery is expanding with the changing technological landscape, providing greater opportunities and flexibility for audiologists and patients. There are clear opportunities for interdisciplinary collaboration and for collaboration with on-site local facilitators. Local facilitators, with training, can assist in connecting individuals to follow-up care, provide educational support, and needed hands-on assistance for specialised testing.

Keywords:

• Telehealth
• telemedicine
• ehealth
• audiology
• hearing

The World Health Organisation (WHO) estimates that one in ten, approximately 466 million people, experience the consequences of disabling hearing loss and that the number is expected to increase to 900 million by the year 2050 (WHO 2019). Furthermore, WHO estimates significant costs to society when hearing loss is unaddressed, with annual global costs as much as US$750 billion. Many in need of services face barriers accessing hearing care. Tele-audiology opportunities continue to expand with advances in technology and global connectivity through the internet. Audiologists have an opportunity to embrace the flexibility that remote service delivery offers to improve service accessibility and further individualise services for patients and their families.

Traditional in-person appointments with health-care providers can represent an array of barriers to patients, limiting their ability to obtain needed hearing care and engage in ongoing care. For example, a lack of providers was found as a barrier for adults with hearing loss living in rural areas in the US state of Kentucky (Powell et al. 2019). Similarly, a scoping review found that children with hearing loss living in rural areas of the US and Canada experienced barriers accessing specialised services compared to peers in urban areas (Barr, Dally, and Duncan 2019). It is also likely that individual factors play a role even for patients living in urban areas, such as accessing transportation, mobility challenges, and poor health, making travel to a facility for services difficult (e.g. Coco, Champlin, and Eikelboom 2016). Furthermore, recent developments with the 2020 COVID-19 pandemic and need for physical distancing also support the importance of remote service options. By strategically considering inclusion of delivering services remotely, audiologists can increase patient access to care and support patients in effectively managing their daily hearing needs, ultimately increasing patient engagement and satisfaction.

Scoping reviews can assist audiologists in understanding the extent of tele-audiology, additional research needs, and services they can consider embracing to meet the needs of patients within their practice, as well as reaching those who currently are not able to access services. An earlier literature review of tele-audiology applications found 26 peer-reviewed articles addressing screening, diagnosis, intervention and patient perceptions, published up to May 2009 (Swanepoel and Hall 2010). The authors concluded that while the studies spanned various service types, there were limited peer-reviewed empirical studies and further research was needed; for example, no reports addressed perspectives of audiologists related to remote service provision.

Given mounting interest in tele-audiology solutions for access to care problems, subsequent literature reviews have investigated rehabilitation applications for adults with hearing aids (Tao et al. 2018), the adult hearing aid journey (Paglialonga et al. 2018), and audiologists’ perceptions of tele-audiology (Ravi et al. 2018). These reviews clearly support the growth in attention that tele-audiology has received in recent years. The landscape continues to change for remote hearing care delivery. Therefore, the purpose of this scoping review was two-fold: (1) to provide information about the characteristics, type of service delivery, participant information and outcomes related to tele-audiology in clinical popluations, and (2) to describe documented facilitators and barriers to tele-audiology delivery from the perspectives of practitioners and service recipients.

Method

Procedure

A scoping literature review was completed in November 2019 (Tricco et al. 2018). Scoping reviews follow a systematic process to examine a broad area and can be used to identify main concepts and gaps in research. The purpose of a scoping review is to identify what kind of evidence is available, not necessarily to provide a critical appraisal of the evidence. The Joanna Briggs Institute (Aromataris and Munn 2015) provides a detailed description of the purpose and process for conducting scoping reviews.

For inclusion in the review, the articles needed to address (1) audiological services delivered using tele-audiology to a clinical population (e.g. those with hearing loss) or to individuals suspected or at risk of hearing loss, or (2) clinician, patient, and/or facilitator perspectives on tele-audiology. Peer-reviewed journal articles were included if they were in English and published between 1 January 2010 and 30 October 2019. Research articles were excluded if a clinical population was not used (e.g. lab simulation, associated factors) or if an audiologist was not directly involved in the tele-audiology delivery.

To identify potentially relevant articles, four databases were searched (MEDLINE, CINHAL Complete, PsycINFO via EBSCOhost, Scopus) using the following key words (telemedicine or telerehabilitation or telehealth or telepractice or teleintervention or teleaudiology or ehealth) and (audiology or hearing). For the search in Scopus, mhealth (mobile health) was included as an additional key word; it was not used in the other dabase searches after initial testing with the term did not identify relevant studies.

The database search was performed by two authors (KM; NN). The two reviewers jointly developed a data charting form prior to completing the search, and calibrated the search by working together before continuing the search independently. First, article titles and abstracts were reviewed independently and then the reviewers came together to discuss and resolve any discrepancies in selected articles, updating the charting form in an iterative process. Second, a full text review was completed (NN) followed by discussion to finalise article selection. Finally, reference lists of included articles were reviewed (NN) to identify further articles for consideration. See Figure 1 for article inclusion flowchart.

Figure 1. Article Inclusion Flowchart.

Included articles were analysed to identify characteristics (i.e. publication year, country of origin), type of service delivery (e.g. diagnosis, intervention), participant information, and outcomes. We aimed to describe the characteristics of clinically-focussed tele-audiology research and narratively synthesise the outcomes, to provide an overview of current research.

Results

This scoping review identified 36 tele-audiology articles published from 1 January 2010 to October 2019 conducted with clinical populations or to screen those at risk for hearing loss. Research studies were conducted in four broad areas of service delivery in audiology (see Table 1), with some articles including more than one area within the scope of their article: Screening (n = 5), Diagnostic (n = 5), Intervention (n = 18), and Perceptions (n = 22). The study components included in each category are discussed below and a summary table of the articles is available (see Supplemental Information, Appendix A).

Table 1. Summary of included research articles by category.

Categories	No. of studies	Populations	Test procedures
Screening	5	Infants, children, and adults	Audiometry; OAE; Tympanometry
Diagnosis	5	Infants and adults	ABR, video-otoscopy, tympanometry, audiometry
Intervention	18	Children and adults	CI mapping, tinnitus management, education, counselling, HA programming, Digits in Noise
Perceptions	22	Audiologists, support personnel, parents, adult patients	N/A

OAE: otoacoustic emissions; ABR: auditory brainstem response; CI: cochlear implant; HA: hearing aid. Note. Total number is higher for studies than for articles as some articles included more than one aspect of connected health.

Screening studies

Our scoping review identified five tele-audiology community-based hearing screening studies in children and infants (Ciccia et al. 2011; Monica et al. 2017; Govender and Mars 2018; Eksteen et al. 2019; Ameyaw, Anim-Sampong, and Ribera 2019). These studies described results of audiologists along with trained facilitators at remote sites that provided hearing screening services for infants and children.

Eksteen et al. (2019) reported that use of minimally trained community care workers (CCW) to screen for both hearing and vision was affordable (estimated cost $5.63 USD per child) and provided a scalable service delivery model. Monica et al. (2017) assessed the feasibility of synchronous remote tele-hearing screening using audiometry and distortion product otoacoustic emissions (DPOAE) on a small group of school children (n = 31) in India. They reported that using tele-screening was feasible with the help of teachers as facilitators and results were comparable to in-person screening. The authors noted some of the technical challenges in implementing tele-screening which were related to slow internet bandwidth in remote villages and the high noise levels in schools. In a similarly motivated study, Govender and Mars (2018) evaluated the efficacy of asynchronous screening and diagnostic hearing tests using automated audiometry (KUDUwave 5000) in South Africa. KUDUwave 5000 (eMoyoDotNet, Johannesburg, South Africa) has built-in technology to attenuate ambient noise and monitor noise levels during testing, which is reported to significantly improve the reliability of screening results. Their findings based on testing 73 children (6–12 years) suggested a concerning level of false negatives (i.e. low sensitivity of automated screening test results). Low sensitivity of the screening test (65%) was attributed potentially to test accuracy, possibly related to inadequate probe tip insertion, and low frequency hearing loss.

In Ghana, Ameyaw, Anim-Sampong, and Ribera (2019) explored the feasibility of remote DPOAE screening to expand newborn hearing screening access. Fifty infants were enrolled, and their hearing was screened onsite in addition to using remotely controlled DPOAE system over the internet by an audiologist. Specialised software (Team Viewer 8.0) provided real-time video, audio, and text communication between the audiologist and the test site facilitator. Results showed that remote screening was as effective as the onsite screening and can be an efficient way of providing hearing screening services to remote patients in the Greater Accra Region. To improve screening access to children in an urban area of the United States, Ciccia and colleagues (2011) explored remote synchronous screening for speech, language, and hearing. They screened 411 children up to 6 years of age, and during the 2 years of the study the reliability of pure-tone screening and DPOAE screening were 100%, they had around 84% reliability for tympanometry results done remotely compared to in-person.

Diagnostic testing

Five studies were identified that evaluated remote diagnostic testing procedures (Hayes et al. 2012; Dharmar et al. 2016; Ramkumar, Rajendran, et al. 2018; Ramkumar et al. 2019; Hatton et al. 2019). Three of the studies assessed the feasibility of remote testing to reduce loss to follow-up from newborn hearing screening (Hayes et al. 2012; Dharmar et al. 2016; Hatton et al. 2019). Findings from these remote testing studies provide strong clinical evidence that tele-audiology diagnostic hearing services can be successfully implemented for infant hearing testing. In addition, results also suggest that remote diagnostic testing reduces costs and also reduces loss to follow-up of infants due to easy access to hearing health care for patients who live in remote areas.

The Children’s Hospital at Colorado and the University of Guam successfully conducted a pilot study with nine infants and demonstrated the advantages of tele-audiology diagnostic testing (Hayes et al. 2012). An experienced audiologist from the Children’s Hospital remotely operated the diagnostic equipment in Guam and performed hearing testing with a trained facilitator to set up the equipment. The audiologist conducted auditory evoked potential and OAE testing and also provided counselling and feedback to families. Two infants were identified with hearing loss and were referred to a primary health care provider. Dharmar et al. (2016) evaluated the California tele-audiology program, which provides a remote tele-audiology diagnostic audiological evaluation for children who do not pass their newborn hearing screening. Twenty-two infants who underwent a comprehensive tele-audiology test battery, including case history, video otoscopy, immittance, DPOAE and ABR testing. A paediatric audiologist remotely conducted all the testing with the aid of a facilitator who prepared the infant’s skin, placed electrodes, tympanometry probe and also positioned the otoscope. The team successfully evaluated all the infants and identified 13 children with hearing loss and 60% of those children were identified within the first tele-audiology visit.

In a large-scale study of 102 infants who failed their newborn hearing screening and/or had risk factors for hearing loss, the British Columbia Early Hearing Program (BCEHP) conducted a tele-audiology diagnostic test battery with the help of trained audiometric technicians located at the patient site (Hatton et al. 2019). Overall, the authors found that the tele-audiology diagnostic testing substantially reduced costs for British Columbia’s EHDI program, averting $91,250 in travel cost for 102 infants. In addition, the efficiency for tele-audiology was comparable to in-person testing. Twenty children were identified with permanent hearing loss. Some limitations highlighted in these studies are related to lack of common policies and underdeveloped support infrastructure (e.g. lack of common approach to incident management, and lack of reliable access to IT support and resources) across health facilities. Ramkumar and colleagues (2018) explored remote diagnostic testing for children and adults with cleft lip/palate (n = 160). They identified 22 ears with hearing loss, and the individuals received the diagnosis and recommendations via tele-conference. More coverage for people in need of services was achieved with this approach and internet connectivity was a barrier for only a few. Ramkumar and colleagues (2019) included diagnostic testing for children 0–5 years that failed the remote hearing screening by village health workers. They found that having access to remote ABR testing improved the follow-up rate after a failed screening.

Intervention

There were 18 studies in the intervention category that addressed hearing aid adjustments, cochlear implant testing, tinnitus management, and rehabilitation. There were two hearing aid studies (Novak et al. 2016; Pross, Bourne, and Cheung 2016); six cochlear implant studies (Rodríguez et al. 2010; McElveen et al. 2010; Wasowski et al. 2012; Hughes et al. 2012; Cullington and Agyemang-Prempeh 2017; Slager et al. 2019), four tinnitus studies (Henry et al. 2012; Beukes et al. 2017; Beukes et al. 2018; Henry et al. 2019), and six rehabilitation studies (Thorén et al. 2011; Thorén et al. 2014; Abrams, Bock, and Irey 2015; Brännström et al. 2016; Muñoz et al. 2017; Gomez and Ferguson 2020).

The two hearing aid studies were based on large number of adults (total of 1190 patients) suggest that quality HA fitting including probe-mic verification and adjustment services can be provided remotely using facilitators such as nurses or trained audiology technicians. The five CI mapping studies were mainly for adults and older children, and found remote CI mapping to be feasible and provide identical outcomes to in-person mapping visits. Researchers also highlight that it is important to have alternative communication strategies (video communication for speech reading and sign language or text messaging) during remote mapping sessions. The four tinnitus studies, including two RCT studies, provide strong evidence for tele-intervention options for adult patients with tinnitus. Moreover, all studies clearly support an increased quality of life and reduced tinnitus distress following tele-tinnitus services. However, it is possible that online administration of the survey in studies might have excluded some of the participants.

Hearing aid adjustments

Novak and colleagues (2016) implemented an interprofessional education project using faculty and students in the nursing and Doctor of Audiology programs to provide hearing aid service using a tele-audiology approach. Using remote desktop access and video conferencing, nursing faculty and students facilitated hearing aid (HA) fitting performed remotely by the audiology faculty and students at the remote site. A total of 205 individuals were referred to the tele-audiology clinic and 181 patients were successfully fitted with hearing aids that included probe microphone measures, with nursing conducting probe placement and providing patient education components. The majority of the patients reported significant improvement in their communication and quality of life following hearing aid use.

In a population-based study at the Veterans Health Administration, Pross, Bourne, and Cheung (2016) assessed the effectiveness of tele-audiology for hearing aid services. Among 42,697 veterans who received hearing aids and completed hearing outcome measures 1,009 received remote services and 41,688 received conventional in-person care. Tele-audiology HA fitting and follow-up services included real-time video conferencing between an audiologist and patient which was facilitated by an audiology technician. The audiologist conducted the hearing evaluation, probe mic measurement, HA fitting and adjustment. The authors reported that the tele-audiology model provided cost effective services with HA satisfaction comparable to an in-person service delivery model.

Cochlear implant programing

Two studies, one retrospective (McElveen et al. 2010) and one prospective (Rodríguez et al. 2010) demonstrated the feasibility of remote CI mapping on a small group of adult patients. Rodríguez and colleagues used a program to remotely control the CI mapping system and sucessfully performed 1, 3, 6 and 12 months post-implantation mapping for 7 CI patients. A separate audio-video linkage program was used to facilitate communication between the patient and the audiologist. Both studies reported that tele-audiology is a viable cost-effective option that can be successfully implemented for CI mapping. More importantly, results from both studies confirmed that the post CI mapping outcome (audiological measure) of cHealth and in-clinic patients were comparable.

In a similar study conducted using 23 adults and 6 children, Hughes et al. (2012) showed that CI mapping and audiological measures can be obtained using a tele-audiology platform with a minimally trained assistant without specialised knowledge of audiology and/or CI; however, speech perception measures were poorer in the remote condition as they were not done in a sound booth. One main limitation noted by the authors was related to communication with patients when the CI was connected to the programming interface which makes the CI microphone inactive. They recommended using sign-language or speech reading to communicate in those situations.

A large-scale nationwide study (Wasowski et al. 2012) that included 94 adult CI patients in 8 centres in Poland investigated remote CI mapping using a facilitator. The authors reported that remote mapping improved post-operative care. In another multi-site tele-audiology, Slager and colleagues (2019) evaluated 40 CI subjects (12 years and older) and found tele-audiology mapping to be safe and that it provided similar outcomes in patients’ speech perception ability compared to in-person mapping.

Tinnitus management

Four studies evaluated the effectiveness of remote services for tinnitus management using educational resources and counselling to help manage tinnitus distress. Henry et al. (2012) assessed the feasibility of providing remote tinnitus management for 36 patients with traumatic brain injury. Patients were provided 6 sessions of telephone-based counselling to facilitate therapeutic use of sound and cognitive behaviour training by an audiologist and a psychologist. Results based on the pre- and post- Tinnitus Handicap Inventory outcomes showed positive benefits. In a recent randomised control trial (RCT), Henry et al. (2019) replicated their 2012 study on a large group of patients (n = 205) with special emphasis on patients with traumatic brain injury (TBI). They randomised patients into 6-month remote tele-progressive tinnitus management intervention group or wait list control. Tele-progressive tinnitus management program, involved two telephone appointments with an audiologist who taught how to use the therapeutic sounds and three telephone appointments with a psychologist who taught tinnitus coping skills based on cognitive-behavioural therapy (CBT). Results strongly supported the use of tele-progressive tinnitus management services to patients with bothersome tinnitus.

Two similar studies (Beukes et al. 2017; Beukes et al. 2018) were conducted to explore a remote tinnitus treatment. In their 2017 study, Beukes and colleagues demonstrated the feasibility and cost-effectiveness of remote delivery using a single group study design with 37 adults with tinnitus. Participants reported significant improvements in their quality of life following an 8-week intervention that included continuously guided CBT with audiologist support. Beukes et al. (2018) then conducted an efficacy study with 73 experimental and 73 control group participants. Results showed a significant reduction in tinnitus distress and increased quality of life effect for individuals in the intervention group. The investigators documented a moderate effect size (Cohen’s d = 0.7) for the remote CBT intervention results.

Rehabilitation

Thorén et al. (2011, 2014) evaluated the benefit of tele-audiology rehabilitative intervention for adult hearing aid users. In 2011, Thorén and colleagues compared outcomes of online peer-group discussion, rehabilitative education, and interaction with an audiologist to an active control group. Results indicated positive gains in both groups. Authors developed an intervention that incorporated aspects of both the control and intervention conditions to foster positive behavioural changes in hearing aid users and in their 2014 study, the authors determined the 5-week intervention improved patient outcomes compared to the control group. Recently, Gomez and Ferguson (2020) conducted a randomised intervention trial to study the effectiveness of publicly funded multimedia educational program (C2hearonline.com) for first-time hearing aid users. Significant improvement for the intervention group (n = 24) in self-efficacy and knowledge of hearing aids was observed compared to a control group (n = 23). Abrams, Bock, and Irey (2015) examined the effectiveness of a computer-based auditory training program in improving first time hearing users’ speech perception in noise ability. Results based on comparing scores of clinical speech-in-noise test scores indicated that there were no significant differences between the intervention and control groups.

Finally, one study documented the benefit of virtual visits by an audiologist to monitor children’s hearing aid use with datalogging and to help parents manage their child’s hearing aids (Muñoz et al. 2017). Result based on 6 months of longitudinal data collected on four families showed that the average hearing aid wear time increased from 7 to 10.5 h by the end of the study. Another study explored use of an Internet-based support system for 23 adult hearing aid users to improve self-efficacy and consequences of hearing loss (Brännström et al. 2016). The authors found significant improvement in perceived consequences but no differences for self-efficacy.

Perspective studies

Perspectives of providers, adult patients, parents of paediatric patients, and test facilitators related to tele-audiology services were explored in 22 studies. Two studies sought perspectives related to screening (Ciccia et al. 2011; van Wyk et al. 2019), four related to diagnostics (Hayes et al. 2012; Dharmar et al. 2016; Ramkumar et al. 2016; Hatton et al. 2019), six related to cochlear implants (Rodríguez et al. 2010; Wasowski et al. 2012; Hughes et al. 2012; Kuzovkov et al. 2014; Cullington and Agyemang-Prempeh 2017; Slager et al. 2019), four related to hearing aids (Penteado et al. 2014; Novak et al. 2016; Muñoz et al. 2017; Thrum, Driscoll, and Keogh 2018), and three related to rehabilitation (Brännström et al., 2016; Beukes et al. 2017; Thrum, Driscoll, and Keogh 2018). Three studies sought perspectives of audiologists broadly related to tele-audiology services (Singh et al. 2014; Eikelboom and Swanepoel 2016; Rashid et al. 2019).

Parents of children who underwent tele-audiology screening or diagnostic services expressed a positive experience and advantages of remote testing, especially easy and early access to testing. Patient who participated in remote CI reported an overall positive experience with a high level of satisfaction with the service. However, participants in two studies also reported that they would prefer in-person appointments over remote programming. Patient perspectives for remote hearing aid programming and adjustment revealed that patients were overall satisfied. Studies related to audiologists’ perspectives towards tele-audiology services found that most audiologists had positive attitudes towards tele-practice. However, not all audiologists are currently providing tele-audiology services.

Screening perspectives

van Wyk et al. (2019) evaluated the knowledge and experience of CCWs (n = 15) who performed the hearing screening. Overall CCWs reported a positive experience with community tele-audiology service. The majority of the workers agreed that it was easy to perform hearing screening on adults and children using the mobile technology. Perspectives of parents of children under six years (n = 411; Ciccia et al. 2011) were similarly positive. Parents indicated that they were satisfied and would seek remote screening in the future for their children if it is available.

Diagnostic perspectives

Parent satisfaction following tele-audiology ABR diagnostic testing was high (Hayes et al. 2012; Dharmar et al. 2016; Ramkumar et al. 2016; Hatton et al. 2019) and the majority of the caregivers thought that they could access service providers sooner with tele-audiology (Hatton et al. 2019). Dharmar and colleagues (2016) reported that almost all parents were engaged and comfortable talking about the testing through teleconferencing and providers also reported positive perceptions with the experience. For both parents and providers, however, the response rate was low, 50% and 54% respectively, limiting understanding of the experience for both groups.

Intervention perspectives

Perspectives about remote cochlear implant mapping were positive overall. Wasowski and colleagues (2012) found high patient satisfaction and the overwhelming majority of patients reported that tele-audiology is a good alternative for in-person follow up (86 patients) and that they are willing to use remote mapping in the future (88 patients); however, only 33 patients agreed that tele-audiology is a good alternative for first time CI mapping. Kuzovkov and colleagues (2014) sought perspectives of patients, facilitators and audiologists from 33 remote programming sessions in Italy, Sweden and Russia from 26 CI patients. The authors obtained a positive response for all aspects of CI mapping. Rodríguez and colleagues (2010) obtained positive responses from patients and providers regarding remote mapping. Furthermore, Slager and colleagues (2019) found that patients reported a high level of satisfaction with remote programming of their CI devices and 80% (n = 39) of them also reported that they would recommend remote CI mapping. In the Cullington and Agyemang-Prempeh (2017) study, most patients felt that the remote services were convenient and cost effective; however, 9 out of 17 patients reported that their hearing could be better assessed in the clinic and that it was easier to discuss their difficulties during a clinical visit in person. Similarly, participants in the Hughes et al. (2012) reported that while they would use remote CI services again, they felt they were poorer than in person appointments.

Perspectives related to remote hearing aid services were also positive. Angley, Schnittker, and Tharpe (2017) evaluated perceived benefit of providing tele-audiology HA follow-up appointments with 50 adult HA users. Participants were provided with proprietary distance support hardware and software for remote visits. Results revealed that 80% of distance support appointments were perceived to be as effective as in-person appointments. Overall participants had a positive reaction to remote care, and their satisfaction was greatly increased with the use of a web camera during the in-house appointment. A high-level of patient satisfaction was reported in other studies that employed remote hearing aid fitting, adjustment, and support (Penteado et al. 2014; Novak et al. 2016; Muñoz et al. 2017).

Similarly, perceptions were positive for studies related to rehabilitation. Brännström et al. (2016) evaluated audiologists’ and patients’ perception towards tele-audiology internet support for first time hearing aid users to understand the quality of content, ease of navigation and benefit from the program. Patients in general expressed satisfaction and a positive view towards the support system. Some patients felt that navigating the support system required an advanced level of technological experience. Audiologists however reported that the support system did not address all their patients’ needs. Beukes et al. (2017) assessed patient satisfaction following tinnitus intervention and found that overall rating was high with a mean rating of 4.29 on a 5-point Likert scale. Both patients and audiologists reported high levels of satisfaction with a remote rehabilitation study in Australia (Thrum, Driscoll, and Keogh 2018).

Audiologist perspectives broadly

Three studies surveyed audiologists about their perspectives towards tele-audiology services (Singh et al. 2014; Eikelboom and Swanepoel 2016; Rashid et al. 2019). Singh and colleagues (2014) surveyed 152 audiologists and 49 hearing instrument specialists in Canada using an attitude towards tele-audiology scale for practitioners. Most thought tele-audiology would have a minimal effect on quality and on client-practitioner interactions and a positive effect on accessibility; however, some thought it would have a negative impact on quality. Respondents’ willingness to use remote service delivery was based on type of service, expressing more positive reactions to services that do not require a need to touch the patient (e.g. counselling, minor adjustments).

Based on an online survey, Eikelboom and Swanepoel (2016) found that overall audiologists (n = 269) had positive attitudes towards using tele-audiology to deliver services. However, less than one-quarter of audiologists who responded to the survey reported having used tele-audiology services. A recent survey of audiologists (n = 43) in Malaysia (Rashid et al. 2019) found that about 50% felt that tele-audiology could have an overall positive effect on quality of care, accessibility and their clinical practice. Results also indicated a greater willingness of audiologists to implement tele-audiology if it would improve quality of care, not just accessibility.

Discussion

Access to hearing-health care continues to be a global challenge for large populations that live in remote locations, are not in good health to travel, or those with other factors that interfere with their ability to travel to receive in-person services. With availability of affordable broadband internet, computers, and mobile phones with built in communication accessories (such as a webcam and microphone), tele-audiology is not only feasible, but is becoming more common across the globe. The purpose of this literature review was to (1) to provide information about the characteristics, type of service delivery, participant information and outcomes related to tele-audiology in clinical popluations, and (2) to describe documented facilitators and barriers to tele-audiology delivery from the perspectives of practitioners and service recipients. This information can assist hearing care professionals in considering opportunities to expand tele-audiology services within their practice.

Based on our review, several research groups have successfully implemented tele-audiology screening using community health workers in remote places that have limited healthcare resources. The key advantage of any community- based health-care program that utilises locally existing resources is the sustainability and cost effectiveness of the program. Minimally trained health workers and school teachers can be employed to successfully screen large populations of adults and school children using smart-phone based hearing screeners. Screening devices with built-in quality control measures such as monitoring ambient noise levels and detecting false alarm rates have shown to improve the sensitivity of screening results. Community health workers can also be trained to perform OAE screening for infants and assist in preparing babies for cHealth ABR testing (Ramkumar et al. 2019). Global implementation of tele-audiology community screening programs are crucial for early identification and management of hearing disorders, particularly for those living in remote rural and underserved areas.

No recent studies were identified in our review on tele-audiology diagnostic hearing assessment for older children and adults. Studies on clinical populations are clearly warranted before recommending tele-audiology diagnostic hearing threshold estimation without audiometric sound treated rooms. However, several included studies have successfully implemented cHearing diagnostic evaluation for infants to address the loss to follow-up after a failed newborn hearing screening. CDC (2017) summary of Early Hearing Detection and Intervention (EHDI) hearing screening and follow-up survey data suggest that 34.8% of infants (n = 21,872) who did not pass hearing screening in the United States did not have a diagnostic evaluation documented with their state EHDI program. Remote infant diagnostic testing is an opportunity to reach more children within the timeframe benchmarks described in the Joint Committee on Infant Hearing Position Statement (JCIH 2020). The feasibility study by Canada’s British Columbia Early Hearing Program can serve as a model for implementing tele-audiology diagnostic services for infants (Hatton et al. 2019). Recent advances in automated CE-Chirp ABR/ASSR show promise in providing objective interpretation of results to obtain faster and accurate estimates of hearing threshold in infants (Sininger et al. 2018), and are an area in need of further research for tele-audiology opportunities, including comparing traditional click and toneburst ABR with novel stimuli (e.g. chirp).

An area in rehabilitative audiology with significant potential for tele-audiology is remote fitting and programming of hearing aids and cochlear implants. Remote hearing aid adjustment has been increasingly popular with major HA manufacturers who have a built-in capability for tele-audiology within their fitting software to remotely adjust hearing aid settings. Several clinical validation studies related to this topic were included in this systematic review. Large-scale validation studies found that tele-audiology aid fitting and follow-up services were as effective as in-person appointments (Pross, Bourne, and Cheung 2016; Novak et al. 2016). After initial CI mapping or HA verification appointment with an audiologist, much of the fine-tuning and programming of these devices can be done remotely with the aid of a smartphone/computer. Remote programming of the Nucleus cochlear implant is currently approved by the FDA in the United Stated for patients 12 years or older. Based on current research evidence, remote mapping of CI and programming of HAs can be a safe and efficient option for adult patients. The number of tele-audiology HA and CI programing studies that have included children under the age of 18 years are limited and further research is needed before considering remote paediatric applications for tele-audiology.

Tinnitus is the most common service-related disability in the United States veterans and the incidence of tinnitus associated with mild TBI is up to 75.7% (Oleksiak et al. 2012). Tinnitus is not only widespread in veterans, but also in the general public. Randomised control studies focussed on tinnitus intervention strongly support the use of tele-audiology intervention. tele-audiology guided cognitive behaviour therapy (CBT)/progressive tinnitus management (PTM) was found to be an easily accessible and clinically effective tinnitus intervention for large number of adults suffering from tinnitus. cHealth CBT intervention has been incorporated by psychologists in regular clinics in Sweden for quite some time now (Kaldo et al. 2013). Recent studies in this review; however, demonstrated feasible and effective collaboration opportunities for audiologists and psychologists in providing comprehensive tinnitus management.

Aural rehabilitation to individuals with hearing loss and assistance to parents of children who are deaf or hard of hearing (DHH) is another area where tele-audiology services can play a significant role in improving the quality of life for individuals. Many older hearing-aid users need training and counselling to maximise the benefits from hearing devices. Tele-audiology rehabilitative studies designed for hearing aid users have consistently shown positive consequences, including improved hearing aid satisfaction and improved quality of life for patients (e.g. Gomez and Ferguson 2020; Thorén et al. 2014). Clinicians implementing remote rehabilitation services may consider including the following elements; (a) providing engaging education materials related to hearing loss and self-management of hearing aids/assistive listening devices, (b) strategies to help adjust to new hearing-aids and (c) online support groups for first time hearing aid users. Even though most studies included in our review were focussed on adult hearing-aid users, similar tele-audiology services can be easily adopted to benefit CI users, and parents of children who are DHH. One study showed that using a virtual audiologist significantly improved the hearing aid wear time with children (Muñoz et al. 2017).

Further research is needed to investigate the benefits of individual elements of tele-audiology rehabilitative services, especially in the paediatric population. Furthermore, there is increasing evidence showing the link between hearing loss and cognitive decline in older adults (e.g. Lin et al. 2013), underscoring the importance of implementing accessible rehabilitation options for this population. Additionally, studies are needed that evaluate the benefits of tele-audiology audiological rehabilitation services on addressing the social and psychological consequences of hearing loss.

A limitation to the expansion and widespread use of tele-audiology services, at least in the United States, has been reimbursement for services as most insurance agencies and Medicare/Medicaid have not considered Audiologists as eligible providers of tele-audiology services (American Speech-Language-Hearing Association 2020). Furthermore, the lack of reciprocity between states for licensure makes it difficult to provide tele-audiology services to patients who live in other states without dual licensure. Rapid changes in healthcare accessibility and increased demands for tele-audiology services require changes in current policies and procedures at state and federal levels. With the current COVID-19 emergency, policies that impact tele-audiology are rapidly evolving along with innovative telepractice solutions for providing hearing health care for vulnerable populations. For example, in the United States health plans such as Medicare and Medicaid services have significantly broadened their coverage for telepractice services including reimbursement (Center for Medicare and Medicaid Services 2020, Centers for Disease Control and Prevention 2020). Similarly, the Australian government has added teleaudiology services to their Medicare system to provide person centred care (Audiology Australia 2020). Widespread adoption of teleaudiology services due to COVID-19 has provided hearing health care professionals with an opportunity to reimagine service delivery models to incorporate synchronous and asynchronous hearing services.

Conclusion

Hearing healthcare service delivery is expanding with the changing technological landscape, providing greater opportunities and flexibility for providers and patients. Remote service delivery can increase access to lifechanging services for individuals living in underserved areas and those who experience other barriers to attending clinic appointments. Opportunities for interdisciplinary collaboration abound, improving continuity of care, as demonstrated in recent tinnitus studies. Additionally, there are opportunities for collaboration with on-site local facilitators. Local facilitators, with training, can assist in connecting individuals to follow-up care, provide educational support, and needed hands-on assistance for specialised testing.

Disclosure statement

No potential conflict of interest was reported by the author(s).