Racial/Ethnic and Sex Representation in US-Based Clinical Trials of Hearing Loss Management in Adults: A Systematic Review

"Close to My Community": A Qualitative Study of Community Health Worker-Supported Teleaudiology Hearing Aid Services

OBJECTIVES

Given well-documented disparities in rural and minority communities, alternative service delivery models that help improve access to hearing care are needed. This article reports on a study of older Latino adults with hearing loss who received hearing aid services with Community Health Workers (CHWs) providing support via teleaudiology. The present study used qualitative data to explore perceptions of this novel service delivery model.

DESIGN

Participants completed semistructured interviews related to their experiences in the intervention approximately 17 weeks after the hearing aid fitting appointment. Two coders independently coded the data, using an iterative deductive and inductive thematic analysis approach. Inter-rater reliability was good (κ = 0.80).

RESULTS

Of the 28 participants, 19 were interviewed (CHW group: n = 9, 8 females; non-CHW group: n = 10, 9 females). Both groups of participants reported experiencing barriers in access to care and reported positive experiences with teleaudiology and with hearing aids as part of the trial. CHW group participants reported interactions with patient-site facilitators that were indicative of patient-centeredness.

CONCLUSIONS

Results demonstrate the feasibility and potential effectiveness of trained CHWs as patient-site facilitators in teleaudiology-delivered hearing aid services for adults.

Country Differences in Older Men's Hearing Difficulty Disadvantage

Objectives: Hearing difficulty is prevalent in older adulthood and projected to increase via global aging, particularly among men. Currently, there is limited research on how this gender disparity might vary by country. Methods: Using 2018 data (n = 29,480) from the Health and Retirement Study (HRS) international family of studies, we investigate gender disparities in hearing difficulty among respondents ages 55-89 from the United States (n = 12,566), Mexico (n = 10,762), and Korea (n = 6152) with country-specific ordinal logistic regression models that progressively adjust for demographic, social, and health indicators. Results: In the United States, men's hearing difficulty disadvantage was consistently observed. In Mexico, men's hearing difficulty disadvantage was explained by the interactive effect of gender and age group but resurfaced after adjusting for comorbidities. In Korea, there was consistently no gender difference in hearing difficulty. Discussion: Our results highlight the heterogeneity in older men's hearing difficulty disadvantage among a diverse group of aging countries.

Participant characteristics and exclusion from phase 3/4 industry funded trials of chronic medical conditions: meta-analysis of individual participant level data

Objectives

To assess whether age, sex, comorbidity count, and race and ethnic group are associated with the likelihood of trial participants not being enrolled in a trial for any reason (ie, screen failure).

Design

Bayesian meta-analysis of individual participant level data.

Setting

Industry funded phase 3/4 trials of chronic medical conditions.

Participants

Participants were identified using individual participant level data to be in either the enrolled group or screen failure group. Data were available for 52 trials involving 72 178 screened individuals of whom 24 733 (34%) were excluded from the trial at the screening stage.

Main outcome measures

For each trial, logistic regression models were constructed to assess likelihood of screen failure in people who had been invited to screening, and were regressed on age (per 10 year increment), sex (male v female), comorbidity count (per one additional comorbidity), and race or ethnic group. Trial level analyses were combined in Bayesian hierarchical models with pooling across condition.

Results

In age and sex adjusted models across all trials, neither age nor sex was associated with increased odds of screen failure, although weak associations were detected after additionally adjusting for comorbidity (odds ratio of age, per 10 year increment was 1.02 (95% credibility interval 1.01 to 1.04) and male sex (0.95 (0.91 to 1.00)). Comorbidity count was weakly associated with screen failure, but in an unexpected direction (0.97 per additional comorbidity (0.94 to 1.00), adjusted for age and sex). People who self-reported as black seemed to be slightly more likely to fail screening than people reporting as white (1.04 (0.99 to 1.09)); a weak effect that seemed to persist after adjustment for age, sex, and comorbidity count (1.05 (0.98 to 1.12)). The between-trial heterogeneity was generally low, evidence of heterogeneity by sex was noted across conditions (variation in odds ratios on log scale of 0.01-0.13).

Conclusions

Although the conclusions are limited by uncertainty about the completeness or accuracy of data collection among participants who were not randomised, we identified mostly weak associations with an increased likelihood of screen failure for age, sex, comorbidity count, and black race or ethnic group. Proportionate increases in screening these underserved populations may improve representation in trials.

Trial registration number

PROSPERO CRD42018048202.

Clinical Practice Guideline: Age-Related Hearing Loss Executive Summary

OBJECTIVE

Age-related hearing loss (ARHL) is a prevalent but often underdiagnosed and undertreated condition among individuals aged 50 and above. It is associated with various sociodemographic factors and health risks including dementia, depression, cardiovascular disease, and falls. While the causes of ARHL and its downstream effects are well defined, there is a lack of priority placed by clinicians as well as guidance regarding the identification, education, and management of this condition.

PURPOSE

The purpose of this clinical practice guideline is to identify quality improvement opportunities and provide clinicians trustworthy, evidence-based recommendations regarding the identification and management of ARHL. These opportunities are communicated through clear actionable statements with an explanation of the support in the literature, the evaluation of the quality of the evidence, and recommendations on implementation. The target patients for the guideline are any individuals aged 50 years and older. The target audience is all clinicians in all care settings. This guideline is intended to focus on evidence-based quality improvement opportunities judged most important by the Guideline Development Group (GDG). It is not intended to be a comprehensive, general guide regarding the management of ARHL. The statements in this guideline are not intended to limit or restrict care provided by clinicians based on their experience and assessment of individual patients.

ACTION STATEMENTS

The GDG made strong recommendations for the following key action statements (KASs): (KAS 4) If screening suggests hearing loss, clinicians should obtain or refer to a clinician who can obtain an audiogram. (KAS 8) Clinicians should offer, or refer to a clinician who can offer, appropriately fit amplification to patients with ARHL. (KAS 9) Clinicians should refer patients for an evaluation of cochlear implantation candidacy when patients have appropriately fit amplification and persistent hearing difficulty with poor speech understanding. The GDG made recommendations for the following KASs: (KAS 1) Clinicians should screen patients aged 50 years and older for hearing loss at the time of a health care encounter. (KAS 2) If screening suggests hearing loss, clinicians should examine the ear canal and tympanic membrane with otoscopy or refer to a clinician who can examine the ears for cerumen impaction, infection, or other abnormalities. (KAS 3) If screening suggests hearing loss, clinicians should identify sociodemographic factors and patient preferences that influence access to and utilization of hearing health care. (KAS 5) Clinicians should evaluate and treat or refer to a clinician who can evaluate and treat patients with significant asymmetric hearing loss, conductive or mixed hearing loss, or poor word recognition on diagnostic testing. (KAS 6) Clinicians should educate and counsel patients with hearing loss and their family/care partner(s) about the impact of hearing loss on their communication, safety, function, cognition, and quality of life. (KAS 7) Clinicians should counsel patients with hearing loss on communication strategies and assistive listening devices. (KAS 10) For patients with hearing loss, clinicians should assess if communication goals have been met and if there has been improvement in hearing-related quality of life at a subsequent health care encounter or within 1 year. The GDG offered the following KAS as an option: (KAS 11) Clinicians should assess hearing at least every 3 years in patients with known hearing loss or with reported concern for changes in hearing.

Clinical Practice Guideline: Age-Related Hearing Loss

OBJECTIVE

Age-related hearing loss (ARHL) is a prevalent but often underdiagnosed and undertreated condition among individuals aged 50 and above. It is associated with various sociodemographic factors and health risks including dementia, depression, cardiovascular disease, and falls. While the causes of ARHL and its downstream effects are well defined, there is a lack of priority placed by clinicians as well as guidance regarding the identification, education, and management of this condition.

PURPOSE

The purpose of this clinical practice guideline is to identify quality improvement opportunities and provide clinicians trustworthy, evidence-based recommendations regarding the identification and management of ARHL. These opportunities are communicated through clear actionable statements with explanation of the support in the literature, evaluation of the quality of the evidence, and recommendations on implementation. The target patients for the guideline are any individuals aged 50 years and older. The target audience is all clinicians in all care settings. This guideline is intended to focus on evidence-based quality improvement opportunities judged most important by the guideline development group (GDG). It is not intended to be a comprehensive, general guide regarding the management of ARHL. The statements in this guideline are not intended to limit or restrict care provided by clinicians based on their experience and assessment of individual patients.

ACTION STATEMENTS

The GDG made strong recommendations for the following key action statements (KASs): (KAS 4) If screening suggests hearing loss, clinicians should obtain or refer to a clinician who can obtain an audiogram. (KAS 8) Clinicians should offer, or refer to a clinician who can offer, appropriately fit amplification to patients with ARHL. (KAS 9) Clinicians should refer patients for an evaluation of cochlear implantation candidacy when patients have appropriately fit amplification and persistent hearing difficulty with poor speech understanding. The GDG made recommendations for the following KASs: (KAS 1) Clinicians should screen patients aged 50 years and older for hearing loss at the time of a health care encounter. (KAS 2) If screening suggests hearing loss, clinicians should examine the ear canal and tympanic membrane with otoscopy or refer to a clinician who can examine the ears for cerumen impaction, infection, or other abnormalities. (KAS 3) If screening suggests hearing loss, clinicians should identify sociodemographic factors and patient preferences that influence access to and utilization of hearing health care. (KAS 5) Clinicians should evaluate and treat or refer to a clinician who can evaluate and treat patients with significant asymmetric hearing loss, conductive or mixed hearing loss, or poor word recognition on diagnostic testing. (KAS 6) Clinicians should educate and counsel patients with hearing loss and their family/care partner(s) about the impact of hearing loss on their communication, safety, function, cognition, and quality of life (QOL). (KAS 7) Clinicians should counsel patients with hearing loss on communication strategies and assistive listening devices. (KAS 10) For patients with hearing loss, clinicians should assess if communication goals have been met and if there has been improvement in hearing-related QOL at a subsequent health care encounter or within 1 year. The GDG offered the following KAS as an option: (KAS 11) Clinicians should assess hearing at least every 3 years in patients with known hearing loss or with reported concern for changes in hearing.

Demographic Representation in Clinical Research Relative to a Cochlear Implant Patient Population

OBJECTIVES

Research samples that are representative of patient populations are needed to ensure the generalizability of study findings. The primary aim was to assess the efficacy of a study design and recruitment strategy in obtaining a participant sample that was representative of the broader cochlear implant (CI) patient population at the CI center. A secondary aim was to review whether the CI recipient population was representative of the state population.

METHODS

Demographic variables were compared for a research participant sample (n = 79) and the CI patient population (n = 338). The participant sample was recruited from the CI patient population. The study design included visits that were at the same location and frequency as the recommended clinical follow-up intervals. The demographics for the combined group (participant sample and patient population) were then compared to the reported demographics for the population in North Carolina.

RESULTS

There were no significant differences between the participant sample and patient population for biological sex, age at implantation, racial distribution, socioeconomic position, degree of urbanization, or drive time to the CI center (p ≥ 0.086). The combined CI recipient population was significantly different from the North Carolina population for the distributions of race, ethnicity, and degree of urbanization (p < 0.001).

CONCLUSION

The study design and recruitment strategy allowed for recruitment of a participant sample that was representative of the CI patient population. Disparities in access to cochlear implantation persist, as supported by the significant differences in the combined CI recipient population and the population for our state.

LEVEL OF EVIDENCE

3 Laryngoscope, 2024.

National Cohort Data Suggests an Association Between Serious Mental Illness and Audiometric Hearing Loss

OBJECTIVE

To explore whether there is an association between serious mental illness (SMI) and hearing loss (HL) among US Hispanic adults.

STUDY DESIGN AND SETTING

Cross-sectional epidemiological study (Hispanic Community Health Study), including multicentered US volunteers.

METHODS

Multivariable linear regressions were conducted to study the association between SMI and HL. Adjustments were made for potential confounders including age, sex, education, vascular disease (hypertension or diabetes mellitus), and cognition. SMI was defined by (1) antipsychotic medication classification and (2) the use of at least 1 antipsychotic medication specifically used to treat SMI in clinical psychiatric practice. HL was measured by pure tone audiometry.

RESULTS

A total of 7581 subjects had complete data. The mean age was 55.2 years (SD = 7.5 years) and the mean pure tone average in the better ear was 16.8 dB (SD = 10.7 dB). A total of 194 (2.6%) subjects were taking a HCHS-defined antipsychotic and 98 (1.3%) were taking at least 1 antipsychotic specifically used to treat SMI. On multivariable regression, use of HCHS's classified antipsychotics was associated with 3.75 dB worse hearing (95% confidence interval [CI] = 2.36-5.13, P < .001) and use of antipsychotics specific for SMI was associated with 4.49 dB worse hearing (95% CI = 2.56-6.43, P < .001) compared to those not using antipsychotics.

CONCLUSION

SMI, as defined by either the use of HCHS-defined antipsychotics or the use of antipsychotic medication specific for SMI, is associated with worse hearing, controlling for potential confounders. Whether SMI contributes to HL, antipsychotic medication (through ototoxicity) contributes to HL, or whether HL contributes to SMI is unknown and warrants further investigation.

Hearing loss and cognitive decline: Prioritizing equity in a world in which hearing health matters

Alzheimer's disease and related dementias (ADRDs) and age-related hearing loss are the intersection of two major public health challenges. With age as the primary risk factor for both disease processes, the burden of ADRDs and age-related hearing loss is growing, and each field maintains significant barriers to broadscale identification and management that is affordable and accessible. With the disproportionate burden of ADRDs among racial and ethnic minority older adults and existing disparities within hearing care, both areas face challenges in achieving equitable access and outcomes across diverse populations. The publication of the Aging and Cognitive Health Evaluation in Elders (ACHIEVE) trial in July 2023 marked a significant moment in the fields of brain and hearing health. The ACHIEVE trial was the first randomized controlled trial to examine whether providing hearing intervention, specifically provision of hearing aids, compared to an education control, would reduce cognitive changes over 3 years. The participants most at risk for cognitive decline, with lower education, lower income, more likely to identify as Black, and have more cardiovascular risk factors, were the participants who benefited most from the hearing intervention and are also the least likely to be represented in research and the least likely to obtain hearing care. With growing evidence of the interconnection between cognitive and sensory health, we have an opportunity to prioritize equity, from purposeful inclusion of diverse participants in trials to influencing the emerging market of over-the-counter hearing aids to supporting expanded models of hearing care that reach those who have traditionally gone unserved. No longer can hearing go unrecognized by clinicians, researchers, and advocates for brain health. At the same time, the fields of brain and hearing health must center equity if we are going to meet the needs of diverse older adults in a world in which hearing health matters.

Use of Socioeconomic Demographic Data in Studies on Pediatric Unilateral Hearing Loss: A Scoping Review

OBJECTIVES

Social determinants of health (SDOH) (healthcare access and quality, education access and quality, socioeconomic status, social and cultural context, neighborhood and built environment) ( Healthy People 2030 ) have been shown to impact a wide range of health-related outcomes and access to care. Given the medical and nonmedical costs associated with children with unilateral hearing loss (UHL), the varied insurance coverage for hearing healthcare services, and the differences in hearing aid utilization rates between children of different sociodemographic classes, the sociodemographic information of children with UHL enrolled in research studies should be collected to ensure the generalizability of hearing healthcare interventions. Therefore, the objective of this scoping review is to assess the reporting of SDOH data for participants in studies of pediatric UHL and its comparison to population trends.

DESIGN

Two searches of published literature were conducted by a qualified medical librarian. Two reviewers then evaluated all candidate articles. Study inclusion parameters were from 2010 to present, peer-reviewed studies with prospective study design, and participant population including children (age 0 to 18 years old) with UHL.

RESULTS

Two literature searches using PubMed Medline and Embase found 442 and 3058 studies each for review. After abstract and paper review, 87 studies were included in final qualitative review, with 22 of these studies reporting race distribution of participants, 15 reporting insurance status or family income, and 12 reporting the maternal education level.

CONCLUSIONS

Sociodemographic data are not commonly reported in research studies of children with UHL. In reported samples, research participants are more likely to have private insurance and higher family income compared with overall population distribution. These demographic biases may affect the generalizability of study results to all children with UHL. Further evaluation is warranted to evaluate whether participant recruitment affects outcomes that reflect the overall population.

Risk factors associated with occupational noise-induced hearing loss in the Hispanic community health study/study of Latinos: A cross-sectional epidemiologic investigation

The purpose of this study was to estimate the prevalence of occupational noise exposure and risk factors of occupational noise-induced hearing loss (NIHL) in Hispanic/Latino adults included in the baseline wave of the Hispanic Community Health Study/Study of Latinos collected from 2008 to 2011. Sequential multiple linear regression modeled the relationship between occupational NIHL (defined as a 3-, 4-, 6-kHz pure-tone average [PTA]) and occupation type, self-reported noise exposure, cardiovascular disease (CVD) risk score, and hearing protective device (HPD) use. The final model controlled for sex, age, and recreational noise exposure. Among 12,851 included participants, approximately 40% (n = 5036) reported occupational noise exposure "Sometimes" (up to 50% of the time) or "Frequently" (75-100% of the time). In the final fitted model, longest-held occupation and CVD risk were associated with poorer hearing. Specifically, those in non-skilled, service, skilled, and military/police/other job categories had between 2.07- and 3.29-dB worse PTA than professional/office workers. Additionally, a shift in the CVD risk score category from low to medium was associated with a 2.25- and 8.20-dB worse PTA for medium and high CVD risk, respectively. Age and sex were also significantly associated with poorer hearing, such that men presented with 6.08 dB worse PTA than women, and for every one-year increase in age, PTA increased by 0.62 dB (ps < .001). No interactions were seen between noise*sometimes or frequent exposure to other ototoxic agents and PTA (ps = .33 & .92, respectively). The prevalence of occupational noise exposure was high in this cross-sectional investigation of adults from Hispanic/Latino backgrounds. Findings contribute to the extant literature by demonstrating that risk factors for occupational NIHL in adults from varying Hispanic/Latino backgrounds are consistent with those of other previously studied groups.

Sex and Race Representation in Temporal Bone Histopathology Studies in the United States: A Systematic Review

OBJECTIVES

The author's objective was to evaluate sex and race representation in temporal bone histopathology studies.

DESIGN

PubMed, Embase, Cochrane, Web of Science, and Scopus were searched for studies written in English examining temporal bone histopathology specimens from U.S.-based institutions from January 1, 1947, to September 1, 2021. Two authors then performed "snowballing" by reviewing references from the initial search and included the studies that fulfilled the inclusion criteria. For each study, the following information was collected: publication details, study design, funding, institution from where temporal bone specimens were procured, number of study specimens, and donor demographical information.

RESULTS

The authors found that out of 300 studies, 166 (55%) report sex while only 15 (5%) reported race information. Over the past 70 years, the ratio of studies reporting sex to those that do not has increased from 1.00 to 2.19 and the number of female temporal bone histopathology subjects relative to male has increased from 0.67 to 0.75. Over 90% of studies that do report this information feature participant racial compositions that do not reflect the diversity of the U.S. population.

CONCLUSIONS

Studies of temporal bone histopathology often do not report participant sex or race. The reporting of participant sex and the inclusion of specimens from female donors have both increased over time. However, temporal bone histopathology study cohorts are not representative of the racial diversity of the U.S. population. The otolaryngology community must strive to build temporal bone histopathology libraries that are representative of the diverse U.S. population.

Evidence-Based Medicine in Otolaryngology Part 14: Falsehood and Bias

OBJECTIVE

Falsehood and bias can have tangible effects, whether related to the "hoax" of Corona virus disease/COVID-19 or the impact of personal protective equipment in city-wide news. The spread of false information requires the diversion of time and resources into rebolstering the truth. Our objective is thus to elucidate types of bias that may influence our daily work, along with ways to mitigate them.

DATA SOURCES

Publications are included which delineate specific aspects of bias or address how to preempt, mitigate, or correct bias, whether conscious or unconscious.

REVIEW METHODS

We discuss: (1) the background and rationale for proactively considering potential sources of bias, (2) relevant definitions and concepts, (3) potential means to limit effects of inaccurate data sources, and (4) evolving frontiers in the management of bias. In doing so, we review epidemiological concepts and susceptibility to bias within study designs, including database studies, observational studies, randomized controlled trials (RCTs), systematic reviews, and meta-analyses. We additionally discuss concepts such as the difference between disinformation and misinformation, differential or nondifferential misclassification, bias toward a null result, and unconscious bias, among others.

CONCLUSION

We have the means to mitigate sources of potential bias in database studies, observational studies, RCTs, and systematic reviews, beginning with education and awareness.

IMPLICATIONS FOR PRACTICE

False information may spread faster than true information, so it is beneficial to understand potential sources of falsehood we face, in order to safeguard our daily impressions and decisions. Awareness of potential sources of falsehood and bias forms the foundation for accuracy in our everyday work.

Reporting of Sociodemographic Data in Cochlear Implant Clinical Trials: A Systematic Review

OBJECTIVE

The purpose of this study was to systematically evaluate the literature on the frequency of reporting of sociodemographic data (gender, race, ethnicity, education status, health insurance status, geographic location of residence, and socioeconomic status) among interventional clinical trials involving cochlear implant patients.

DATABASES REVIEWED

A systematic search was performed in PubMed, Cochrane Database of Systematic Reviews, Web of Science, and SCOPUS to identify peer reviewed research.

METHODS

A systematic review was performed, which included original prospective clinical trial research studies involving cochlear implantation and/or interventional trials involving cochlear implant patients. Collected data included funding type, level of evidence, race reporting, ethnicity reporting, socioeconomic status reporting, education level reporting, type of insurance, geographic location, and gender of patients.

RESULTS

A total of 644 articles were included for review. Gender was the most reported sociodemographic factor (70% of included studies). Reporting of other data among included studies was low: educational level (6%), socioeconomic status (2%), race (1%), ethnicity (1%), insurance status (0.3%), and geography (1%). The odds of reporting gender (odds ratio [OR] = 1.51), education (OR = 1.81), and geography (OR = 2.72) increased with each subsequent publication date decade; however, this trend was not seen for reporting of race, ethnicity, socioeconomic status, or insurance. The reporting of gender was less likely to be reported in studies with the pediatric participants (OR = 0.62), level II evidence (OR = 0.14), and device programming interventional studies (OR = 0.26).

CONCLUSION

Reporting of sociodemographic data, other than gender, is low among prospective clinical trials involving cochlear implant patients. The lack of reporting of this key data may limit research rigor and generalizability. Clinical researchers are advised to prospectively collect these data to promote equity in cochlear implant research and clinical care.

Sex-Linked Biology and Gender-Related Research Is Essential to Advancing Hearing Health

There is robust evidence that sex (biological) and gender (behavioral/social) differences influence hearing loss risk and outcomes. These differences are noted for animals and humans-in the occurrence of hearing loss, hearing loss progression, and response to interventions. Nevertheless, many studies have not reported or disaggregated data by sex or gender. This article describes the influence of sex-linked biology (specifically sex-linked hormones) and gender on hearing and hearing interventions, including the role of sex-linked biology and gender in modifying the association between risk factors and hearing loss, and the effects of hearing loss on quality of life and functioning. Most prevalence studies indicate that hearing loss begins earlier and is more common and severe among men than women. Intrinsic sex-linked biological differences in the auditory system may account, in part, for the predominance of hearing loss in males. Sex- and gender-related differences in the effects of noise exposure or cardiovascular disease on the auditory system may help explain some of these differences in the prevalence of hearing loss. Further still, differences in hearing aid use and uptake, and the effects of hearing loss on health may also vary by sex and gender. Recognizing that sex-linked biology and gender are key determinants of hearing health, the present review concludes by emphasizing the importance of a well-developed research platform that proactively measures and assesses sex- and gender-related differences in hearing, including in understudied populations. Such research focus is necessary to advance the field of hearing science and benefit all members of society.

Effect of a Community Health Worker-Delivered Personal Sound Amplification Device on Self-Perceived Communication Function in Older Adults With Hearing Loss: A Randomized Clinical Trial

IMPORTANCE

Age-related hearing loss that impairs daily communication is associated with adverse health outcomes, but use of hearing aids by older adults is low and disparities exist.

OBJECTIVE

To test whether an affordable, accessible hearing care intervention, delivered by community health workers using over-the-counter hearing technology, could improve self-perceived communication function among older adults with hearing loss compared with a wait-list control.

DESIGN, SETTING, AND PARTICIPANTS

Open-label randomized clinical trial conducted between April 2018 and October 2019 with 3-month data collection completed in June 2020. The trial took place at 13 community sites, including affordable independent housing complexes (n = 10), senior centers (n = 2), and an older adult social club (n = 1) in Baltimore, Maryland. A total of 151 participants aged 60 years or older with hearing loss were randomized.

INTERVENTIONS

Participants were randomized to receive a community health worker-delivered hearing care intervention (n = 78) or to a wait-list control group (n = 73). The 2-hour intervention consisted of fitting a low-cost amplification device and instruction.

MAIN OUTCOMES AND MEASURES

The primary outcome was change in self-perceived communication function (Hearing Handicap Inventory for the Elderly-Screening Version [HHIE-S]; score range, 0-40; higher scores indicate poorer function) from baseline to 3 months postrandomization. The average treatment effect was estimated using the doubly robust weighted least squares estimator, which uses an outcome regression model weighted by the inverse probability of attrition to account for baseline covariate imbalance and missing data.

RESULTS

Among 151 participants randomized (mean age, 76.7 [SD, 8.0] years; 101 [67.8%] women; 65 [43%] self-identified as African American; 96 [63.6%] with low income [<$25 000 annual household income]), 136 (90.1%) completed 3-month follow-up for the primary outcome. In the intervention group, 90.5% completed the intervention session and reported at least 1 hour of daily amplification use at 3 months postrandomization. Mean scores for the HHIE-S were 21.7 (SD, 9.4) at baseline and 7.9 (SD, 9.2) at 3 months (change of -13.2 [SD, 10.3]) in the intervention group, and 20.1 (SD, 10.1) at baseline and 21 (SD, 9.1) at 3 months (change of 0.6 [SD, 7.1]) in the control group. Self-perceived communication function significantly improved in the intervention group compared with the control group, with an estimated average treatment effect of the intervention of a -12.98-point HHIE-S change (95% CI, -15.51 to -10.42). No study-related adverse events were reported.

CONCLUSIONS AND RELEVANCE

Among older adults with hearing loss, a community health worker-delivered personal sound amplification device intervention, compared with a wait-list control, significantly improved self-perceived communication function at 3 months. Findings are limited by the absence of a sham control, and further research is needed to understand effectiveness compared with other types of care delivery models and amplification devices.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT03442296.

A Five-Year Update on the Profile of Adults Undergoing Cochlear Implant Evaluation and Surgery-Are We Doing Better?

OBJECTIVE

To characterize the influence of expanding indications on the profile of adults undergoing cochlear implantation (CI) at a high-volume CI center.

STUDY DESIGN

Retrospective review.

SETTING

Tertiary referral center.

PATIENTS

774 adults undergoing CI evaluation from August 2015 to August 2020.

MAIN OUTCOME MEASURES

Demographics; audiometry; speech recognition; speech, spatial, and qualities of hearing scale (SSQ-12).

RESULTS

Of 745 (96.3%) patients qualifying for implantation, 642 (86.6%) pursued surgery. Median age at evaluation was 69 years; 56.3% were men; 88.2% were Caucasian. Median distance to our center was 95 miles. The majority (51.8%) had public insurance (Medicare, Medicaid), followed by private (47.8%) and military (0.4%). Mean PTA, CNC, and AzBio in quiet and noise for the ear to be implanted were 85.2 dB HL, 15.0%, and 19.2% and 3.5%, respectively. Hybrid/EAS criteria were met by 138 (18.5%) CI candidates, and 436 (77.0%) unilateral CI recipients had aidable contralateral hearing for bimodal hearing configurations. Younger age (odds ratio [OR], 0.96; 95% confidence interval, 0.93-0.99) and non-Caucasian race (OR, 6.95; 95% confidence interval, 3.22-14.98) predicted candidacy. Likelihood of surgery increased for Caucasian (OR, 8.08; 95% confidence interval, 4.85-13.47) and married (OR, 2.28; 95% confidence interval, 1.50-3.47) patients and decreased for those with public insurance (OR, 0.45; 95% confidence interval, 0.29-0.69). A lower SSQ-12 score predicted both candidacy and surgery.

CONCLUSION

Despite expansions in criteria, speech understanding remained extremely low at CI evaluation. Younger age and non-Caucasian race predicted candidacy, and Caucasian, married patients with private insurance and lower SSQ scores were more likely to pursue surgery.

Speech-in-noise testing: Innovative applications for pediatric patients, underrepresented populations, fitness for duty, clinical trials, and remote services

Speech perception testing, defined as providing standardized speech stimuli and requiring a listener to provide a behavioral and scored response, has been an integral part of the audiologic test battery since the beginning of the audiology profession. Over the past several decades, limitations in the diagnostic and prognostic validity of standard speech perception testing as routinely administered in the clinic have been noted, and the promotion of speech-in-noise testing has been highlighted. This review will summarize emerging and innovative approaches to speech-in-noise testing with a focus on five applications: (1) pediatric considerations promoting the measurement of sensory and cognitive components separately; (2) appropriately serving underrepresented populations with special attention to racial, ethnic, and linguistic minorities, as well as considering biological sex and/or gender differences as variables of interest; (3) binaural fitness for duty assessments of functional hearing for occupational settings that demand the ability to detect, recognize, and localize sounds; (4) utilization of speech-in-noise tests in pharmacotherapeutic clinical trials with considerations to the drug mechanistic action, the patient populations, and the study design; and (5) online and mobile applications of hearing assessment that increase accessibility and the direct-to-consumer market.

Race/Ethnicity, Gender, and Socioeconomic Status Representation in U.S.-Based Randomized Controlled Trials of Tinnitus: A Systematic Review

PURPOSE

The purpose of this study was to investigate if peer-reviewed randomized controlled trials (RCTs) for the management/treatment of tinnitus conducted in the United States include diverse participants in terms of gender, race/ethnicity, education, occupation, and income.

METHOD

We performed a comprehensive and systematic literature search via PubMed, Web of Science, Clinical-Trials.gov, and the Cochrane Central Register of Controlled Trials. Our goal was to identify prospective RCTs of tinnitus intervention conducted in the United States from January 1994 to September 2021 and published in peer-reviewed journals.

RESULTS

A total of 2,584 studies were retrieved. Thirty-two peer-reviewed articles met all inclusion criteria. Of the included studies, approximately 96% reported participants' gender. Approximately 15% studies reported race/ethnicity information in alignment with the U.S. Census Bureau. However, an underrepresentation of both females and people of color was evident across studies. Reporting of socioeconomic status information of participants was also scarce, with only 25% studies reporting education and/or occupation of participants and 0% reporting income levels.

CONCLUSIONS

This study indicates underrepresentation and underreporting of diverse participant pools in tinnitus research. Reasons for such underrepresentation are explored. Additionally, this systematic review indicates that recent research in tinnitus portrays an optimistic trend in terms of reporting and recruitment of diverse participant groups. Sustainable strategies for including diverse research participants are essential for hearing health care equity. Research and strategies to promote this goal are discussed.

Expanding Clinical Trials Designs to Extend Equitable Hearing Care

Clinical trials are critically important to translate scientific innovations into clinical practice. Hearing healthcare depends on this translational approach to improve outcomes and quality of life. Across the spectrum of healthcare, there is a lack of diverse participation in clinical trials, a failure to recruit and retain underrepresented and underserved populations, and an absence of rigorous dissemination and implementation of novel research to broader populations. The field of hearing healthcare research would benefit from expanding the types and designs of clinical trials that extend hearing healthcare and novel interventions to diverse populations, as well as emphasizing trials that evaluate factors influencing how that care can be delivered effectively. This article explores the following: (1) the role, value, and design types of clinical trials (randomized controlled, cluster randomized, stepped wedge, and mixed methods) to address health equity; (2) the importance of integrating community and stakeholder involvement; and (3) dissemination and implementation frameworks and designs for clinical trials (hybrid trial designs). By adopting a broader range of clinical trial designs, hearing healthcare researchers may be able to extend scientific discoveries to a more diverse population.

Underreporting and Underrepresentation of Race and Ethnicity in Head and Neck Cancer Trials, 2010-2020: A Systematic Review

Importance

There is substantial evidence demonstrating racial disparities in the survival outcomes of patients with head and neck cancer. The reporting and representation of race and ethnicity in cancer trials is crucial for generalizability of trial results to patient care and reduction of racial health disparities in head and neck cancers. Racial disparities in oncologic outcomes across various therapeutic interventions may only manifest when diverse races are appropriately represented in trials.

Objective

To characterize the reporting and representation of race and ethnicity in head and neck cancer clinical trials.

Evidence Review

A systematic search of published trials and those available on ClinicalTrials.gov was conducted to identify 3973 studies from 2010 to 2020. Title, abstract, and full-text review yielded 155 trials for data extraction of patient demographics. Year of publication, type of intervention, publication source, and funding source were also collected. Race and ethnicity data were compared with Surveillance, Epidemiology, and End Results (SEER) Program cancer registry data.

Findings

Of the 155 included studies, only 89 (57%) reported race or ethnicity. Only 81 (52%) of the studies reported detailed classification of race or ethnicity per the US Census Bureau classification scheme. Race and ethnicity reporting varied considerably with year of publication, type of intervention, data source, and funding source. Studies in the latter half of the decade were more likely to report race or ethnicity (odds ratio, 2.78; 95% CI, 1.33-5.80), with the highest number in 2019 (24 of 30 [80%] trials), followed by 2020 (20 of 29 [69%] trials). Among the possible interventions, trials on therapeutic chemoradiation most frequently reported race or ethnicity (11 of 12 [92%]), followed by supportive drug trials (22 of 31 [71%]), and then therapeutic chemotherapy trials (28 of 48 [58%]). When compared with SEER data, race and ethnicity distribution in clinical trials showed fewer Black patients (10% vs 8%) and Asian or Pacific Islander patients (6% vs 2%).

Conclusions and Relevance

In this systematic review, nearly half of head and neck cancer trials in the past decade did not report the race or ethnicity of participants. Participation of Black and Asian or Pacific Islander patients does not adequately reflect the US population's head and neck cancer demographics, limiting the generalizability of trial results and adding to racial health disparities in patients with head and neck cancers.

Racial and Ethnic Differences in Hearing Aid Use Among Medicare Beneficiaries

OBJECTIVES

We examined individual-level factors associated with hearing aid use by race and ethnicity in a nationally representative sample of Medicare beneficiaries.

METHODS

We used the Medicare Current Beneficiary Survey (cycles 2016-2018) for 10,301 older adults with hearing loss and hearing aid use as the primary outcome. Covariates included education, income, urban residence, chronic conditions, functional limitations, and Medicaid eligibility. Multivariable logistic regression stratified by race and ethnicity was used to identify factors associated with hearing aid use.

RESULTS

Factors associated with hearing aid use included higher education among White (OR = 1.35, 95%CI:1.16, 1.58), Black (OR = 1.76, 95%CI:1.02, 3.05), and Hispanic (OR = 1.77, 95%CI:1.17, 2.68) beneficiaries. Urban residence was associated with hearing aid use for Black participants (OR = 3.06, 95%CI:1.17, 8.03) and Medicaid eligibility for Hispanic participants (OR = 1.58, 95%CI:0.97, 2.59), although the confidence interval included the null hypothesis.

DISCUSSION

ndividual-level factors associated with hearing aid use differed by race and ethnicity among Medicare beneficiaries.

Evidence-Based Medicine in Otolaryngology, Part XIII: Health Disparities Research and Advancing Health Equity

OBJECTIVE

To provide a contemporary resource for clinicians and researchers on health equity research and implementation strategies to mitigate or eliminate disparities in health care.

DATA SOURCES

Published studies and literature on health disparities, applicable research methodologies, and social determinants of health in otolaryngology.

REVIEW METHODS

Literature through October 2021 was reviewed, including consensus statements, guidelines, and scientific publications related to health care equity research. This research focus provides insights into existing disparities, why they occur, and the outcomes of interventions designed to resolve them. Progress toward equity requires intentionality in implementing quality improvement initiatives, tracking data, and fostering culturally competent care. Priority areas include improving access, removing barriers to care, and ensuring appropriate and effective treatment. Although research into health care disparities has advanced significantly in recent years, persistent knowledge gaps remain. Applying the lens of equity to data science can promote evidence-based practices and optimal strategies to reduce health inequities.

CONCLUSIONS

Health disparities research has a critical role in advancing equity in otolaryngology-head and neck surgery. The phases of disparities research include detection, understanding, and reduction of disparities. A multilevel approach is necessary for understanding disparities, and health equity extensions can improve the rigor of evidence-based data synthesis. Finally, applying an equity lens is essential when designing and evaluating health care interventions, to minimize bias.

IMPLICATIONS FOR PRACTICE

Understanding the data and practices related to disparities research may help promote an evidence-based approach to care of individual patients and populations, with the potential to eventually surmount the negative effects of health care disparities.

Community-Based Participatory Research and Human-Centered Design Principles to Advance Hearing Health Equity

OBJECTIVES

Inclusive and equitable research is an ethical imperative. Community-based participatory research (CBPR) as well as human-centered design are approaches that center partnership between community members and academic researchers. Together, academic-community research teams iteratively study community priorities, collaboratively develop ethical study designs, and co-create innovations that are accessible and meaningful to the community partners while advancing science. The foundation of the CBPR approach is reliant on its core principles of equity, colearning, shared power in decision-making, reciprocity, and mutual benefit. While the CBPR approach has been used extensively in public health and other areas of healthcare research, the approach is relatively new to audiology, otolaryngology, and hearing health research. The purpose of the present article is to advance an understanding of the CBPR approach, along with principles from human-centered design, in the context of research aimed to advance equity and access in hearing healthcare.

DESIGN

The literature is reviewed to provide an introduction for auditory scientists to the CBPR approach and human-centered design, including discussion of the underlying principles of CBPR and where it fits along a community-engaged continuum, theoretical and evaluation frameworks, as well as applications within auditory research.

RESULTS

Recent applications of CBPR have been framed broadly within the theoretical positions of the socioecological model for a systems-level approach to community-engaged research and the Health Services Utilization model within health services and disparities research using CBPR. Utilizing human-centered design strategies can work in tandem with a CBPR approach to engage a wide range of people in the research process and move toward the development of innovative yet feasible solutions.

CONCLUSIONS

Leveraging the principles of CBPR is an intricate and dynamic process, may not be a fit for some topics, some researchers' skillsets, and may be beyond some projects' resources. When implemented skillfully and authentically, CBPR can be of benefit by elevating and empowering community voices and cultural perspectives historically marginalized in society and underrepresented within research. With a focus on health equity, this review of CBPR in the study of hearing healthcare emphasizes how this approach to research can help to advance inclusion, diversity, and access to innovation.

COVID-19 Disparities and Vaccine Hesitancy in Black Americans: What Ethical Lessons Can Be Learned?

OBJECTIVE

This state of the art review focuses on bioethical questions and considerations from research findings and methodological issues, including design and recruitment of participants, in studies related to COVID-19 vaccine hesitation in Black individuals. Ethical concerns identified were applied to otolaryngology with recommendations for improving health inequities within subspecialties.

DATA SOURCES

An internet search through PubMed, CINAHL, and socINDEX was conducted to identify articles on COVID-19 vaccine hesitation among the Black population between 2020 and 2021.

REVIEW METHODS

A systematic review approach was taken to search and analyze the research on this topic, which was coupled with expert analysis in identifying and classifying vital ethical considerations.

CONCLUSIONS

The most common COVID-19 vaccine hesitation factors were related to the development of the vaccine, mistrust toward government agencies, and misconceptions about safety and side effects. These findings raised bioethical concerns around mistrust of information, low health literacy, insufficient numbers of Black participants in medical research, and the unique positions of health professionals as trusted sources. These bioethical considerations can be applied in otolaryngology and other health-related areas to aid the public in making informed medical decisions regarding treatments, which may reduce health inequalities among Black Americans and other racial and ethnic minority groups.

IMPLICATIONS FOR PRACTICE

Addressing ethical questions by decreasing mistrust, tailoring information for specific populations, increasing minority representation in research, and using health professionals as primary sources for communicating health information and recommendations may improve relationships with Black communities and increase acceptance of new knowledge and therapies such as COVID-19 vaccination.