Research Forum
Adult Hearing Screening: Health Policy Issues—What Happens Next?1 Adrian Davisa and Pauline Smithb
Purpose: Ten percent of adults in England have some type of hearing loss and would greatly benefit from hearing aids or other forms of hearing management. However, 76% of these adults do not have hearing aids or other management. The impact of this unmet need can be substantial and has been linked to depression, social isolation, employment problems, loss of independence, and dementia. This article explores how hearing screening—universal, targeted, or opportunistic—can address prevalent, incident, and future needs for hearing services as well as better define the extent of need. Method: Adults age ≥60 years living at home in England took part in a health survey, part of which was to determine the extent of need for hearing services in this population. Survey
methods included a face-to-face interview and hearing screening using pure tones as well as a self-report questionnaire on other health issues. Results: The survey highlighted additional hearing-related factors that will enable referral decisions in primary care to be made with reasonable confidence that patients will use hearing aids and benefit from them. Some relevant nonhearing factors are also reported. Conclusion: There is a growing aging population with increasing needs and expectations for hearing services. Targeted screening and triage in primary care, as well as use of advanced technologies, are discussed for the future.
I
hospital audiology services after visiting their primary care physician with reported hearing problems. The impact of this unmet need for hearing services can be substantial and has been linked to depression, social isolation, employment problems, loss of dependence, and dementia (Hjalte, Bra¨nnstro¨m, & Gerdtham, 2012; Huang, Dong, Lu, Yue, & Liu, 2010; Lin et al., 2011; Morris, Lutman, Cook, & Turner, 2012).
n England, 10% of individuals ages 18–80 years, or 4.9 million, have a moderate level of hearing loss (>35 dB HL in the better hearing ear averaged across 0.5–4.0 kHz) that would greatly benefit from hearing aids or other forms of hearing management. However, 76%, or 3.8 million, of them do not have hearing aids or other clinical management (Davis, 1995, updated to current population demographics). So there is significant unmet need for hearing services not just from mild cases of hearing loss, but across all severities. Table 1 shows the numbers of people in England in each severity category as well as cumulatively (e.g., 4.9 million have at least a moderate hearing loss). Our study for the U.K. Health Technology Assessment (HTA) Programme (Davis, Smith, Ferguson, Stephens, & Gianopoulos, 2007) found that of the 14% of 55- to 74-year-olds who have a bilateral hearing impairment of at least 35 dB HL, only 3% currently receive intervention through use of hearing aids. The HTA report also found that only 41% in that same age range were referred to a
Royal Free London NHS Foundation Trust, UK b University Hospitals of Leicester NHS Trust, UK Correspondence to Adrian Davis: [email protected]
Key Words: hearing loss, screening, auditory rehabilitation
Meeting Unmet Need Given the high prevalence of hearing loss, we need to continually address the unmet need in the population if we are to ensure that adults age well. This unmet need is substantial because many people delay seeking help, often for more than 10 years. Prevention of disability will include identifying the ability to benefit from interventions to improve hearing, communication, and quality of life.
Screening for Hearing Loss: The Evidence We have shown that hearing screening can be cost effective (Davis et al., 2007; Morris et al., 2012) in the United Kingdom, but questions remain about its acceptability or impact. This article explores how screening for hearing loss,
Editor: Larry Humes Received November 5, 2012 Accepted February 18, 2013 DOI: 10.1044/1059-0889(2013/12-0062)
1
Part of this work was presented at AHS 2012, the 2nd International Conference on Adult Hearing Screening, June 7–9, 2012, in Cernobbio (Lake Como), Italy.
American Journal of Audiology N Vol. 22 N 167–170 N June 2013 N ß American Speech-Language-Hearing Association
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Table 1. Number of people in England with varying severities of hearing loss. Severity of hearing loss People # in each category # cumulatively
Mild
Moderate
Severe
Profound
5,804,578 10,775,582
2,735,013 4,971,004
1,847,909 2,235,991
388,082 388,082
whether universal, targeted, or opportunistic, can address prevalent, incident, and future needs for hearing services as well as better define the extent of need.
Method In 2011, we conducted a survey to determine the extent of need for hearing services in adults age ≥60 years. We also looked at comorbidity: Are there target groups that might give high yield for more cost-effective screening? Our sample consisted of 1,000 people in England living at home who were age 60 years or older (>80% of people provided with hearing aids in England are ≥60 years old), randomized with quota sampling for age. The survey included a face-toface interview followed by a hearing screening test using the Siemens HearCheck Screener, which is a handheld batteryoperated device that is suitable to use in patients’ homes and/ or in primary care or community settings. Tones at two frequencies were presented: 1 kHz at 55, 35, and 20 dB HL and 3 kHz at 75, 55, and 35 dB HL. Participants also completed a self-report questionnaire concerning other health issues.
Results Some of the key findings of the study were that (a) 13% of the participants said that they had seen their primary care/hospital doctor about their hearing in the last year, (b) 14% already wore hearing aid/s, (c) 3% had tried hearing aids but did not wear them now, and (d) ,80% of those fitted with hearing aids used them. Our HTA study (Davis et al., 2007) indicated that 35 dB HL 3 kHz loss is a research-based, objectively measurable starting point for primary care physicians in deciding whether to refer a patient to secondary care for further assessment. Our 2011 survey highlighted additional hearing-related factors that will enable these physicians in the consultation to make the decision to refer with reasonable confidence, in that referral and assessment will result in the patient using hearing aids and benefiting from them. For example, we found that the more patients emphasize hearing difficulty (indicating greater hearing loss and greater impact of that hearing loss), the more likely they are to be able to access and benefit from hearing services, based on earlier findings from the HTA study (Davis et al., 2007). Similarly, patients who reported annoyance from loud sounds, tinnitus, a tendency to dizziness, or occupational noise exposure are also more likely to be able to benefit from hearing services.
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American Journal of Audiology N Vol. 22 N 167–170 N June 2013
This may be explained because all of these factors indicate greater likelihood of at least moderate levels of hearing loss, which could be taken into account by the referring physicians. There was a difference between participants who used hearing aids and those who did not (including those who did not have them and those who did have them but did not use them). We looked at the multivariate data controlling for age and hearing loss, and they are similar to the univariate data (chi squared) described here for simplicity. The hearing aid users were more likely than the nonusers to have high blood pressure (56% vs. 42%, p ≤ 0.01), be forgetful (63% vs. 47%, p ≤ 0.01), have sleep problems (56% vs. 44%, p ≤ 0.01), and suffer from depression (15% vs. 8%, p ≤ 0.01). In terms of lifestyle, the hearing aid users reported lower quality of life, scoring
Adult Hearing Screening: Health Policy Issues—What Happens Next?1 Adrian Davisa and Pauline Smithb
Purpose: Ten percent of adults in England have some type of hearing loss and would greatly benefit from hearing aids or other forms of hearing management. However, 76% of these adults do not have hearing aids or other management. The impact of this unmet need can be substantial and has been linked to depression, social isolation, employment problems, loss of independence, and dementia. This article explores how hearing screening—universal, targeted, or opportunistic—can address prevalent, incident, and future needs for hearing services as well as better define the extent of need. Method: Adults age ≥60 years living at home in England took part in a health survey, part of which was to determine the extent of need for hearing services in this population. Survey
methods included a face-to-face interview and hearing screening using pure tones as well as a self-report questionnaire on other health issues. Results: The survey highlighted additional hearing-related factors that will enable referral decisions in primary care to be made with reasonable confidence that patients will use hearing aids and benefit from them. Some relevant nonhearing factors are also reported. Conclusion: There is a growing aging population with increasing needs and expectations for hearing services. Targeted screening and triage in primary care, as well as use of advanced technologies, are discussed for the future.
I
hospital audiology services after visiting their primary care physician with reported hearing problems. The impact of this unmet need for hearing services can be substantial and has been linked to depression, social isolation, employment problems, loss of dependence, and dementia (Hjalte, Bra¨nnstro¨m, & Gerdtham, 2012; Huang, Dong, Lu, Yue, & Liu, 2010; Lin et al., 2011; Morris, Lutman, Cook, & Turner, 2012).
n England, 10% of individuals ages 18–80 years, or 4.9 million, have a moderate level of hearing loss (>35 dB HL in the better hearing ear averaged across 0.5–4.0 kHz) that would greatly benefit from hearing aids or other forms of hearing management. However, 76%, or 3.8 million, of them do not have hearing aids or other clinical management (Davis, 1995, updated to current population demographics). So there is significant unmet need for hearing services not just from mild cases of hearing loss, but across all severities. Table 1 shows the numbers of people in England in each severity category as well as cumulatively (e.g., 4.9 million have at least a moderate hearing loss). Our study for the U.K. Health Technology Assessment (HTA) Programme (Davis, Smith, Ferguson, Stephens, & Gianopoulos, 2007) found that of the 14% of 55- to 74-year-olds who have a bilateral hearing impairment of at least 35 dB HL, only 3% currently receive intervention through use of hearing aids. The HTA report also found that only 41% in that same age range were referred to a
Royal Free London NHS Foundation Trust, UK b University Hospitals of Leicester NHS Trust, UK Correspondence to Adrian Davis: [email protected]
Key Words: hearing loss, screening, auditory rehabilitation
Meeting Unmet Need Given the high prevalence of hearing loss, we need to continually address the unmet need in the population if we are to ensure that adults age well. This unmet need is substantial because many people delay seeking help, often for more than 10 years. Prevention of disability will include identifying the ability to benefit from interventions to improve hearing, communication, and quality of life.
Screening for Hearing Loss: The Evidence We have shown that hearing screening can be cost effective (Davis et al., 2007; Morris et al., 2012) in the United Kingdom, but questions remain about its acceptability or impact. This article explores how screening for hearing loss,
Editor: Larry Humes Received November 5, 2012 Accepted February 18, 2013 DOI: 10.1044/1059-0889(2013/12-0062)
1
Part of this work was presented at AHS 2012, the 2nd International Conference on Adult Hearing Screening, June 7–9, 2012, in Cernobbio (Lake Como), Italy.
American Journal of Audiology N Vol. 22 N 167–170 N June 2013 N ß American Speech-Language-Hearing Association
167
Table 1. Number of people in England with varying severities of hearing loss. Severity of hearing loss People # in each category # cumulatively
Mild
Moderate
Severe
Profound
5,804,578 10,775,582
2,735,013 4,971,004
1,847,909 2,235,991
388,082 388,082
whether universal, targeted, or opportunistic, can address prevalent, incident, and future needs for hearing services as well as better define the extent of need.
Method In 2011, we conducted a survey to determine the extent of need for hearing services in adults age ≥60 years. We also looked at comorbidity: Are there target groups that might give high yield for more cost-effective screening? Our sample consisted of 1,000 people in England living at home who were age 60 years or older (>80% of people provided with hearing aids in England are ≥60 years old), randomized with quota sampling for age. The survey included a face-toface interview followed by a hearing screening test using the Siemens HearCheck Screener, which is a handheld batteryoperated device that is suitable to use in patients’ homes and/ or in primary care or community settings. Tones at two frequencies were presented: 1 kHz at 55, 35, and 20 dB HL and 3 kHz at 75, 55, and 35 dB HL. Participants also completed a self-report questionnaire concerning other health issues.
Results Some of the key findings of the study were that (a) 13% of the participants said that they had seen their primary care/hospital doctor about their hearing in the last year, (b) 14% already wore hearing aid/s, (c) 3% had tried hearing aids but did not wear them now, and (d) ,80% of those fitted with hearing aids used them. Our HTA study (Davis et al., 2007) indicated that 35 dB HL 3 kHz loss is a research-based, objectively measurable starting point for primary care physicians in deciding whether to refer a patient to secondary care for further assessment. Our 2011 survey highlighted additional hearing-related factors that will enable these physicians in the consultation to make the decision to refer with reasonable confidence, in that referral and assessment will result in the patient using hearing aids and benefiting from them. For example, we found that the more patients emphasize hearing difficulty (indicating greater hearing loss and greater impact of that hearing loss), the more likely they are to be able to access and benefit from hearing services, based on earlier findings from the HTA study (Davis et al., 2007). Similarly, patients who reported annoyance from loud sounds, tinnitus, a tendency to dizziness, or occupational noise exposure are also more likely to be able to benefit from hearing services.
168
American Journal of Audiology N Vol. 22 N 167–170 N June 2013
This may be explained because all of these factors indicate greater likelihood of at least moderate levels of hearing loss, which could be taken into account by the referring physicians. There was a difference between participants who used hearing aids and those who did not (including those who did not have them and those who did have them but did not use them). We looked at the multivariate data controlling for age and hearing loss, and they are similar to the univariate data (chi squared) described here for simplicity. The hearing aid users were more likely than the nonusers to have high blood pressure (56% vs. 42%, p ≤ 0.01), be forgetful (63% vs. 47%, p ≤ 0.01), have sleep problems (56% vs. 44%, p ≤ 0.01), and suffer from depression (15% vs. 8%, p ≤ 0.01). In terms of lifestyle, the hearing aid users reported lower quality of life, scoring
