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Let the Numbers Speak: Promoting Evidenced-Based Hearing Wellness

Weinstein, Barbara E., PhD

doi: 10.1097/01.HJ.0000544488.88138.0c
Golden Rules

Dr. Weinstein is a professor of audiology and founding executive officer of the Health Sciences Doctoral Programs at the Graduate Center, City University of New York, and coauthor of the Hearing Handicap Inventory for the Elderly/Adults.

Hearing health care has once again emerged as a critical public health issue with the publication of two notable articles in JAMA Otolaryngology–Head & Neck Surgery. The study by Mahboubi, Lin, and Bhattacharyya addressed the prevalence and burden of hearing loss as well as the benefits of early detection (JAMA Otolaryngol Head Neck Surg. 2018;144(1):65). The investigation by Mahmoudi, Zazove, Meade, and McKee spoke to the economics of hearing aid use and health care costs (JAMA Otolaryngol Head Neck Surg. 2018 Apr 26). The conclusions on the importance of early identification and management of hearing loss dovetails nicely with the discussion of the economics of hearing health. The papers also lent support to a lifespan approach to hearing health care and efforts to improve affordability and accessibility as summarized by Cassel and Penhoetpcast (, 2015). Taking mid-life actions on hearing health care can contribute to cognitive resilience, improved brain reserve, and healthier aging, and conversations around these actions must be steered by audiologists (Lancet. 2017 Dec 16;390(10113):2673).

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Hearing loss is now the fourth leading contributor to years lived with a disability, and its effects go far beyond just sensory impairment (Lancet. 2017 Dec 2;390(10111):2503). Age-related hearing loss (ARHL) impairs the ability to effectively communicate, resulting in negative health outcomes such as social disengagement, cognitive decline, and threats to safety. Mishearings or misinterpretation of physicians are commonplace in many health care settings like acute care, emergency departments, and intensive care units due to noise and other factors. Hence, physician-patient communication is often compromised, and patients with hearing loss are less likely to give favorable ratings of communication with their doctors (JAMA Otolaryngol Head Neck Surg. 2017 Oct 1;143(10):1054; J Am Geriatr Soc. 2014 Nov; 62(11): 2207; BMJ. 2018 Jan 18;360:k21).

Because multi-morbidity is the rule rather than the exception, older adults incur frequent primary care visits, thus representing the majority of consumers in the health care system (J Am Geriatr Soc. 2017 Sep;65(9):1900). Primary care physicians (PCPs) are the gatekeepers who control access to other physicians. However, it was found that they rarely refer people with hearing loss to an otolaryngologist or an audiologist for hearing-related problems.

Using a large data set from the 2014 National Health Interview Survey (NHIS), Mahboubi and colleagues investigated the prevalence of self-reported hearing difficulties and physician referral patterns using data from a representative sample of adults in the United States (JAMA Otolaryngol Head Neck Surg. 2018;144(1):65). About 17 percent of respondents reported some degree of hearing difficulty, and 21 percent indicated that they had trouble hearing or understanding in the presence of background noise. Among the respondents who reported they had “less than good hearing,” 30.5 percent (15.7 million) expressed frustration with their hearing difficulties and 11.2 percent (5.5 million) admitted that their hearing loss caused concerns about their safety. Despite these self-reported difficulties, 62 percent (147 million) of respondents had never seen a clinician regarding hearing difficulties, and 50 percent (117 million) had never undergone a hearing test. Overall, 21 percent (49 million) of respondents had seen a professional regarding their hearing, with 33 percent (16 million) being referred to an otolaryngologist and 27 percent (13 million) to an audiologist. Of note is that five percent of respondents who indicated that they could not hear someone shouting in a quiet room were referred for a cochlear implant (CI), and 22 percent of those referred reported receiving one. On average, only 14 to 18 percent of those reporting functional hearing difficulties reported being recommended for hearing aids. It is noteworthy that three percent of respondents indicated they were using hearing aids at the time they completed the survey. However, the average usage time was reportedly only one hour per day. Finally, most respondents with self-reported hearing loss indicated an average age of onset that ranged from 40 to 70 years old. Clearly, there are gaps in physician and consumer knowledge about hearing loss, the burden associated with untreated hearing loss, and the cost of neglecting hearing health.

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The study by Mahmoudi and colleagues highlighted the advantages of attending to hearing wellness (JAMA Otolaryngol Head Neck Surg. 2018 Apr 26). They conducted a retrospective cohort study using data from the 2013-2014 Medical Expenditure Panel Survey designed to evaluate the use and benefits of hearing aids by a sample of hearing-impaired adults 65 years of age and older. Notably, 55 percent of respondents with self-reported hearing loss were not using hearing aids. Hearing aid users were slightly older (mean age: 78 years old) than non-hearing aid users (mean age: 76 years old), and had more education and higher income levels than non-users. Researchers found that the total Medicare expenditures were slightly lower for hearing aid users. The use of hearing aids was associated with a decrease in the likelihood of emergency department (ED) visits, inpatient hospital stays, as well as a reduction in the number of nights in the hospital for those reporting hospitalizations.

However, hearing aid users reportedly incurred more annual office visits to their physicians than non-hearing aid users and higher out-of-pocket health care expenses. The fact that hearing aid users were older, had more severe hearing loss, and greater self-reported hearing difficulties and health issues may help explain their higher expenses. Significant hearing loss does increase the level of dependency even among hearing aid users, who are more likely than non-hearing aid users to rely on community support services (Ann Epidemiol. 2011 Jul;21(7):497).

Finally, a study by Fisher, et al., explored the link between hearing and vision impairment and mortality status in older adults residing in Iceland (Age Ageing. 2014 Jan;43(1):69). They found that among people with hearing loss or dual sensory impairments (DSI), older hearing aid users with more severe hearing loss had significantly lower risk of all-cause mortality than non-hearing aid users. The finding may actually not be surprising given the link between hearing aid use and social engagement, as well as the link between social engagement, loneliness, mobility, and mortality (Soc Sci Med. 2012 Mar;74(6):907).

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Back in 2012, the U.S. Preventive Services Task Force (USPSTF) concluded that the available evidence at the time was insufficient to assess the balance of benefits versus the harms of screening asymptomatic adults aged 50 and older for hearing difficulties (Ann Intern Med. 2012 Nov 6;157(9):655). Today, however, I would argue that evidence on the individual and societal cost of unaddressed hearing loss abounds. The recent evidence is clear: Hearing care professionals must work to increase the number of older people who benefit from timely and efficacious treatment of hearing difficulties, and devote more resources toward educating general practitioners about ARHL and their critical role in its management and treatment. The above studies underscore the importance of promoting hearing wellness—the earlier, the better.

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