By Craig W. Newman, PhD; Sharon A. Sandridge, PhD; and Sarah A. Sydlowski, AuD, PhD

Shared medical appointments (SMAs) are gaining recognition in the healthcare arena as a cost- and time-efficient way to conduct office visits. SMAs allow clinicians to deliver the same information to multiple patients at the same time, thereby maximizing available resources in a busy clinical practice. From a patient’s viewpoint, SMAs allow individuals to realize that others are coping with the same chronic condition and similar quality-of-life issues. Moreover, patients can learn management strategies from fellow patients as well as clinicians.

Small-Group Sessions

The Section of Audiology in Cleveland Clinic’s Head & Neck Institute has capitalized on the benefits of SMAs through our Tinnitus Management Clinic (TMC). The primary goal of the TMC is to equip patients with the knowledge and tools that will help them overcome tinnitus-related psychosocial problems (e.g., anxiety, depression, inability to participate in everyday work and recreation) and physical difficulties (e.g., sleep deprivation, muscular tension). Because this chronic, bothersome condition has multiple underlying causes, we take a multidisciplinary team approach that involves specialists in five areas.

Six patients participate in each monthly SMA, which we began offering in June 2007. Once patients receive medical clearance from an otolaryngologist and undergo examination by an audiologist, they are scheduled for a three-hour group appointment. Each SMA includes a 90-minute group education session followed by rotating individual 15-minute visits with two audiologists, a dentist, a neurologist, a physical therapist and a psychologist.

What Happens in the Group Education Session?

Each member of the clinical team participates in the group education session and uses a PowerPoint presentation to guide the flow of the session. The information presented is geared toward increasing patients’ understanding of tinnitus and their knowledge of the management strategies to be offered by each SMA team member. Specific objectives include:

• Clarifying misconceptions about tinnitus (e.g., will I go deaf because of my tinnitus?)
• Demystifying tinnitus by providing simple explanations about its underlying mechanisms and the anatomy and physiology of the auditory system
• Describing common psychosocial reactions to tinnitus
• Offering practical suggestions and techniques that may provide patients with immediate relief
• Providing hope for future management options

At the beginning of the session, one of the audiologists explains the ground rules and the need for strict confidentiality outside the room. Then the patients are encouraged to share their experiences about their tinnitus. The clinicians take care to control this part of the session so that no single patient dominates.

What Happens in the Individual Sessions?

Each specialist conducts a short screening assessment to determine if a more thorough follow-up visit is necessary later:

• The audiologists review and demonstrate various sound therapy options for tinnitus relief.
• The dentist screens for specific dental problems, including temporomandibular disorders.
• The neurologist screens for potential neck/cervical disorders that may be related to somatic tinnitus.
• The physical therapist screens for problems associated with neck, spine, jaw or shoulder injuries, or strains caused by job requirements or poor posture.
• The psychologist screens for depression/anxiety disorders and introduces the importance of the mind-body connection.

What Happens After the Patients Leave?

After the patient sessions conclude, the clinical team gathers to discuss each patient’s case and provide recommendations. A summary of each specialist’s findings is mailed to each patient, along with a consensus treatment plan that includes specific recommendations for follow-up. Subsequent management may include one or more of the following options

• Sound therapy incorporating use of hearing aids/sound generators/combination units
• Bite modification appliances
• Cognitive behavioral therapy/acceptance therapy
• Further medical management
• Physical therapy

Is There Evidence that the SMAs Work?

Following each SMA, questionnaires are mailed to the participating patients to assess the benefits they gained from their experience. The primary outcome measure is the Tinnitus Handicap Inventory (THI). The THI is used to evaluate how tinnitus limits patients’ daily activities.

We recently mailed questionnaires along with the THI to a sample of patients. Among the 63 patients who returned questionnaires, 69 percent experienced a clinically significant reduction in perceived disability/handicap by attending the TMC, as reflected in their THI scores. Of that group, 96 percent reported receiving some benefit from attending the SMA (Figure). Moreover, all those who knew someone with tinnitus said they would recommend the TMC to them.

Building on Success: SMAs for Cochlear Implant Recipients

Our experiences in the TMC have given us confidence that the SMA model can be applied to other areas of audiologic care in which self-management is critical to success.

We will soon expand the scope of our audiology SMAs to include a separate session for cochlear implant recipients. Just as we do for tinnitus patients, we will give implant recipients the chance to share experiences and benefit from the questions of others with a similar degree of hearing loss. We will also review the use, care and maintenance of the implants and discuss other therapy options. Patients will also receive written materials and video demonstrations. Finally, development of a cochlear implant SMA will lower costs by minimizing nonbillable activities and streamlining counseling.

Dr. Newman (newmanc@ccf.org) is Section Head of Audiology and Co-Director of the Audiology Research Laboratory

Dr. Sandridge (sandridges@ccf.org) is Director of Clinical Audiology Services and Co-Director of the Audiology Research Laboratory.

Dr. Sydlowski (sydlows@ccf.org) is Audiology Director of the Hearing Implant Program.