Economic Impact of Idiopathic Sudden Sensorineural Hearing Loss: Cost Analysis : The Hearing Journal

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Economic Impact of Idiopathic Sudden Sensorineural Hearing Loss: Cost Analysis

Missner, Alexander A. BS; Crossley, Jason MD; Hoa, Michael MD

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The Hearing Journal 76(01):p 14,15,20, January 2023. | DOI: 10.1097/01.HJ.0000911296.83475.19
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Sudden sensorineural hearing loss (SSNHL) involves abnormalities of the cochlea, auditory nerve, or processes of central auditory perception causing sudden unilateral or bilateral hearing loss. The established criteria for this condition is defined as rapid-onset sensation of hearing impairment in one or both ears, involving a decrease in hearing of  30 decibels affecting at least three consecutive frequencies, within a 72-hour period. 1 Accompanying symptoms often include tinnitus, dizziness and/or vertigo. 1

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www.shutterstock.com. Idiopathic sudden sensorineural hearing loss, ISSNHL, sudden sensorineural hearing loss, SSNHL, auditory rehabilitation
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Table 1:
Medicare Reimbursement Fees Associated With ISSNHL Diagnosis and Treatment.

The estimated incidence of SSNHL is 66,000 new cases in the United States, with between 5 to 27 per 100,000 people annually. 2,3 Data from other countries suggest this number may be 160 per 100,000. 4 Data from the All of Us research program, a U.S. sample that includes minority groups historically underrepresented in medicine, reported sudden hearing loss incidence to be 0.34%, suggesting the true incidence of SSNHL in the U.S. may be higher than prior estimates. 5,6 These estimates may be low due to strict diagnostic criteria for SSNHL and variable patient behavior with regard to seeking treatment. 2–4 Ninety percent of SSNHL cases are idiopathic (ISSNHL), while 10% are due to etiologies including viral, bacterial, tumors, thrombosis, and immunologic. 1

An estimate of the cost of diagnosis and treatment of ISSNHL is made at the individual and population levels for the U.S. health care system. Cost analysis utilizing practice clinical guidelines and Medicare reimbursement rates has not been published prior to this study. The calculated estimates are intended to form the foundation for further research into the economic impact of ISSNHL. Current costs and heterogenous response to medication in ISSNHL support the development of novel therapies as well as the wider use of rehabilitative therapies including hearing aids and cochlear implants.

PRACTICE GUIDELINES

The diagnosis and management of ISSNHL is summarized in the American Academy of Otolaryngology – Head & Neck Surgery (AAO-HNS) Clinical Practice Guideline. 1 Key Action Statements (KAS) convey the following guidelines: a) rapid diagnosis for ISSNHL requires a thorough initial assessment, including history and physical with tuning fork testing to distinguish between conductive and sensorineural hearing loss; b) blood work is not indicated when there is a high suspicion that etiology is idiopathic; c) audiometry is performed as soon as possible and within 14 days; d) MRI or auditory brainstem response is completed to evaluate for retrocochlear pathology; e) if treatment is pursued, oral corticosteroid intervention is initiated within two weeks of symptoms or intratympanic steroid therapy for salvage within two to six weeks following onset; and f) audiometric follow-up is conducted at the conclusion of treatment and at six months post treatment.

Patients that present to physicians less than one week after onset of ISSNHL have improved odds of recovery. 1,2,7–9. ISSNHL may spontaneously resolve in approximately half of patients that present early to an otolaryngologist. 7 When these patients receive steroid treatment orally or by intratympanic membrane infusion, the recovery rate may reach 78%, although lower rates are frequently reported. 7,10 Corticosteroid treatment has been shown to be most effective within the first two weeks after ISSNHL. 1 Successful treatment often results in improved tinnitus. 11 Thus, prompt diagnosis and treatment of ISSNHL has been shown to be an important prognostic factor.

COSTS

Studies on the economic burden of ISSNHL on the U.S. health care system are lacking. An attempt at cost analysis is made using currently published estimates of annual incidence put together with estimates of health care costs. To appraise the health care costs of one case, we assembled Medicare reimbursement fees for timely diagnosis and initial management of ISSNHL (Table 1). Based on the costs of at least one initial plus one follow-up ENT assessment, one initial plus two follow-up audiometry testing post treatment and post six months, one set of imaging, and oral or intratympanic membrane steroid therapy, the estimated total range is $614.56 - $1,438.91 per person. Given the previously described estimated incidence of 5 to 27 per 100,000 patients, the minimum economic impact for health care costs on the U.S. economy ranges from $40.6 million to $95 million. One can appreciate how any additional care, such as emergency department visits, added blood work, additional imaging, and hospitalization can drive up costs that frequently accompany the diagnosis for ISSNHL. 12 Importantly, these estimates do not include the costs of reduced work productivity or auditory rehabilitation. These further costs are not estimated here due to the complexity of these estimates.

Studies indicate that adherence to clinical ISSNHL guidelines is low among non-otolaryngologists, and it is estimated that between 15,000 and 60,000 patients are seen in emergency rooms, urgent care centers, or primary care clinics for this diagnosis. 1,12 In these settings, basic testing such as the tuning fork exam is underutilized. 15 Incomplete physical exam likely delays care and elevates health care costs of ISSNHL. Innovative solutions such as cellphone vibrations in the place of a tuning fork may improve access to this crucial part of the exam that may be skipped in absence of readily-available equipment. 16

Failure to effectively diagnose and treat SSNHL leads to worse outcomes for patients physically and psychologically while driving up health care costs. A study found that after SSNHL, 42% of patients experienced persistent and detrimental tinnitus, and that among this cohort, there was a three-fold increase in sick leave from their occupation. 17 Patients experienced negative psychosocial consequences, lower quality of life, and those with higher persistent tinnitus were more likely to require expensive long-term rehabilitation. Factors such as poor speech understanding in noisy environments and improper sound localization exacerbates the negative psychological impact on patients. 18,19 Other studies have shown poorer quality of life with significant emotional distress and psychosocial burden on patients. 1,20,21 Proper diagnosis and treatment, therefore, are fundamental for streamlining care for ISSNHL, improving prognosis, and optimizing the effectiveness of health care expenditures.

AUDITORY REHABILITATION

Auditory rehabilitation is indicated for patients that have incomplete recovery and/or residual tinnitus from ISSNHL. Auditory rehabilitation options include hearing aids and cochlear implants. In some cases, osseointegrated bone conduction devices are necessary where degradation of central auditory pathways may play a larger role in the ability to benefit from cochlear implantation. 1 These interventions have been shown to improve quality of life and reduce psychological distress. 22–24 Cochlear implants are now the preferred treatment for non-longstanding single-sided deafness. 25 These devices restore hearing and improve sound localization. 23–29 Benefits include cost-effectiveness of cochlear implants due to positive trends in quality-of-life outcomes. The benefit of cochlear implantation for single-sided deafness is optimized when implanted closest to the onset of deafness, underscoring the value of timely diagnosis and management. 29 In-depth economic analyses is needed to support advocacy for coverage of cochlear implants for single-sided deafness under Medicare. While the costs of these interventions are not insignificant, the lack of auditory rehabilitation has consequences that impact individual health and wellness, as well as, some clear economic impacts related to both employment and reduced productivity at work which have broader impacts on our economy. 30–34 Teachers, specifically, have decreased employability with untreated hearing loss. 32 Further, untreated hearing loss is associated with increased incidence of health problems from significant morbidity, including myocardial infarction, stroke, dementia, and falls. 35

CONCLUSION

ISSNHL has a significant economic impact at both the individual and population levels. There is a significant fraction of patients that are seen initially in primary care, urgent care, or ER settings where care concordant with AAO-HNS clinical practice guidelines may not be followed. 12 Divergence from practice guidelines delays diagnosis, worsens prognosis, and drives up health care and workplace productivity costs. Educating physicians in urgent care/emergency department settings to use tuning forks or a potential equivalent such as the cell phone vibration test in order to distinguish sensorineural hearing loss from conductive hearing loss would be a quick and reliable tool for rapid referral for hearing testing and consultation with an otolaryngologist. 15,16 The persistence of hearing loss despite steroid pharmacotherapy emphasizes the importance of current and future efforts to find new treatments for ISSNHL. 36,37 Cochlear implantation offers some hope for SSNHL patients who both meet candidacy requirements and whose insurance covers this indication. This commentary is a call for more research into the economic impact of ISSNHL that will ultimately provide support for the need to develop accurate recognition, awareness of treatment recommendations, and novel therapies for patients who suffer from this disease.

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