4 hearing preservation conversations to consider

Interview with Alejandro Rivas, MD and new Chief of Otolaryngology at University Hospitals in Cleveland, on growing a CI program and incorporating new innovation including telehealth

By Patti Trautwein, MA, AuD, Vice President, Product Management & Marketing, Cochlear Americas

On June 1, 2020, Alejandro Rivas, MD, joined University Hospitals of Cleveland (UH) as the Chief of Otology/Neurotology, moving from Vanderbilt University Medical Center. Dr. Rivas’s new role includes directing the hospital’s large hearing implant program. I had the pleasure of catching up with Dr. Rivas to learn more about his vision for the program and incorporating the latest innovations in cochlear implants and telehealth.  

PT: You recently made a big transition from Vanderbilt to UH/Case Western Reserve University School of Medicine. Tell us about your new role and the hearing implant program?

AR: The UH program is well established and was started by Dr. Anthony Maniglia, Dr. James Arnold and Dr. Cliff Megerian as well as our Director of Audiology, Gail Murray, PhD.  The program has been supporting 80-120 cochlear implant surgeries per year. We see both adults and children, currently 60/40 split between adults and pediatrics. In addition to myself, Dr. Sarah Mowry is actively implanting new patients. Between August and October, two additional physicians will join so we will have four fellowship trained neurotology surgeons supporting our implant program. We also have over 22 audiologists, six of which are providing care for our cochlear implant patients. We conduct surgery out of three hospitals and have many regional satellite locations for care.  

PT: You transitioned to UH amidst the pandemic. How is your new program scheduling patients? How long does a patient have to wait to get an appointment with you?

AR: During the pandemic we continued to see patients as medically needed with approximately 20% of appointments in clinic and another 50% virtual. Currently, we are back at 90% live appointments and the wait time for an appointment with a cochlear implant surgeon in my group is about one week. We have worked diligently through these last months to assure we have rescheduled any affected patients and are at this point, up to date from a scheduling and procedural perspective.   

PT: What process changes has your hospital implemented for you to continue to offer ear surgeries during these uncertain times? How are cases being prioritized?

AR: We are following enhanced infection control procedures which include social distancing, masking, pre-operative COVID testing and increased sanitization. We have no restrictions currently on elective surgeries and our OR suites are at full capacity. We do not view cochlear implants and many other ear surgeries as elective, given the impact of hearing loss on our patients’ ability to communicate and overall health. Therefore, we have continued to implant CI, safely and carefully, to assure we are optimizing each patient’s overall quality of life and function.  Dr. Megerian, a neurotologist and pioneer in cochlear implants, has been appointed President of the University Hospitals Health System and will assume the role of CEO next year, so we expect hearing health to continue being a high priority.

PT: Considering COVID, how are you counseling patients who may be hesitant or fearful to move forward with a hearing implant now?

AR: I empathize and understand the concern, however COVID may be here to stay and we may not have a vaccine for some time. Hearing loss can incapacitate your life. Hearing aids are not able to provide you the hearing, especially in noise, that you need. Delaying your treatment is not in your best interest as it impacts your overall health, including your ability to communicate. To me, the hospital may be one of the safest places you can go. We have plenty of personal protection equipment (PPE), follow strict infection control measures and test all patients prior to a procedure. Patients with COVID are not treated in the same part of the hospital, which further helps us to maintain excellent infection control measures in the operating rooms. So, there should not be a delay in getting a cochlear implant.

PT: You have been engaged with Cochlear on product development and research for many years now. You are one of the first surgeons to access the new Slim 20 electrode. Cochlear has provided surgeons with a portfolio of electrodes including Slim Modiolar that uses a perimodiolar array to place the electrodes closer to the hearing nerve. How will you use the portfolio to meet the varying needs of your patients? 

AR: I prefer the Slim Modiolar (CI632) for most patients based on research including my own. I will use the new Slim 20 electrode (CI624) in patients with more measurable low frequency hearing; specifically, I reference the hearing levels in the low frequencies to 1kHz.

PT: What would you recommend to a colleague about selecting an electrode?

AR: For surgeons with less experience in cochlear implantation or who will likely only do a few cases per year, I would suggest the Slim Straight or Slim 20 given the ease of handling and placement. The first priority for patient outcomes is an atraumatic placement in scala tympani without disruption of the basilar membrane. 

PT: How often have patients asked you about which electrode you select?

AR: Very rarely, I can think of only a few times. In those cases, I explain as needed my preference for that case and try to make this a decision they simply do not need to be concerned about.

PT: In addition to implant innovations, Cochlear has launched a suite of Remote Care services.  How do you see Remote Care or telehealth fitting into clinical practice today and in the future? 

AR: During the lockdown we saw a dramatic increase in the number of telehealth appointments, upwards of 50%. I see this as something that will continue and be valued by patients here in Cleveland. Overall, patients want to be seen closer to home.  Nothing is closer than telehealth for that purpose.  We are working actively on a UH telehealth CI program to assure patients can access the care they need quickly and efficiently, regardless of where they live. We do have a growing number of satellite offices and it is my intent to have cochlear implant services offered in those locations, but we will still need telehealth services and will need to manage reimbursement hurdles as government policies change. 

PT: How do we overcome the hurdles?

AR: There is an opportunity to reduce the number of clinical appointments required for cochlear implant care. I have a vision to completely transform the surgery and activation process to be more efficient for the CI team and easier on the patient. In my opinion, a same-day surgery and activation is possible with technology and intraoperative measures with tools that can easily be used in the OR by the surgical team. This frees valuable audiology time to manage more challenging clinical cases and new implant evaluations. In two years, this program should see 300 new cochlear implant patients per year.

PT: Cochlear implants have evolved over a 40-year history. Your research as well as that of others consistently demonstrates benefits of cochlear implants over hearing aids for patients with moderate sloping to profound hearing loss over hearing aids.  Yet, far fewer patients get the treatment than the growing incidence of hearing loss. What would you want hearing health professionals and people with hearing loss in your new community to know to improve awareness of this treatment option?

AR: Make it simple to understand by using speech perception in noise. Understanding in quiet is not enough. If a patient cannot hear well in noise (50%) with hearing aids, then recommend they be seen for a cochlear implant evaluation.  

Thank you for your time, Dr. Rivas. Congratulations again on your new role as Division Chief of Otology/Neurotology at University Hospitals in Cleveland. I am glad your transition has been smooth and your vision to grow the program is exciting. On behalf of everyone at Cochlear, we look forward to continuing to partner with you to raise awareness of cochlear implantation in your community, advance product innovation and transform clinical care model to best meet patient needs today and in the future.  

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About the author: Patricia’s 25 years in the hearing healthcare industry includes roles in research and clinical studies, product management, education and training, sales and marketing. As Cochlear America’s VP of Marketing, Patricia is responsible for the marketing strategy, communications and public relations, brand ambassador program and product management. Her organization is responsible for positioning Cochlear Americas growth strategy, cultivating opportunities in new and existing customer markets and growing demand for Cochlear’s hearing solutions in the region.

This communication is intended to educate on the experience of other healthcare professionals and is not meant to provide medical guidance. The techniques mentioned in these materials reflect those of the authors, not those of Cochlear.