Cost-Effectiveness of Hearing Screening in Older Adults: A Scoping Review

Audiological profile of first-time hearing aid users - implications for the development of a fast-track fitting protocol

OBJECTIVE

To assess the feasibility of implementing a fast-track process (single-session assess-and-fit appointment with no ENT specialist's examination) in hearing rehabilitation by investigating the accuracy of the protocol assignment applying various cut-off criteria and describing the audiometric profile of patients being evaluated for their first hearing aids.

DESIGN

Retrospective chart review.

STUDY SAMPLE

Patients from a single institution (n = 1807, median age 75 years, IQR 67-82 years) undergoing the evaluation for their first hearing aid fitting.

RESULTS

There were no audiometric signs warranting further diagnostic evaluation in 1259 subjects (69.7%). These subjects could be identified using a single criterion: the average threshold difference between the ears in the frequencies from 0.5 to 4 kHz less than 10 dB. Age was found to be a good predictor for the success of a single-session evaluation and fitting, with a cut-off value of 75 years. Altogether, 593 persons (32.8%) were candidates for a fast-track process. The time-saving from a single-session process was estimated to be 1.0%.

CONCLUSIONS

It is feasible to have a fast-track hearing aid fitting protocol. Patients can be preselected with excellent accuracy using a single audiometric criterion and an age limit of 75. Time savings for a single-session process are insignificant.

Health screening and its association with emergency department visits and related costs among home-dwelling older adults

BACKGROUND

The aim of this study was to evaluate the effectiveness of the health screening procedure for home-dwelling older adults in reducing emergency department visits and associated costs.

METHODS

Data were derived from health screenings from 2020 to 2021 for 75-year-old home-dwelling residents of Western Finland. The study compared emergency department visits and associated costs between older adults who participated in the health screening (intervention group) and those who did not (non-intervention group). For each older adult, three non-intervention controls were matched according to age, sex, health screening year and wellbeing service county. Emergency department visits and International Classification of Diseases (ICD)-10 codes from one year before to two years after health screening were analyzed.

RESULTS

In the non-intervention group, a 19% increase in emergency visit rates was seen (457-564 per 1000 person-years), while the intervention group showed a 67% decrease (165-23). Annual costs for the non-intervention group increased from 148 euros (€) to €183, a mean ratio increase of 1.24 per person-year (range 1.08-1.40). In contrast, the intervention group's costs decreased from €53 to €8, a mean reduction ratio of 0.15 per person-year (range 0.10-0.71). The intervention group had lower frequency of visits for respiratory and circulatory diseases but higher for digestive and metabolic diseases, unlike the non-intervention group.

CONCLUSIONS

The implementation of the health screening is an effective strategy for reducing both the frequency of emergency department visits and associated costs in home-dwelling older adults in good condition.

Hearing impairment amongst people with Osteogenesis Imperfecta in Germany

INTRODUCTION

Hearing impairment concerns a relevant percentage of individuals with Osteogenesis Imperfecta (OI). When looking at the current literature, the percentage of affected individuals with OI varies greatly from 32 to 58% of patients having mild OI and 21% to 27% of patients having moderate to severe OI. Little is known about the German population with OI.

METHOD

The goal of this study was to detect how many patients with OI, who visited the annual meeting of the German Association for Osteogenesis Imperfecta in 2023, proved to have a hearing impairment. In this prospective, cross-sectional study, each included individual obtained ear microscopy, audiometry, stapedius reflexes, tympanometry, and OAEs. Furthermore, each patient was asked a set of questions concerning the medical history.

RESULTS

Of the included patients, 33% had hearing impairment. A significant difference was found for the mean air-bone gap (ABG) as well as the hearing threshold of the right ears. The difference was found between OI type III and IV (p = 0.0127) for the mean ABG and OI type I and IV (p = 0.0138) as well as III and IV (p = 0.0281) for the hearing threshold. Spearman's rank correlation showed a high correlation between age and hearing threshold. Of the patients between 40 and 50 years old, 56% had hearing loss.

CONCLUSION

Hearing loss in individuals with OI is still a relevant problem, especially age-related in OI type I. Audiometry should be performed at least when individuals experience subjective hearing loss. The implementation of a screening starting at 40 years should be discussed and studied.

Integrated digit in noise test (iDIN) for rapid hearing and cognitive screening: a preliminary exploration

BACKGROUND

Hearing and cognitive impairments are common amongst older adults, both affecting communication and are not easy to distinguish from each other.

OBJECTIVE

To preliminarily evaluate the efficacy of the integrated Digit in Noise Test (iDIN) for rapid screening of hearing and cognitive functions in older adults.

DESIGN

This cross-sectional cohort study was conducted at multiple clinical sites.

SETTING

Data collection occurred in sound-treated booths and quiet rooms at several outpatient clinics and elderly community centres.

SUBJECTS

The study included 107 older adults, aged 58-96, who were long-term residents of Hong Kong and native Cantonese speakers. Participants were selected through convenience sampling.

METHODS

Primary outcomes were the speech reception thresholds (SRTs) for 2-, 3- and 5-digit sequences with forward and 3-digit sequences with backward recall measured on iDIN. Hearing level was assessed using pure-tone audiometry. Cognitive function was assessed using the Hong Kong version of the Montreal Cognitive Assessment (HK-MoCA).

RESULTS

The 2-digit and 3-digit SRTs effectively distinguished participants with hearing loss, demonstrating high sensitivity (0.815 and 0.908, respectively) and specificity (0.905 and 0.853, respectively). The SRT3b-3f index effectively discriminated between participants who passed or failed the MoCA, with sensitivities of 0.727 and 0.781, and specificities of 0.885 and 0.787 using the two MoCA scoring methods. No significant correlation was found between SRT3b-3f and hearing levels after adjustment for educational background.

CONCLUSIONS

iDIN demonstrates significant promise for rapid and effective screening of both hearing and cognitive impairments in older adults.

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.

Plain Language Summary: Age-Related Hearing Loss

The plain language summary explains age-related hearing loss to patients, families, and care partners. The summary is for any patient aged 50 years and older, families, and care partners. It is based on the 2024 "Clinical Practice Guideline: Age-Related Hearing Loss." This plain language summary is a companion publication to the full guideline, which provides greater detail for clinicians. Guidelines and their recommendations may not apply to every patient, but they can be used to find best practices and quality improvement opportunities.

Early Detection of Hearing Loss among the Elderly

BACKGROUND

Age-related hearing loss (ARHL) is a complex communication disorder that affects the cochlea and central auditory pathway. The goal of this study is to characterize this type of hearing loss and to identify non-invasive, inexpensive, and quick tests to detect ARHL among elderly adults, seeking to preserve quality of life and reduce the burden on healthcare systems.

METHODS

An observational, prospective study is conducted with >55-year-old subjects divided into the following groups: normal range (Group A), detected but not treated (Group B), and detected and treated (Group C). During follow-up, Speech Spatial Qualities (SSQ12), and Hearing Handicap Inventory in the Elderly Screening test (HHIE-S) questionnaires were assessed, along with hearing levels (hearing thresholds at 4 kHz were studied in more depth), and a series of tests and questionnaires to assess balance, cognitive level, level of dependence, and depression.

RESULTS

A total of 710 patients were included in this study. The duration of hearing loss (11.8 yr. in Group B and 21.0 yr. in Group C) and average time-to-treatment for Group C (14.1 yr.) are both protracted. Both of the used questionnaires show statistically significant differences among the groups, revealing greater handicaps for Group C. Audiometry performed at 4 kHz shows how hearing loss progresses with age, finding differences between men and women. There is a correlation between time-to-treatment in Group C and the cognitive test DSST (-0.26; p = 0.003).

CONCLUSIONS

HHIE-S, SSQ12, and 4 kHz audiometry are sensitive and feasible tests to implement in screening programs.

Screening for hearing loss using the electronic whisper test: A prospective cross-sectional study

Background

Hearing screening is a method for early identification of hearing loss. Hearing screening is widely used in hospitals as part of physical examination. However, some of them are difficult to operate outside the hospitals regarding portability and user-friendliness. Therefore, we developed a simple yet easy-to-use portable electronic whisper test (EWT) for field deployment, particularly on many subjects. The EWT validity is a hearing screening method compared to pure-tone audiometry.

Methods

This study was a cross-sectional comparative with a prospective approach. The subjects were outpatients at the Audiology Clinic of Dr. Soetomo Academic Medical Center, Surabaya, Indonesia, who met the inclusion and exclusion criteria. Statistical analysis made sensitivity and specificity tables using a 2 × 2 table, positive and negative predictive values.

Results

Samples of 50 participants (100 ears) obtained a sensitivity value of 83%, specificity of 78%, positive predictive value of 45%, and negative predictive value of 95%.

Conclusions

The EWT is valid for use as a hearing screening method.

A pragmatic clinical trial of hearing screening in primary care clinics: cost-effectiveness of hearing screening

BACKGROUND

Hearing loss is a high prevalence condition among older adults, is associated with higher-than-average risk for poor health outcomes and quality of life, and is a public health concern to individuals, families, communities, professionals, governments, and policy makers. Although low-cost hearing screening (HS) is widely available, most older adults are not asked about hearing during health care visits. A promising approach to addressing unmet needs in hearing health care is HS in primary care (PC) clinics; most PC providers (PCPs) do not inquire about hearing loss. However, no cost assessment of HS in community PC settings has been conducted in the United States. Thus, this study conducted a cost-effectiveness analysis of HS using results from a pragmatic clinic trial that compared three HS protocols that differed in the level of support and encouragement provided by the PC office and the PCPs to older adults during their routine visits. Two protocols included HS at home (one with PCP encouragement and one without) and one protocol included HS in the PC office.

METHODS

Direct costs of the HS included costs of: (1) educational materials about hearing loss, (2) PCP educational and encouragement time, and (3) access to the HS system. Indirect costs for in-office HS included cost of space and minimal staff time. Costs were tracked and modeled for each phase of care during and following the HS, including completion of a diagnostic assessment and follow-up with the recommended treatment plan.

RESULTS

The cost-effectiveness analysis showed that the average cost per patient is highest in the patient group who completed the HS during their clinic visit, but the average cost per patient who failed the HS is by far the lowest in that group, due to the higher failure rate, that is, rate of identification of patients with suspected hearing loss. Estimated benefits of HS in terms of improvements in quality of life were also far greater when patients completed the HS during their clinic visit.

CONCLUSIONS

Providing HS to older adults during their PC visit is cost-effective and accrues greater estimated benefits in terms of improved quality of life.

TRIAL REGISTRATION

clinicaltrials.gov (Registration Identification Number: NCT02928107).

Cost-Effectiveness of Hearing Screening in Older Adults: A Scoping Review

OBJECTIVES

Age is the most common predictor of hearing loss; however, many older adults are not screened. Hearing screening could improve healthcare access, participation, and outcomes. Establishing whether hearing screening in older adults is cost-effective could improve the availability and utilization of screening.

METHODS

We searched nine databases in January 2020. Studies with populations aged 50+ and provided data on the cost-effectiveness of hearing screening were included in the review.

RESULTS

Five studies met the inclusion criteria and all found hearing screening programs to be cost-effective compared to no hearing screening, regardless of screening method (i.e., instrument or strategy). The maximum number of repeated screenings, coupled with younger ages, was most cost-effective.

DISCUSSION

This review suggests that hearing screening in older adults is cost-effective, however, the evidence is limited. There is pressing need for research focused on economic impacts of hearing healthcare in older adults to inform research, policy and practice.