AUDIOLOGY IN

UNITED STATES OF

AMERICA - By Ross Roeser, 2016

USA

Population: 324 million(2016 Estimate) Area: 3,535,111 square miles GDP(PPP): $18.558 trillion(2016 Estimate) Currency: US Dollars (1 USD = 1.00 US Dollars) Languages: English (Official)

ABOUT AUTHOR

Director Emeritus of The University of Texas at Dallas /Callier and Clinical

Professor in Department of Otorhinolaryngology/

Head and Neck Surgery at UT Southwestern Medical

Center.

Table of Contents Demographic Information ................................................................................ 1

History of audiology/ aural care .....................................................................2

Hearing loss incidence and prevalence ......................................................... 3

Information about audiology .......................................................................... 4

Education ................................................................................................................... 4

Services offered by Otolaryngologists, Otologist's & Otoneurologists ........ 6

Audiological services ............................................................................................... 6

Professionals ............................................................................................................. 8

Research in Audiology ............................................................................................ 8

Professional and Regulatory bodies .............................................................. 9

Scope of Practice and Licensing .................................................................... 10

Audiology charities ........................................................................................... 10

Acknowledgements ........................................................................................... 11

References ........................................................................................................... 11

Author information .......................................................................................... 13

1

DEMOGRAPHIC INFORMATION

The United States of America is the third most populous nation, with greater than 320 million

people, and is the third largest in total area (3,796,742 square miles/ 9,833,517 km2). The

United States consists of fifty states, a federal district, and various territories. The forty- eight

continental United States and the District of Columbia are located between Canada and Mexico

in the central portion of North America. Alaska, the largest state by land area, is located to the

northwest of the contiguous United States. Hawaii, an island chain, is located in the Pacific

Ocean. The territories controlled by the U.S. are dispersed throughout the Pacific and the

Caribbean. The United States is known as a “melting-pot” as it is a nation of many diverse

cultures, languages, and religions ("United States," 2016)

Table 1: Country information (source Wikipedia)

Country name United States of America Population 324,045,364 (2016 Estimate) Area 3,796,742 Sq. miles/ 9,833,517 km2 GDP (PPP) $18.558 trillion (2016 estimate) Languages English

Many of the founders of the United States had left Europe due to religious persecution. The

United States Constitution explicitly protects the right of free expression, and therefore the

Federal Government is prohibited from declaring a national religion or language. English is

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considered to be the primary language because approximately 80% of households only speak

English. Spanish is the second most common language with approximately 12% of households

speaking primarily Spanish. Many other languages from around the globe are actively spoken

throughout the nation ("United States," 2016).

Christianity is the most commonly practiced religion in the United States. However, Judaism,

Islam, Buddhism, Hinduism, and many other faiths are also practiced ("United States," 2016).

The United States is a relatively young nation, at just 240 years. Nevertheless, the U.S. has

developed its own unique culture.

HISTORY OF AUDIOLOGY/ AURAL CARE The history of American Audiology is full of fascinating stories of collaboration, complex

research, and innovative thinking. Audiology is a relatively young profession, which is rapidly

gaining attention in America due to the aging population.

Audiology in the United States truly took its modern form during and after World War II. There

were a significant number of soldier returning home with hearing loss who needed

rehabilitation. The development of three major military centers are the initial vehicle of the

aural rehabilitation programs. Near the end of the war, returning Army soldiers were

designated to one of three major rehabilitation programs where they and a loved one were

taught about hearing loss, coping strategies, and communication strategies. In September of

1946 the rehabilitation centers were closed and hearing care for veterans was turned over to the

Department of Veterans Affairs. The V.A. became a leader in developing evaluation and

treatment protocols.

When hearing aid technology began to flourish, audiologists took on a role of diagnostician, as

audiologists were not able to dispense hearing aids. During this time period, patients would see

an audiologist for a diagnostic evaluation and then would see a hearing aid specialist if hearing

aids were recommended. It was not until 1979 that audiologists outside of the V.A. were allowed

to dispense hearing aids.

The advent of clinical electrophysiology equipment, and the discovery of otoacoustic emissions

(OAEs) led to significant changes in the practice of audiology. Early electrophysiology

equipment was used to establish the first newborn hearing screening program in Colorado in

1962. As previously mentioned, OAEs and auditory brainstem responses are currently used for

newborn hearing screenings. The implementation of newborn hearing screenings has allowed

for pediatric audiology to flourish as children with hearing loss are being identified earlier. The

increased attention to pediatric audiology has led to significant advances in amplification, both

hearing aids and cochlear implants.

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The American Speech Language Hearing Association has been providing standards and

certifications for audiologists and speech language pathologists since 1952 ("American Speech-

Language-Hearing Association," 2016). A small group of audiologists, who were dissatisfied

with ASHA’s representation of the profession, banded together to develop the American

Academy of Audiology in 1988 ("American Academy of Audiology," 2016). The creation of two

major professional organizations has been challenging in some instances, but has propelled the

field forward.

HEARING LOSS INCIDENCE AND PREVALENCE (Disorders, 2016)NIH: 2-3 of every 1,000 births= “detectable hearing loss in one or both

ears”

15% over 18 (37.5 million) report some trouble hearing.

“About 2 percent of adults aged 45 to 54 have disabling

hearing loss. The rate increases to

8.5 percent for adults aged 55 to 64. Nearly 25 percent of

those aged 65 to 74 and 50 percent of those who are 75

and older have disabling hearing loss.”

10% (25 million) adults “has experienced tinnitus lasting

at least five minutes in the past year.”

“Among adults aged 70 and older with hearing loss who

could benefit from hearing aids, fewer than one in three

(30 percent) has ever used them. Even fewer adults aged

20 to 69 (approximately 16 percent) who could benefit

from wearing hearing aids have ever used them”

December 2012: 324,200 CI worldwide, US Adults:

about 58,000, kids: about 38,000 5/6 kids have otitis

media by age 3.

(Prevention, 2015)CDC: 0-4.6 per 1000 babies screened. In 2013 97% of newborns were

screened- 1.6% did not pass final or most recent screening

69% of refers were diagnosed or not by 3 months. In 2013 87.3% of diagnosed were

referred for ECI services

50-60% genetic; 20% have a syndrome

30% infection during pregnancy, environmental, complications after birth

The implementation of newborn hearing screenings and early childhood intervention (ECI)

services have led to a greater understanding of the prevalence of hearing loss in children. The

National Institute of Deafness and Other Communication Disorders (NIDCD) indicates that

hearing loss is identified in 2-3 newborns out of every 1,000 births in the U.S. (Disorders, 2016).

The Centers of Disease Control and Prevention (CDC) indicates a range of 0-4.6 per 1,000

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babies who received a newborn hearing screening. The CDC reported that in 2013, 97% of

newborns were screened for hearing loss. 1.6% of newborns screened did not pass their final or

most recent screening. By three months of age, 69% of the infants that did not pass a newborn

hearing screening had received a diagnosis regarding the presence or absence of hearing loss.

In 2013, 87.3% of infants that were diagnosed with hearing loss were referred for ECI services.

The CDC reports that 50-60% of congenital hearing loss stem from a genetic component. Of the

50-60% of genetic hearing losses, 20% of the children have a co-occurring syndrome. 30% of

hearing loss that is not genetic in nature arise from infection during pregnancy, environmental

factors, or complications after birth (Prevention, 2015). According to the NIDCD, 5 out of 6

children in the U.S. have experienced otitis media by the age of three (Disorders, 2016). After

the newborn hearing screening, children receive audiologic services based on medical need or

parental desire. All children are typically screened at regular intervals upon entering public

school systems.

The prevalence of hearing loss in adults is more difficult to estimate than in children. The

NIDCD estimates that approximately 15% (37.5 million) of American adults report some

difficulty with hearing. The number of adults with a “disabling hearing loss” increases with age,

with a projected 50% of individuals aged 75 and older having a disabling hearing loss. That

being said, only about 30% of adults aged 70 and older who could benefit from a hearing aid

have tried one. The percentage of younger adults (20-69 years) who could benefit from hearing

aids and have tried them is approximately half of the 70 and over cohort (Disorders, 2016).

INFORMATION ABOUT AUDIOLOGY EDUCATION

The education requirements for

audiologists have recently undergone

significant modifications. In 2012 the

standard degree required for the practice of

audiology in the U.S. became the Doctorate

of Audiology (Au.D.). Previously a Master’s

degree was an acceptable level of education

for audiologists. Audiologists who were

already practicing with a Master’s degree

were allowed to continue to practice; many

have since obtained the Doctorate of

Audiology. 74 universities in the United

States offer an Au.D. program.

The Doctorate of Audiology requires both classroom and clinical learning experiences. Most

Au.D. programs are four years in length; which include three years of classes and one year of

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externship. During the three years of academic work, students are required to take a wide

variety of classes including: anatomy and physiology, hearing science, amplification, courses

related to research in the field, etc. Depending on university policy, classes and local clinical

rotations may occur concurrently. Most programs provide some level of clinical experience

before students accept an externship position. The externship year allows students to become

apprentices to audiologists already working in the field. Students are still required to be

enrolled in their Au.D. program during externship. Students typically apply for a position (as

if applying for a job), and undergo an interview process. Upon completing the externship

requirement, students return to their university for graduation.

Many universities offer four year undergraduate degrees which focus on both audiology and

speech language pathology. These programs require students to attend classes regarding to

both professions, as they are closely related. The undergraduate programs often help students

to determine which of the professions they are interested in. An undergraduate degree related

to audiology or speech pathology is not required to enter an Au.D. program, though some

prerequisite classes are required.

For students with an interest in research, many universities offer a Doctor of Philosophy under

their audiology program. Some universities allow interested students to concurrently complete

Au.D. and Ph.D. degree plans.

For a comprehensive list of Doctor of Audiology programs in the U.S. see the following link:

http://www.audiology.org/education-research/education/doctoral-programs-audiology

Audiology Practice: Public Vs Private

In the United States, audiologic care is considered to be a public service, in that any individual

who wishes to seek care may do so. However, the provider may or may not be contracted (for

the desired services) with the patient’s health insurance carrier. If the patient chooses a

provider who is not contracted, the patient must pay out of pocket for the services.

Most health insurance plans require a referral from a primary care provider in order for the

patient to receive audiology and/or otolaryngology services. This process attempts to ensure

that one medical professional manages much of the patient’s healthcare. Due to the need for

referrals, the primary care physician is often the first medical professional to address hearing

concerns for adults. Some offices will conduct a hearing screening, others will refer the patient

to an audiologist and/or otolaryngologist based on the nature of the patient’s concern.

Patients are encouraged to see an otolaryngologist in addition to seeing an audiologist in hopes

of providing comprehensive hearing care. The otolaryngologist can provide medical clearance

for amplification, and can offer guidance for individuals who could benefit from medical

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management of hearing related pathologies. Patients over the age of 18 can elect to forego the

process of obtaining medical clearance from an otolaryngologist.

The path to receiving audiologic care can be quite different for adults and children. Newborn

hearing screenings are typically completed before a baby departs from the hospital. If the baby

passes the newborn screening, they are to be monitored by parents and pediatricians. If a baby

is referred for follow-up testing, they can be re-screened at a designated interval and/or

diagnostic evaluations may take place. Children in public schools are also screened periodically

by a trained staff member.

As previously mentioned, health insurance plans dictate which services and/or devices are

covered. Some plans assist with the cost of hearing aids, while many others do not provide this

benefit. Office visits related to hearing aids are typically not covered by insurance, unless the

fees are bundled with the price of the devices. Cochlear implants and office visits can be covered

by insurance with restrictions.

For patients who cannot afford the costs related to amplification, it is common for larger

institutions to establish charity programs. In some locations, community hearing screenings

and educational sessions are also available for these patients.

SERVICES OFFERED BY OTOLARYNGOLOGISTS, OTOLOGIST'S &

OTONEUROLOGISTS

Otolaryngologists in the United States offer a diverse selection of ear related services. Services

may include: diagnosis and management of acute and chronic pathologies, balance disorders,

traumatic injuries, and congenital malformations; surgical management of pathology, tumors,

and implantable devices. The most common surgical implants available are cochlear implants,

bone anchored hearing aids and middle ear implants. It is becoming more common for small

procedures, such as the placement of PE tubes for adults, to be completed in the

otolaryngologist’s office. Depending on comfort level, many will also provide, in the office,

inter-tympanic steroid injections for the treatment of sudden sensorineural hearing loss.

AUDIOLOGICAL SERVICES

Audiologists in the U.S. can work in a variety of settings, which may include very different

responsibilities. However, the available services can vary widely between clinics and

professionals. The major career paths available to American audiologists are as follows:

Otolaryngology Office: Audiologists who work with otolaryngologists are typically

involved in the diagnosis and management of hearing and balance disorders. This may or

may not include the dispensing of hearing aids. Depending on the services offered by the

otolaryngologists, they may also be involved in the mapping of cochlear implants, and the

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programming of other surgical implants. Often these audiologists provide monitoring

services throughout the course of medical management.

Private Practice: Private practice audiologists are generally known for diagnosing hearing

loss and dispensing hearing aids. However, private practices can offer many more services.

Some offer specialized testing and management for tinnitus, vestibular, and auditory

processing disorders. Cochlear implant mapping can also be included.

University Clinic: Clinics housed within

a university can often provide more

resources than can be found in the general

community. As teaching facilities,

university clinics attempt to provide

students with well-rounded experiences.

This can lead to the provision of a multitude

of services including: hearing and

vestibular diagnostics, amplification

(hearing aids and/or cochlear implants),

tinnitus management, cerumen

management, and aural rehabilitation.

Hospital/ Medical Center: Hospitals and medical centers can provide more specialized

service (e.g. sedated electrophysiological testing) than other clinic locations. Hospitals with

maternity wards and neonatal intensive care units (NICU) are required to offer newborn

hearing screenings. Ototoxicity monitoring programs are also common in hospitals that

provide oncology services, especially for children. Intraoperative monitoring can be

conducted by audiologists during surgical procedures.

Department of Veterans Affairs: Veterans Affairs Medical Centers offer comprehensive

audiological services to American Veterans. In order to provide equitable care around the

nation, the Department of Veterans Affairs has developed protocols for each type of service.

Under certain qualifications, Veterans can receive amplification at no cost to the patient.

The V.A. is also known to use group service delivery models for hearing aid orientation and

tinnitus management, among others.

Industry: Industrial audiologists play a key role in ensuring compliance to occupational

regulations regarding noise exposure. Industrial audiologist take measurements of work

environments, screen employees for work related noise induced hearing loss, and provide

hearing protection.

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Educational Institution: Educational audiologists provide audiological services to school

children. These services typically include FM set-up and maintenance, advocacy for students

with hearing loss, provision of loaner hearing aids, and functional listening tests.

PROFESSIONALS

The table below shows the professionals who regularly interact with individuals with hearing

loss. The ratios are estimates calculated based on the population of 324,045,364 ("United

States," 2016). As previously mentioned, primary care practitioners are often the first to

encounter patients with hearing loss. However, there are disproportionately fewer hearing care

professionals to whom primary care professionals can make referrals.

Table 2: Ear and hearing care professionals in the United States of America

Professionals Approximate number Ratio to the population

Audiologists 12,070 (Statistics, 2016a) 1:26847

Otolaryngologists 8600 (Kim, Cooper, & Kennedy, 2012) 1:37680

Neurotologists 351 1:922664 (Audiology, 2014)

Physician Assistants 94,400 (Statistics, 2015a) 1:3433

Nurse Practitioner 136,060 (Statistics, 2016c) 1:2382

Physicians 708,300 (Statistics, 2015b) 1:457

Speech-Language

Pathologists

131,450 (Statistics, 2016d) 1:2465

Hearing Aid

Specialists

5,920 (Statistics, 2016b) 1:54737

RESEARCH IN AUDIOLOGY

Research in audiology is highly active in the United States. Most research is conducted through

educational facilities and large research driven institutions. Current works span the entire

scope of audiological practice.

Though there is a plethora of research being conducted, there is still much to be learned about

the auditory system, (re)habilitative devices, the (re)habilitation process, and many other topics.

The ever increasing literature collection improves the ability for audiologists to conduct

evidence based practice.

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Currently, American audiology research is headlined by studies of correlation between hearing

loss and cognition, noise induced hearing loss, tinnitus, and long-term outcomes of cochlear

implantation.

There are several peer-reviewed audiology related journals published in the United States.

Providing audiologists with peer-reviewed research from around the world is an important part

of growing the profession within the U.S. and beyond.

The American Journal of Audiology (AJA) has been published by ASHA since 1991. Currently,

the journal is only published online. AJA reports that in 2014 the journal had an impact factor

of 1.280 ("About AJA,").

The Journal of the American Academy of Audiology (JAAA), established in 1990, transitioned

to an online format in 2011. The journal publishes ten issues each year for its members("Journal

of the American Academy of Audiology," 2016). In 2015 JAAA had an impact factor of 1.24

("Journal of the Amercian Academy of Audiology," 2016).

PROFESSIONAL AND REGULATORY BODIES There are several professional organizations available to audiologists in the United States. As

previously mentioned the primary organizations are: The American Academy of Audiology

(AAA) and the American Speech-Language-Hearing Association (ASHA).

The American Academy of Audiology was founded in

1988 by a small group of audiologists. AAA now boasts a

membership of over 12,500 audiologists. AAA is an

organization that encourages integration of scientific

research with clinician experience to optimize the

patient experience ("American Academy of Audiology,"

2016). Each year, AAA hosts a large convention for

fellows to be exposed to the newest research and

technology. Students are also allowed to attend these conferences as attendees and/or to

present student research. The Student Academy of Audiology has been charted under AAA to

provide students to the same resources as practicing audiologists.

The American Speech-Language- Hearing Association has been a leading organization in

communication sciences and disorders since the 1920s. ASHA encourages evidence based

practice and interdisciplinary cooperation. ASHA has greater than 186,000 members, however,

this accounts for audiologists and speech language pathologists. ASHA’s annual conference

features speech pathology and audiology exhibits. The National Student Speech Language

Hearing Association provides graduate and undergraduate students with the benefits of ASHA

membership.

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The Certificate of Clinical Competence in Audiology (CCC-A) is available through ASHA to

clinicians who complete rigorous continuing education requirements and train under other

certified audiologists.

Both organizations offer accreditation of educational programs. This encourages Au.D.

programs to provide high quality academic and clinical experiences.

SCOPE OF PRACTICE AND LICENSING

The American Academy of Audiology (AAA) and the American Speech-Language-Hearing

Association (ASHA) each provide an explicit statement of the scope of practice for audiology.

In addition, each provide guidelines for clinical services. The federal government does not

provide guidelines to ensure the equity of care.

Licensing of audiologists is maintained at the state level. Each state has different requirements

to obtain and maintain a license to practice audiology. Also, it is common for states to require

a separate license to dispense hearing aids. Some states require a written exam and/or a

practical exam in order to obtain licensing. Most states accept the Praxis Examination in

Audiology as a display of professional competence. The Praxis exam is typically taken between

the completion of graduate coursework and the first year of independent clinical practice.

Each state also has different requirements for continuing education in order to maintain a valid

license.

AUDIOLOGY CHARITIES The following are a few of the many highly active

audiology related charities:

Alexander Graham Bell Association for the

Deaf and Hard of Hearing: http://nc.agbell.org

American Academy of Audiology Foundation:

http://www.audiologyfoundation.org/

American Cochlear Implant Alliance:

http://www.acialliance.org

American Tinnitus Association:

http://www.ata.org

Hearing Charities of America: http://hearingcharities.org/

Hearing Health Foundation: http://hearinghealthfoundation.org/

Hearing Loss Association of America: http://www.hearingloss.org/

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Lions Club International Hearing Aid Recycling Program:

http://members.lionsclubs.org/EN/serve/hearing/hearing-aid-recycling.php

Challenges, opportunities and notes

Public awareness of hearing loss and the negative stigma attached to hearing loss pose a

significant challenge to providing audiology services. Improving public awareness will

require a multidisciplinary approach.

There is a disproportionately low number of audiologists for the growing American

population.

Providing services in rural areas is also difficult. Many patients have to travel long distances

to receive specialty services.

Currently, there are limited measures to ensure the equity of care around the nation.

ACKNOWLEDGEMENTS Rebecca Rogers, currently a Doctor of Audiology student at the University of Texas at

Dallas/Callier Center for Communication Disorders, helped to prepare this information.

REFERENCES About AJA. Retrieved August 15, 2016, from http://aja.pubs.asha.org/ss/aboutaja.aspx

American Academy of Audiology. (2016). Retrieved August 8, 2016, from

www.audiology.org

American Speech-Language-Hearing Association. (2016). Retrieved August 8, 2016, from

www.asha.org

Audiology, A. A. o. (2014). Too Many Neurotologists? In the News. Retrieved August 8, 2016,

from http://www.audiology.org/news/too-many-neurotologists

Disorders, N. I. o. D. a. O. C. (2016, June 17, 2016). Quick Statistics about Hearing.

Retrieved July 25, 2016, from https://www.nidcd.nih.gov/health/statistics/quick-statistics-

hearing#7

Journal of the Amercian Academy of Audiology. (2016). Retrieved August 15, 2016, from

https://www.researchgate.net/journal/1050-

0545_Journal_of_the_American_Academy_of_Audiology

Journal of the American Academy of Audiology. (2016). Retrieved August 15, 2016, from

http://www.audiology.org/publications/about-journal-american-academy-audiology

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Kim, J. S. C., Cooper, R., & Kennedy, D. (2012). Otolaryngology- Head and Neck Surgery

Physician Work Force Issues: An Analysis for Future Specialty Planning. Otolaryngology-

Head And Neck Surgery, 146(2).

Prevention, C. f. D. C. a. (2015, December 18, 2015). Hearing Loss in Children: Data and

Statistics.RetrievedJuly 25, 2016, from

http://www.cdc.gov/ncbddd/hearingloss/data.html

Statistics, U. S. B. o. L. (2015a, December 17, 2015). Physician Assistant. Occupational

Outlook Handbook. Retrieved August 8, 2016, from

http://www.bls.gov/ooh/healthcare/physician-assistants.htm

Statistics, U. S. B. o. L. (2015b, December 17, 2015). Physicians and Surgeons. Retrieved

August 7, 2016, from http://www.bls.gov/ooh/healthcare/physicians-and-surgeons.htm

Statistics, U. S. B. o. L. (2016a, March 30, 2016). Occupational Employment Statistics:

Audiologists. Retrieved August 8, 2016, from

http://www.bls.gov/oes/current/oes291181.htm#(1)

Statistics, U. S. B. o. L. (2016b, March 30, 2016). Occupational Employment Statistics:

Hearing Aid Specialists. Retrieved August 8, 2016, from

http://www.bls.gov/oes/current/oes292092.htm

Statistics, U. S. B. o. L. (2016c, March 30, 2016). Occupational Employment Statistics:

Nurse Practitioners. Retrieved August 8, 2016, from

http://www.bls.gov/oes/current/oes291171.htm

Statistics, U. S. B. o. L. (2016d, March 30, 2016). Occupational Employment Statistics:

Speech-Language Pathologists. Retrieved August 7, 2016, from

http://www.bls.gov/oes/current/oes291127.htm

United States. (2016, July 24,2016). Retrieved July 25, 2016, from

https://en.wikipedia.org/wiki/United_States

Useful Links

American Academy of Audiology: www.audiology.org

American Speech-Language-Hearing Association: www.asha.org

American Board of Audiology: http://www.boardofaudiology.org/

Centers for Disease Control and Prevention: http://www.cdc.gov/

International Journal of Audiology: http://www.internationaljournalofaudiology.com/

National Institute of Health: https://www.nih.gov/

World Health Organization (W.H.O): http://www.who.int/en/

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AUTHOR INFORMATION Dr. Roeser holds the Lois and Howard Wolf Professorship in

Pediatric Hearing in the School of Behavioral and Brain Sciences, and

is Director Emeritus of The University of Texas at Dallas/ Callier

Center for Communication Disorders in Dallas, Texas. He is also

a Clinical Professor in the Department of Otorhinolaryngology/Head

and Neck Surgery at UT Southwestern Medical Center. He is the

founding Editor-in-Chief of Ear and Hearing and is currently the

Editor-in-Chief of the International Journal of Audiology and has

contributed to multiple publications to the audiological literature.

Email: roeser@utdallas.edu

Tel: +1 (214) 905 3116