Downstream Consequences of Aging is a bi-monthly series written by guest columnist Barbara Weinstein, PhD.
The Physician Quality Reporting System (PQRS) is a program through the Centers for Medicare and Medicaid Services (CMS) designed to improve the quality of care to Medicare Part B beneficiaries by tracking practice patterns of health care practitioners.
PQRS Regulation Applies to Audiologists
This regulation applies to audiologists in diverse settings:
- Audiologists in independent practices
- Audiologists who provide services in university clinics
- Audiologists who provide services in otolaryngology offices (i.e. when billing with individual NPI as the rendering provider of the service)
- Audiologists who bill for services provided for outpatient traditional Medicare Part B beneficiaries on the CMS 1500 form or its electronic equivalent.
Sweeping Change and Opportunity
Indeed the 2016 system of reporting differs dramatically from 2015 as domains of function directly related to age related hearing loss including depression and falls risk are included.
While some may see this as a system-driven burden, I suggest this is an opportunity not to be squandered.
Falls, depression, and hearing loss are among the most prevalent chronic conditions afflicting older adults. Age related hearing loss and self reported psychosocial hearing related difficulties increase risk for falls and depression, hence screening for each of these conditions and verifying how hearing aid use impacts performance on patient reported outcome measures (PROMs) will be value added from the perspective of incentive based payment plans.
I will focus on depression in this post. A future post will will discuss falls risk, mobility, fear of falling, and vestibular dysfunction as relates to age related hearing loss.
Depression and Hearing Loss in the Aging Population
Like hearing loss, depression is not a normal part of the aging process. The numbers are compelling:
- 20 percent of adults age 55 and older have a mental health disorder (e.g. anxiety, depression) that is not part of normal aging (CDC, 2008).
- An estimated 7 million of 39 million adults aged 65 years and older are affected by depression (e.g. persistent feeling of sadness, emptiness).
- Nearly 30 million people over the age of 60 are hearing impaired.
Often triggered by presence of other chronic conditions common as people age, symptoms of depression are often overlooked and untreated. Similarly, age related hearing loss typically goes unrecognized and untreated.
Cost of Depression and Hearing Loss in the Aging Population
Health care expenditures are higher in older patients with symptoms of depression and with documented self reported hearing loss (Foley et al., 2014). Depression is a major contributor to healthcare costs among older adults and is projected to be the leading cause of disease burden in older populations by the year 2020 (Huang, et al., 2010).
Hearing loss is also tied to increased health care expenditures. Foley and colleagues (2014) found that patients with hearing loss had significantly greater odds of nonzero expenditures on office-based, outpatient, and emergency department visits, and their physical and mental health summary scores were lower than scores of individuals with no hearing loss.
Depression and Hearing Loss are Linked in the Aging Population
The evidence linking hearing loss, self reported psychosocial hearing related difficulties and depression, is convincing. Here are seminal studies of discovery and delineation of the link.
Gopinath et al. (2009)
This prospective, cross-sectional study reported a connection between bilateral hearing loss and depression as measured using the Mental Health Index (MHI). Notably, depressive symptoms were more common among women, and women with hearing loss who were younger than 70 years were more likely to report depressive symptoms than were women 70+ years of age.
Li, et al. (2014)
This study extrapolated from National Health and Nutrition Examination Survey (NHANES), 2005-2010, a nationally representative sample. The authors found prevalence of depression to vary with severity of hearing loss. Prevalence of moderate to severe depression measured using the Patient Health Questionnaire (PHQ-9) was 11.4% for adults with any self-reported hearing impairment (HI) as compared to 5.9% for those without HI, with prevalence higher among women. Notably, an additional 19.1% of participants had mild depressive symptoms.
The strength of the association between self reported HI and depression remained after controlling for significant covariates including diabetes, history of cardiovascular disease, and age. Confirming the data of Gopinath et al. (2012), moderate HI in women aged 70 years or older was associated with increased odds of depression after adjusting for covariates, but this was not true in men. Similarly, self-reported hearing loss severity (HI) was significantly associated with decreased odds of depression among participants aged 70 years of age and older.
Logic and Evidence for Public Health Policy
Fairly easy to detect and highly treatable, depression is considered a public health problem. Similarly, HI is prevalent, symptoms are easy to detect and treat, and is considered a public health problem.
A recent meta-analysis of literature linking chronic disease to depression risk revealed that hearing loss is independently associated with depression in older adults with poor hearing (Huang, et al., 2010). Other chronic conditions placing individuals at risk for depression included stroke, poor vision, cardiac disease and chronic lung disease.
Both hearing loss and depression are considered candidates for prevention efforts—making each an excellent focus for public health initiatives.
Next Step, Next Post
Part 2 of this post builds on the HI-depression relationship by introducing evidence of two related links that make the case for a public policy initiative for clinical treatment:
- Self-rated significant hearing handicap (HH) is an independent factor associated with severity and development of depressive symptoms.
- Even minimal daily use of hearing aids is associated with significantly lower likelihood of having depressive symptoms.
CDC. Centers for Disease Control and Prevention and National Association of Chronic Disease Directors. The State of Mental Health and Aging in America Issue Brief 1: What Do the Data Tell Us? Atlanta, GA: National Association of Chronic Disease Directors; 2008.
Foley, D., Frick, K., Lin, F. (2014). Association between hearing loss and healthcare expenditures in older adults. J Am Geriatr Soc. 62. 1188-1189.
Gopinath, B., Wang, J., Schneider, R., et al., (2009). Depressive symptoms in older adults with hearing impairments: the Blue Mountains study. J Am Geriatr Soc.. 57: 1306-1308.
Gopinath, B., Hickson, L., Schneider, J., McMahon, C., et al., (2012). Hearing-impaired adults are at increased risk of experiencing emotional distress and social engagement restrictions five years later. Age and Ageing. 41: 618–623.
Huang, C., Dong, B., Lu, Z., et al. (2010). Chronic diseases and risk for depression in old age: A meta-analysis of published literature. Ageing Res Rev 9:131–141.
Li, C., Zhang, X,. Hoffman, H., et al., (2014). Hearing Impairment Associated With Depression in US Adults, National Health and Nutrition Examination Survey 2005-2010. JAMA Otolaryngol Head Neck Surg. 140:293-302.
Barbara E. Weinstein, Ph.D. earned her doctorate from Columbia University, where she continued on as a faculty member and developed the Hearing Handicap Inventory with her mentor, Dr. Ira Ventry. Dr. Weinstein’s research interests range from screening, quantification of psychosocial effects of hearing loss, senile dementia, and patient reported outcomes assessment. Her passion is educating health professionals and the public about the trajectory of untreated age-related hearing loss and the importance of referral and management. The author of both editions of Geriatric Audiology, Dr. Weinstein has written numerous manuscripts and spoken worldwide on hearing loss in the elderly. Dr. Weinstein is the founding Executive Officer of Health Sciences Doctoral Programs at the Graduate Center, CUNY which included doctoral programs in public health, audiology, nursing sciences and physical therapy. She was the first Executive Officer the CUNY AuD program and is a Professor in the Doctor of Audiology program and the Ph.D. program in Speech, Language and Hearing Sciences at the Graduate Center, CUNY.