Welcome, everyone, to the webinar, Hearing Loss, Comorbidities, Grow Your Practice Through Physician Outreach and Community Education. We're so glad that you could be here today to learn more about identifying links between hearing loss and comorbidities. Your moderators for today are me, Ted Annas, Senior Marketing Specialist, and Carrie Peterson, Member Services Supervisor. Our expert presenter today is Alina Urdaneta. Alina is Vice President of Marketing and Learning at Savantos and is responsible for marketing strategy and educational programs that support nearly 8,000 customers in the United States. Alina is an accomplished marketer, having implemented a multitude of award-winning media, channel development, and sales effectiveness programs. She serves as Chair of the Market Development Committee at the Better Hearing Institute and is a frequent speaker at marketing and hearing industry conferences. She has been featured in Hispanic Executive and was named one of 2013's Women Worth Watching, as well as Most Important Hispanic in Technology in 2008. We're very excited to have Alina as our presenter today, but before we get started, we have just a few housekeeping items. Please note that we're recording today's presentation so that we may offer it on demand through the IHS website in the future. This webinar is available for one continuing education credit through the International Hearing Society. You've uploaded the CE quiz to the handouts section of the webinar dashboard, and you may download it at any time. You can also find out more about receiving continuing education credit at our website IHSinfo.org. Click on the webinar banner on the homepage or choose webinars from the navigation menu. You'll find the CE quiz along with information on how to submit your quiz to IHS for credit. If you'd like a copy of the slideshow from today's presentation, you can download it from the handouts section of the webinar dashboard, or you can access it from the webinar page at the IHS website. Feel free to download the slides now. Tomorrow you will receive an email with a link to a survey on this webinar. It is brief, and your feedback will help us create valuable content for you moving forward. Today we'll be covering the following topics. Healthcare reform gives priority to hearing screening. Physician outreach program. How to discuss prevalent health conditions that have a strong link to hearing loss. Reducing hearing loss is key to preserving your patient's health and safety. At the end, we'll move on to a Q&A session. You can send us a question for Alina at any time by entering your question in the question box on your webinar dashboard, usually located to the right or the top of your webinar screen. We'll take as many questions as we can in the time we have available. Now I'm going to turn it over to Alina, who will guide you through today's presentation. Take it away, Alina. Thank you so much, Ted, for that kind introduction, and I'm very happy to be here covering this very important topic of healthcare reform now giving priority to hearing screening and what that means for us as a hearing care community. What you see in your screens is the IPPE, the initial patient examination form, as well as the AWV, which is the annual wellness visit. The one that you see there called IPPE, for those of you who are not familiar, is kind of the Welcome to Medicare, and is what a medical doctor, an MD, or a general practitioner would use to go through everything that has to be evaluated. It's kind of like the welcome introduction to Medicare for their patients. The other form that you see there is the AWV, which is the annual wellness visit. The good news is that since 2012, hearing impairment is front and center as the third or the fourth condition that is being evaluated by a medical doctor. It wasn't until 2014 that this became a mandate, which means that medical doctors, when they submit a claim, this form has to be completed. The objective here is to determine the patient's hearing impairment and see what is their functional ability and their ability to live independently. What does this represent? For us, it's really a time to renew the conversation with physicians on recent studies about the consequences of untreated hearing loss. Some of them are causal pathways, so for example, untreated hearing loss leading to things like cognitive decline, the early onset of dementia, increased risk of injury causing falls, and then there are those comorbidities that have to do – these are conditions that are associated with other prevalent health conditions among seniors like diabetes, cardiovascular disease and stroke, and cancer treatment, and even depression. It's time to renew the conversation with primary care physicians and their staff, and again, with patients and the community. When you look at hearing loss, testing has been traditionally low in seniors, and it has been considered some sort of isolated condition that really was part of a communication disorder but nothing more. In the workshop led by the Institute of Medicine in 2014 on healthy aging, the findings were that between 40% and 86% of healthcare providers did admit that they did not screen routinely with barriers from lack of time or perception of clinical issues that may have been more pressing and lack of reimbursement, especially if they were considering or they were recommending sending to a hearing care provider and the outcome would be using hearing aids. 85% said their practitioners – these are consumers or patients – never talked to them about hearing screening unless he or she mentioned a hearing problem. If you look at MarketTrack 9, and MarketTrack 9 was conducted in 2014, we see that this number increased in all ages to 26% with hearing screen at physical and 23% for people that were considered adults. If you look at what we have found in MarketTrack 9, it was 15% that was being screened during their last physical. We see an increase of about 11 points on the all ages and about 7 or 8 points for the adults, which is definitely progress. We attribute this to the fact that now it is mandatory for either the physician or their assistant to evaluate the patient screening. But yes, for years, the cognitive and psychological and psychosocial consequences of hearing loss, like I said, has been treated in isolation and it hasn't been a big focus for government and healthcare organizations until now. The Institute of Medicine and the PCAST are initiatives, the PCAST being the Presidential Committee on Aging, and hearing has become front and center and has been the object of much deliberation within the federal and the local governments. We now know that hearing loss may have much more wide-ranging consequences than just being a communication disorder and too few health providers know about it and how to treat it. So that's where we come in and that's the objective of this dialogue that we're initiating here in terms of the IPPE and the annual wellness visit. They now create a mandate to uncover hearing loss in patients and a call to action for physicians and their patients, but for us as a hearing care community, it's an opportunity for more patient referrals and also an opportunity to educate the community and doctors on the consequences of untreated hearing loss. So if you look at the workflow for the IPPE, which also applies for the annual wellness visit, the way that this is executed, the protocol dictates that physician office staff a member can use two identification methods, either subjective questions or direct observation. The first method would be subjective questions. Do you have trouble hearing and understanding? Is it difficult for you to have a conversation in a noisy environment? And if the patient responds yes, then they can test the patient using pure tone thresholds and there's the billing code, but many of them may elect to refer to a hearing care professional such as yourselves. If the patient responds no, then they have direct observation. The patient may say that no, they don't have trouble, but at the same time they may be asking the provider, what or what did you say? And so if this is the case, if the observation is yes, then they should test the patient using pure tone thresholds or refer to a hearing care professional, and if not, then this is the end of the evaluation in terms of hearing. But when we created this program in 2014 at Siemens, we did it with the help of the medical profession as well as a chief medical officer at Siemens because they came to us and said, you know, we have this mandate now and many of us don't even know what to do or who to refer after we conduct this examination. But the creation of the Physician Outreach Program here at Siemens helps us illuminate the documented links between hearing loss and prevalent comorbidities, including early onset of dementia, cognitive decline, increased risk of falls and even longer hospitalizations, and then comorbidities like cardiovascular disease, stroke, diabetes, cancer, and depression. And it allows us to harness the opportunity to educate physicians on the impact of untreated hearing loss and their role in preserving the health and safety of their patients. But most importantly for us on this call is it helps us establish our practice as a resource to improve patient outcomes through physician referrals. So the Guide for Physicians is something that we created here at Siemens and it's a booklet. It's a vehicle for communicating with physicians and their staff, like I said, developed by Siemens clinical team and medical doctors that articulates the link between hearing loss and prevalent health conditions. It has a description of everything that needs to be taken into consideration for a patient evaluation at the doctor's office. And then we have very specific fact sheets on each one of these comorbidities, whether hearing loss and the early onset of dementia and cognitive decline, hearing loss and cardiovascular disease, hearing loss and increased risk of falls, hearing loss and cancer and depression. So this material has been developed to support the establishment of your practice as a resource for a physician. And they're very concise, they're very clear, and they have all the bibliography associated to the facts that are outlined on these different fact sheets. Some audiologists and hearing care professionals have taken these fact sheets also for educating their consumers and laminated them and put them in their front office, but they're clearly a vehicle to, we call it like cliff notes, dedicated to educate physicians on the impact of untreated hearing loss and how they relate to all these prevalent conditions. And then the message to treating hearing loss, when you're talking with a physician, it is so key to preserving the patient's health and safety. If a patient has hearing loss, the primary care physician can prevent accelerated cognitive decline and the early onset of dementia. The physician can help preserve and extend their patient's mental health and independence, and they are also responsible for reducing their risk of injury causing falls. And having this data in front of them that clearly outlines that will help them really understand and make the association and make the appropriate referral to you, hearing care professionals in their community. And we know that 95% of people with hearing loss can regain their quality of life and live better and longer with the help of hearing aids. So let's go through the specifics on each one of these associations. Like I said, some prevalent health conditions have a very strong link with hearing loss. The first one, and I think it's the one that has garnered the most interest from the media and from patients in general, is the fact that untreated hearing loss can affect cognitive brain function, especially in older people, and has been associated with the early onset of dementia. That has been a very important discovery and has been researched by University of Pennsylvania, the Perlman Institute, and also by Dr. Frank Lynn in Johns Hopkins University. Very much publicized, and there is now a recent study conducted in France that talks about those people that have treated hearing loss, that use hearing aids, have cognitive decline very similar to people that do not have hearing loss. So that was an important discovery, and we'll go through that as we go through this talk. The second one, and this is also a very startling one because people don't make that association, but hearing loss is tied to three-fold higher incidence of injury-causing falls in the United States. If you have been to a rehabilitation center, you see that there's a lot of older folks that go through falling episodes, and that is one of the leading causes of mortality in seniors, injury-causing falls. These two, like I said, are more causal. This is untreated hearing loss creating this type of condition, particularly in seniors. Then we have the comorbidities. For example, you see that 21% of diabetics have hearing loss compared to 9% of non-diabetics of the same age. Cardiovascular disease, when you look at low-frequency hearing loss, it is associated and could be construed as an early marker for the higher risk of cardiovascular events and stroke. Cancer treatment of the platinum type, which is not used very commonly, but it is a very aggressive treatment for very aggressive types of cancer. There is an association of creating high-frequency hearing loss as a side effect, and it's for treating certain types of very aggressive cancers. Then depression, there has been a connection for those of us who have been in the hearing care industry for a while, that depression and hearing loss can be associated, but now there is very good research that talks about untreated hearing loss causing anxiety, paranoia, relationship problems, stress, and all kinds of psychosocial issues. This is something that we also need to speak with the physicians in our community. If we go to the facts on hearing loss and cognitive decline and dementia, like I said, these are the two institutions that have done very extensive research on cognitive decline and dementia. One of them, a six-year study of almost 2,000 adults, mean age of 77.4, showed that hearing loss is a factor in loss of mental acuity in older adults. The more severe the hearing loss, the more accelerated the decline in the mental function. However, even people with mild hearing loss, 25 dB, were likely to experience cognitive failures. The other study is a 10-year study on 126 participants where 40% had over 25 dB hearing loss and had MRIs taken of the brain every year. Those with hearing loss displayed a shrinkage of one additional cubic centimeter per year of gray matter tissue. This is one cubic centimeter per year of gray matter, and this is around the auditory cortex, which is the structure in the brain responsible for processing sound and speech. The declines in hearing ability not only increase the listening effort necessary to comprehend speech but also creates this situation in the brain where gray matter is lost every year at that rate. Seniors with hearing loss are significantly more likely to develop dementia over time than those who retain their hearing. The link is so strong that the authors talk about preventive treatment options to delay or prevent dementia, and this may include using hearing aids. So hearing aids not only improve hearing but also help preserve the brain. These are very important topics to discuss with doctors, and doctors not only primary care physicians but also neurologists and gerontologists and everybody that has to do with impaired brain function in seniors. So how do you discuss this? This is kind of your script when you are going to talk to a physician and you have given them, let's say, the fact sheet on hearing loss and cognitive decline and dementia. You can very simply state that recent studies at Johns Hopkins University have shown that there's a strong link between hearing loss and cognitive decline, and the research has showed that older people with hearing loss experience gray matter shrinkage at an accelerated rate in the auditory cortex, in that area that processes sound and speech. And this impacts cognitive function, and even subjects with mild hearing loss were found to experience cognitive failures. So it's not that, oh, you are okay, you know, it's very mild still. Even mild hearing loss can lead to these devastating consequences. And studies also found that seniors with hearing loss are significantly more likely to develop dementia over time than those who retain their hearing. And then, you know, you as a physician, by encouraging diagnosis and treatment of hearing loss, you can contribute to prevent cognitive decline and slow down progression of dementia and even Alzheimer's disease in your patients. I mean, this is a very succinct conversation that you can have with any of these physicians and then introduce your practice as a possibility for referrals and helping out, have better outcomes for those patients. And then with patients and the community, you know, as you have your open houses or you have your lunch and learns with folks in your community, a way to address, you know, maybe a more simplified terms, this is kind of the same script but applied to, you know, to consumers or patients in general. So here you have two scripts, one for physicians and another one for patients and the community. And like I said, this is the single topic that, you know, as we publish articles on this or post things on Facebook or have, you know, consumer webinars, this is clearly the number one topic that people are more concerned about as they should be. So let's talk a little bit about the facts on hearing loss and the increased risk of falls. And by increased risk of falls, it also has another series of additions here in the study which talk about longer hospitalizations for people that go, you know, into the hospital. But this study is specifically from the National Health and Nutrition Examination Survey and it was information collected since 1971 and about 2,000 participants and these are the ages from 40 to 69. And the respondents were asked, have you fallen during the past year? And factors like vestibular dysfunction were taken out of the study. The study was specifically focused on people that had falls. And people with 25 decibels, which is, as we all know, considered mild hearing loss, were nearly three times as likely to have a history of falling. This was, you know, mining numerous patients in distinct hospitals. And every additional 10 dB increased likelihood of falling by 1.4. So the explanation is that hearing loss decreases awareness of surroundings and increases cognitive load. And in turn, with all these resources, reduced resources that the patient has, when there's a situation with a lot of stimuli around it, then in turn this raises the potential for falls. They really have cognitive overload and the reason for that is hearing loss. They can't process sounds fast enough. One in three adults over 65 fall each year and falls are the leading cause of fatal and non-fatal injuries. So this is something to take stock and really pause and think about this. And this is the conversation to have with physicians and their staff. And you know, it may also be a good opportunity to go to rehabilitation centers and speak to the staff and the doctors there. The conversation is, you know, studies point to the association between hearing loss and cognitive overload, which raises the potential for falls. And recent research shows that people with even mild hearing loss are nearly three times more likely to have a history of falling. And the risk will increase with the level of hearing loss. And again, falls are the leading cause of fatal and non-fatal injuries among Americans over 65. As a physician or as a healthcare provider, you can preserve your patient's safety and independence by discussing this study and encouraging patients over 65 to have their hearing tested annually. How do you talk about this with your patients and the community? Well, in the same way, but maybe in simpler terms, hearing impaired individuals are more likely to have falls and cognitive overload and compromised brain resources, which make it difficult to maintain balance while straining to hear and process auditory input. So using hearing aids may help reduce cognitive overload and thus decrease your increased risk of falls. When you go into the facts of hearing loss and diabetes, and you know, diabetes is a big healthcare issue in the United States, although I heard, I read recently that it had declined in 2015 compared to the year before. So we're taking steps in the right direction. But the fact is that hearing loss is about twice as common in adults with type 2 diabetes compared to those that don't have the disease. At the onset of diabetes, people may have normal hearing, but they are likely to suffer progressive hearing loss as the disease progresses. And we know this because we have seen in post-mortem studies of diabetic patients that have shown evidence that hearing loss has damaged the nerve vessels of the inner ear due to just pathological changes associated with the condition. When you speak with large diabetic centers, typically these folks have a nurse practitioner that is in charge of education and talking to patients about how their medication should be taken, how to control sugar. It varies in complexity because whether you have a daily medication or you have to take insulin, people really need to understand what their treatment is and what are the things that they need to worry about, you know, limbs, feet, etc. And so that is why preserving their hearing is so important so they can manage the disease. If you look at these studies on the national health and nutrition that show that hearing loss is twice as common in adults with type 2 diabetes compared to those who don't have the disease, I mean, this is really something to be very concerned about. How do you talk about this with patients, with doctors, primary care physicians, and endocrinologists? You can talk about the post-mortem study that evidenced the disease may lead to hearing loss by damaging the nerves and the blood vessels of the inner ear. And most importantly, talk about hearing loss screening that allows for early medical intervention and treating hearing loss with hearing aids, the diabetic patients will be able to hear and understand their treatment, follow up on their instructions on testing, managing their medication, their nutrition, and foot care. And like I said, these large diabetic centers are very keen on ensuring that their patients take care of their hearing and they're very open to make referrals to audiologists and hearing care professionals close to their community. So I would encourage you to not only target the primary care physicians and internists who typically treat diabetes, but also endocrinologists and these larger, more specialized insulin pump centers and diabetic centers throughout the United States. How do you discuss this with your patients? If you know a patient has diabetes because they put it in their intake form, you should talk to them about that. There is a strong link between hearing loss and diabetes, and if you are already being treated for diabetes, hearing loss could be a potential complication. Early diagnosis of hearing loss can lead to effective treatment options that will help you manage your condition better and live better and prevent other more serious conditions. Talking about cardiovascular disease and stroke, there's a large body of research, particularly from the University of Wisconsin, Dr. David Friedland, who is an ENT, and he has conducted numerous research, this particular one with 1,168 patients with specific audiograms. And the results of low-frequency hearing loss was significantly associated with coronary artery disease, TIAs and stroke, peripheral vascular disease, and heart attack. The conclusion was that low-frequency hearing loss could be an early indicator that a patient is at risk for cardiovascular disease, and certain audiogram patterns correlate strongly with stroke and PAD, and may represent a screening test for those at risk. This is very near and dear to my heart because I did experience hearing loss for about 10 years, low-frequency hearing loss in one of my ears, and 10 years after, I had a stroke in 2008, which was a very, very scary situation. My doctor said that a lot of people that go through that just simply die, but I was very fortunate to be in a very good medical center, and I went out of it unscathed. But the fact is that I had pulsatile tinnitus, and I had low-frequency hearing loss during 10 years, and it led to a stroke at a very young age. So it is almost the other way around. It's not that in this case it's a causal pathway, but actually a screening for having a higher risk of this condition. I'm sure many of you are aware that if a patient has low-frequency hearing loss, you should refer them to a cardiologist that will take care of doing further testing on that. In my case, my doctor was an ENT, and he didn't really think too much of it, and as a consequence, unfortunately, I never got to see an audiologist or cardiologist or a neurologist before this. But at any rate, how do you talk to this about physicians and their staff? Studies have shown a significant association between cardiovascular and cerebrovascular status and an audiometric pattern, including stroke and TIAs, peripheral vascular disease, CAD, and even heart attack. Low-frequency hearing loss may predict the presence of potential development of cardiovascular disease, and audiograms could represent a screening test for those at risk. So it's also an opportunity for you to refer that patient to a cardiologist and establish a connection with the medical community also in your area. This patient, this medical doctor in turn, cardiologist or neurologist will make sure and refer patients to you and establish that connection. How do you talk about with patients and the community? Well, studies have indicated a strong association between cardiovascular disease and stroke with low-frequency hearing loss, and in fact, low-frequency hearing loss could be a marker for those at risk of developing cardiovascular disease and stroke. So if you don't have cardiovascular disease, it's time for you to maybe visit a specialist, and if you have cardiovascular disease or are at risk, it is important to have regular hearing evaluations. Early diagnosis of hearing loss can lead to effective treatment options that will help you live better and prevent other more serious conditions like we have seen with the falls and cognitive decline. In terms of cancer, and I'm very proud that we were able to work for a full year with the MD Anderson Cancer Center down in Houston. Siemens created a program called the Baton Pass, and we worked with numerous nonprofits for this, but the bottom line is that we donated a million dollars, an in-kind donation, to the MD Anderson Medical Center for them to fit these hearing aids on people that had gone through cancer treatment by which they had lost their hearing. Unfortunately, chemotherapy from the Platinum Group is frequently used to treat adults with brain, head, and neck, lung, bladder, and ovarian cancer. It's also treated to treat pediatric brain, bone, and liver cancers, and one of the side effects of this very aggressive chemotherapy is hearing loss, and especially high-frequency hearing loss in children. This is a study by ASHA, and I was also able to extract data from this lady that was the head of the Department of Head and Neck Cancer at MD Anderson, and she confirmed that this was the case. The ASHA study was conducted in 67 patients, younger patients, ages 8 to 23, that went through this kind of chemotherapy, and they found that 61% of them developed hearing loss, and mostly high-frequency hearing loss. There's consensus that hearing loss and tinnitus are underreported and undiagnosed as part of these treatments. In addition, chemotherapy in children, when hearing loss is left untreated, the consequences may include significant delay in speech and language, and impact on the cognitive development and their psychosocial development. So it's critical that with survival rates going up, and this is a blessing that cancer treatments today allow for a much better outlook, and the survival rates are continuing to go up, which is a wonderful thing, but then the need for physicians to consider the quality of life after treatment is really crucial. Hearing care providers, like us on this call, can evaluate patients for ototoxic after-effects, and if needed, offer that counseling, that treatment, that could include hearing aids and rehabilitation. So it's really in your best interest to make those associations with cancer centers close to your community and offer yourself as a resource for during and after treatment with children as well as adults. How do you discuss this with physicians and their staff? Primary care physicians, oncologists, hematologists, radiation oncologists, these are all the specialties that work with this kind of treatment, and just states, hearing loss can be an after-effect of platinum-based chemotherapy, I know that. I also know that radiation therapy could cause hearing loss, particularly in the neck and head area, and while treatment is ongoing, I can assist with monitoring for ototoxicity and then after treatment, and by doing this, I can make recommendations for early intervention if needed, improving the quality of life of your patient during and after treatment. And like I said, the hearing loss and tinnitus from ototoxicity exposure is truly underreported and undiagnosed. It's kind of uncharted waters, and few universities have studied it, but it's really important that you establish yourself as a resource. So especially in children, high-frequency hearing loss affects comprehension, and they may not realize it, that they're not interpreting the speech properly, and it can affect their speech, their language, their development, their cognition, and educational outcomes. In a recent study of 1,200 children with minimal hearing loss, results show that 37% fell at least one grade in school compared to the normal 3%. So that's how devastating hearing loss can be on children. So these children have gone through all this treatment, make sure that when treatment kicks in and they're able to go on with their lives, that they are evaluated for hearing loss and treated for hearing loss. And then you can say, you know, our practice specializes in dealing with adults, but maybe you have some value proposition that talks about pediatrics, about tinnitus, et cetera. So it's an opportunity to do this as well. And with patients and community, if you have a cancer patient, make sure that you tell them that you're sure that their physician has looked at treatment options, but sometimes hearing loss can be an after effect of the treatment, and if so, monitoring your hearing during and after treatment could be very important. Let's talk a little bit about depression, because depression for us as a hearing care community has been top of mind, but now it's time to renew the conversation with those other professionals that treat depression. And this is a study from the National Health and Nutrition Examination Survey, where they looked at people, over 18,000 people aged 18 years or older, and audiometric examinations were conducted on adolescents aged from 12 to 19 years and adults 70 or older. participants were tested for hearing loss from 2005 to 2006, and then again from 2009 and 2010. Hearing specialists defined deficit as recognizing only those sounds louder than 25 decibels. And after accounting for other health factors and conditions, they self-reported hearing impairment, and they determined that hearing impairment people were significantly more associated with depression, particularly in women. So healthcare professionals should be aware of an increased risk of depression among adults with hearing loss, and again, especially in women. So how do you talk about this with primary care physicians, psychologists, psychiatrists, general practitioners? You talk about the association between hearing loss and depression. It has been made before, but recent studies have confirmed and reinforced the likelihood of this connection, and while, you know, more research to establish causation may be ongoing, there's enough data to suggest that physicians should inform patients on the link between hearing loss and depression, and evaluate wearing hearing aids if recommended by a hearing care professional. The onset of depression in adults has been associated with development of dementia and Alzheimer's disease, which we also talked about in this webinar. And another important statistic here is that 36% of patients who begin wearing hearing aids experience improved overall mental health, and 34% increase social engagement. So with the community, again, if you have somebody that you know is going through depression, you can talk about communication being vital to social interactions, and when you can't hear becomes a source of stress, and frequent misunderstandings may cause people to just quit going to crowded restaurants and parties where understanding speech is more difficult. And the importance of not withdrawing, and, you know, like we hear many times from our patients, you know, gradually quitting on life and choosing to remain silent and isolated. This is something that can be completely resolved with, you know, the right proper treatment with hearing loss. These are some of our, you know, things that we have developed here at Siemens. The left where you see this is like a poster, many prevalent health conditions have a very strong link with hearing loss, very popular in hearing care professional offices, but also something that you can take to your, you know, physician community. And the two pieces in the middle and the right are more mailers that talk about the association of hearing loss, untreated hearing loss with dementia and cardiovascular disease. Some other tactics that we have are these videos that we have created that can be played through clear digital media in some of our physician offices that are close to your office, for example. So, you know, if you're interested, you can always speak with your Siemens representative about how to take advantage of these programs. But, you know, the real objective of this talk was, you know, go through these things in detail and finally summarize that a stronger working relationship between hearing care professionals and the medical communities will definitely lead to better patient outcomes. So, you know, I would encourage you to please take advantage of this material to grow your practice through physician outreach and community education. Leverage the new provisions in health care reform to renew the dialogue and the conversation with the medical community. Reach out to physicians and their staff, you know, and this not only is your primary care physician, but also all these other specialties, neurologists, cardiologists, endocrinologists, to have that type of dialogue and discussion and illuminate the link between hearing loss and prevalent health conditions. This in turn will help establish your practice as a resource for local physicians and also educate patients and your community. Leverage manufacturer resources, you know, we have this guide for physicians and, you know, regardless of the manufacturer you work with, all manufacturers have some sort of physician outreach, so I would encourage you to use those resources and stay the course. This is not an activity that will last, you know, just a month or a couple of months. This is something that you have to stay in for the long run, but I do believe that I have seen it in our providers and those who stay the course and are disciplined on this have extremely good results, not only financially, but also from a fulfillment perspective of being able to provide much better outcomes for patients and for the community in general. So I think at this point, Ted, I will turn it over to you, and I'll be glad to answer any questions that anybody may have at this point. Great. Thank you so much, Alina. Alina, we're so excited that over 200 people, 200 of your fellow colleagues have joined us today on this webinar. As Alina said, we do have some time for questions. If you have a question for Alina, please enter it in the question box on your webinar dashboard. And Alina, our first question is from Jim, and Jim asks, while there is research that points to hearing loss influencing conditions like dementia and mental decline, some doctors may be skeptical on hearing aids preventing these conditions. Are there any studies that demonstrate that hearing aids actually prevent or slow down the onset of these conditions? That's a great question, Jim, and thank you for posing that. And it is true. As I've been doing this talk for the last year and a half, I do get that skepticism of some of you that have gone out and talked to doctors. And up until recently, there wasn't really – Asha had done a study a while back, but the most significant research that has happened during the last year comes from Helen Amiva, who is – she is a physician in France. And this was conducted by the Institute Victor Single-Age in Bordeaux. And this is a study in France that was conducted in almost 4,000 people. The study began in 1990, so these patients have been evaluated for 25 years, so pretty big longitudinal study by Professor Helen Amiva. And what they concluded was that cognitive decline was very similar in people that had normal hearing and people that were hearing impaired that had used hearing aids for a long period of time. So the cognitive decline, the acceleration and cognitive decline was not higher on people that treated their hearing loss with hearing aids compared to people with normal hearing. However, those people that had untreated hearing loss, their cognitive decline was much more accelerated. So this is a study that was published in the Journal of American Geriatric Society earlier this year, and it has been covered by the press, an extensive 25-year-long scientific French study. So again, the conclusion is those who use hearing aids have about the same cognitive level as those with no hearing loss, which it's a pretty important development. I think that the next step with all of these conditions is going to be the Franklins of the world and the Perelman School of Medicine, all these folks that have identified this linkage now start making these studies where now there's a demonstration of treated hearing loss preventing these conditions or making them similar to people with normal hearing. But this Amoeba study, and I'll be glad to email that to you, was covered earlier this year in a number of press releases, so something to consider and maybe something to take to your doctors as well. Great. Thanks, Alina. Alina, our next question is from David, and David asks, what audiogram pattern is associated with stroke? Well, I'm not a professional audiologist, but I did go through the study from Dr. Friedland, and he had that audiogram pattern in this study. So you can either Google University of Wisconsin, Dr. David Friedland, or I will be glad to send a link to the study, but it was low-frequency hearing loss, having a strong association with people at higher risk of cardiovascular disease and stroke and TIA. Great. Thanks, Alina. Alina, our next question comes from Nancy. Nancy asks, can you discuss some of the strategies that you found helpful in encouraging consistent hearing aid usage with seniors with mid-hearing loss whose dementia has resulted in combative and agitated behavior? I really would have to get back to you on that because, like I said, I am explaining and sharing this information and this body of research, but I think that would be something that you have to work with the specialists treating Alzheimer's. I do know that some people become very combative and they just take off their hearing aids, and it is an issue. I'm afraid I can't comment on that because I haven't been exposed to that in my line of profession. But I can certainly go back to some of our customers that have that type of issue in their practice and that have helped and try to put them in contact with you. Okay. Great. Thanks, Alina. My email... Go ahead. No, I wanted to say that my email is going to be at the end of this webinar, so please email me with that question, and I will be certainly to get back with you and put you in contact with people that do that same kind of treatment. Thanks, Alina. Alina, our next question is from Susan, and Susan says, can you provide us a frame of reference on how many visits and how long it takes for a program such as this to take hold and be successful, and what may we expect in the way of patient referrals? Well, that's a great question, and of course, it's a relationship between the effort you put in it and the return, right? But let me try and give you some financial frame of reference and some activity frame of reference. So, for example, if you are able to establish a good relationship with, let's say, three referring physicians, and this may be in the course of six months and eight months. There will be physicians that you will go to and you will speak to their front staff, front office staff, and you may not get very far. But let's say that you establish the objective of at least going out and visiting three, four physicians every month for those eight months. You may expect, based on observations that we've had with providers that have followed this course of action, let's say three referring physicians. So let's say if three referring physicians would be sending you about three patients a month each, that would be about nine patients a month for you. Let's say you have, I don't know, a 50% closure rate with aidable patients, so that would be five patients and 80% binaural rate, which we all know. So total, let's say, hearing aids that you would fit in addition to your services, in addition to any accessories or ancillary services, and let's say that the retail value of hearing aids, of these hearing aids, is about $2,000 each. This would be about $20,000 a month for your practice, which would mean anywhere from $200,000 to $250,000 additional in revenue for your practice, not to mention establishing a connection with medical professionals in your community that would in turn lead to other, creating other referral sources. And the enormous satisfaction of having been able to help people that have gone through some sort of condition and now you're helping them overcome this condition or preserve their independence or their safety. I would say that you need to stay the course and you need to go at it anywhere from six months to a year. That's what really takes for a practice to build this referral. And not only… I mean, the first year, obviously, you decline the number of visits because you already have established the sources in your community, but the other thing I would suggest is not bring everything at the same time, but if you find a physician that is receptive, you may be bringing this research every month, either sending a letter or showing up at their office with material and then making sure that you secure those 10-15 minutes with the physician or the office manager to establish yourself as a referral. And then with your patients, I would say that if you do a Lunch and Learn or if you do an open house, make sure that at least once a month you're touching your patients, either because you're visiting a nursing home or because you are doing some sort of breakfast or lunch at your practice, because these two go together. You really have to not only educate the physician, but you also have to educate the community. If you have a newsletter, make sure that you are taking that newsletter also to your physician colleagues in your community. In general, it's an 8-12 month effort to establish about three physician referrals, and if those, depending on the traffic they have and the amount of patients that they treat, but you should be, with this effort, you should be able to generate about a total of nine patients, ten patients every month with three physicians. Great. Thanks, Alina. Alina, our next question is from Chelsea, and Chelsea asks, do you find this program has been more effective with a Lunch and Learn style or going to each physician individually? When I mentioned the Lunch and Learns, the Lunch and Learns are probably better for the community. I mean, Lunch and Learn in your particular office. If you are visiting the physicians and their front office staff is typically the gatekeeper, and food is always a wonderful thing, as we all know. We all like to be treated nicely, and if you want to have a lunch and learn, I have seen this be very successful. You engage the office manager or the front office gatekeeper, and usually the doctor will be open to this kind of activity within their clinic. So you bring lunch and then you do a short presentation, you have some material that you leave behind, you follow up after that, and of course, if you can get one-on-one time with the physician, you're even in better shape because you establish even a better relationship there, then the physician knows who you are. You can talk about your credentials, you can talk about your experience, you can talk about how close you are, how convenient you are, and in essence, your value proposition. But any of the two are tactics that within a medical clinic have provided very good results. Like I said, you have to engage the staff because the staff makes the world go around, and if you establish yourself with a doctor, wonderful, but you also have to establish yourself with the staff, and that's what lunch and learns are typically for. You kind of make yourself known and establish yourself as a resource, and you fan out within this clinic. So I would think both of them are important. Great. Thank you, Alina. Alina, I'd like to thank you for an excellent presentation today, and I'd like to thank everyone for joining us today on the IHS webinar, Hearing Loss, Comorbidities, Grow Your Practice Through Physician Outreach and Community Education. If you'd like to get in contact with Alina, you may email her at alina.urdaneta.sabantos.com. For more information about receiving a continuing education credit for this webinar, visit the IHS website at IHSinfo.org, click on the webinar banner or find more information on the webinar tab on the navigation menu. IHS members receive a substantial discount on CE credit, so if you're not already an IHS member, you will find more information. Please keep an eye out for the feedback survey you'll receive tomorrow via email. We ask that you take just a moment to answer a few brief questions about the quality of today's presentation. Thank you again for being with us today, and we will see you at the next IHS webinar.

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