Global Audiology/Americas/USA

The United States of America is the third most populous nation, with more than 320 million people, and the third largest in total area (3,796,742 sq. miles or 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).

Many of the founders of the United States had left Europe due to religious persecution. The United States Constitution explicitly protects the right to free expression, and therefore the federal government is prohibited from declaring a national religion or language. English is 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 old. Nevertheless, the U.S. has developed its own unique culture.

The implementation of newborn hearing screenings and early childhood intervention (ECI) services has 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 for Disease Control and Prevention (CDC) indicate a range of 0-4.6 per 1,000 babies who receive 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 stems 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 arises 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).

History
The history of American audiology is full of fascinating stories of collaboration, complex research, and innovative thinking. Audiology is a relatively young profession that 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 soldiers returning home with hearing loss who needed rehabilitation. The development of three major military centers was the initial vehicle for 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 the role of diagnosticians, as they 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.

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 form 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.

Additional information outlining highlights of the development of audiology in the United States can be found in a book written by James Jerger (Jerger, 2009).

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 Doctor 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 Doctor of Audiology requires both classroom and clinical learning experiences. Most Au.D. programs are four years in length, which includes three years of classes and one year of 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 an 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.

Audiology Practice: Public and Private
In the United States, audiologic care is considered 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 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 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, Otologists & 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 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 and Medical Center
Hospitals and medical centers can provide more specialized services (e.g., sedated electrophysiological testing) than other clinic locations. Hospitals with maternity wards and neonatal intensive care units (NICUs) 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 with occupational regulations regarding noise exposure. Industrial audiologists take measurements of work environments, screen employees for work-related noise-induced hearing loss, and provide hearing protection.

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.

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.

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 provides guidelines for clinical services. The federal government does not provide guidelines to ensure equity in 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.

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 of audiologists to conduct evidence-based practice. Currently, American audiology research is headlined by studies of the correlation between hearing loss and cognition, noise induced hearing loss, tinnitus, and the 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 1990. 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 American Academy of Audiology,” 2016).

The following are a few of the many highly active audiology-related charities:


 * Alexander Graham Bell Association for the Deaf and Hard of Hearing
 * American Academy of Audiology Foundation
 * American Cochlear Implant Alliance
 * American Tinnitus Association
 * Hearing Charities of America
 * Hearing Health Foundation
 * Hearing Loss Association of America
 * Lions Club International Hearing Aid Recycling Program

==== Challenges ====
 * 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 equity of care around the nation.
 * The Audiology Project is a nonprofit organization working to raise awareness of diabetes and other chronic diseases and the effects on hearing and balance. Centers for Disease Control is moving to include audiology in diabetes care. The Audiology Project is the umbrella association for audiology professional groups in this emerging issue. We are presently involved in writing white papers on pathophysiology of diabetes hearing and balance issues, as well as recommendations for identification, management and monitoring by audiology.