By David H. Kirkwood
ROCKVILLE, MD—While many thousands of hearing care providers and people in the hearing industry will undoubtedly disagree, the U.S. Preventive Services Task Force (USPSTF) stated this week that it has found insufficient evidence to recommend that physicians screen for hearing loss among patients 50 years and older without symptoms of hearing loss.
Specifically, the task force said in its August 13 recommendation that evidence is “inadequate to determine whether screening for hearing loss improves health outcomes in persons who are unaware of hearing loss or have perceived hearing loss but have not sought care.” The full text of USPTTF’s recommendation is available online.
Funded by the U.S. Department of Health and Human Services, USPSTF is an independent panel of experts in primary care and prevention that systematically reviews the evidence of effectiveness and develops recommendations for clinical preventive services. Its recommendations are widely used by physicians to decide which screening tests to give to patients.
In its recommendation on hearing screening, the task force noted that it “does not apply to persons seeking evaluation for perceived hearing problems or for cognitive or affective symptoms that may be related to hearing loss. These persons should be assessed for objective hearing impairment and treated when indicated.”
Nor does the task force intend to discourage patients from telling their primary-care physician about any concerns they have about their hearing. In an interview with Reuters Health, Albert Siu, MD, a vice-chair of USPSTF and a physician at Mount Sinai School of Medicine in New York, said, “If you have a hearing problem, you should absolutely bring it up with your doctor.”
Nevertheless, this new recommendation appears likely to set back longstanding efforts by advocates for hearing health to persuade primary-care physicians to screen patients for hearing loss–or at least ask them about their hearing–as part of their regular physical exam. The Hearing Industries Association and the Better Hearing Institute have both actively promoted routine hearing screening by family physicians.
TASK FORCE CHANGES ITS POSITION
USPSTF’s recommendation is a departure from the position it took in 1996. Then its recommendation to physicians called for “periodically questioning older adults about their hearing, counseling them about the availability of hearing aids, and making referrals when appropriate.”
The 2012 recommendation, which supersedes the earlier one, noted that its previous statement “was based on the best available evidence at that time, which was indirect in nature and largely limited to studies of diagnostic accuracy and treatment of persons with established or perceived hearing loss.” At the time, it added, “USPSTF noted that no controlled trials could prove the effectiveness of screening asymptomatic older adults for hearing impairment.”
EXISTING RESEARCH FOUND WANTING
In preparing its 2012 recommendation, USPSTF conducted a thorough review of randomized, controlled trials and controlled observational studies that had been published as of January 2010 on screening for age-related sensorineural hearing impairment in adults aged 50 years or older without diagnosed hearing loss in the primary care setting.
After assessing the relevant research findings, the panel concluded: “Because of a paucity of directly applicable trials, evidence is inadequate to determine whether screening for hearing loss improves health outcomes in persons who are unaware of hearing loss or have perceived hearing loss but have not sought care.”
It cited “one good-quality study” that randomly assigned 194 male veterans (mean age, 72 years) with screen-detected or previously established hearing loss to receive a free hearing aid or be put on a waiting-list control group. The study found that hearing aids “can improve self-reported hearing, communication, and social functioning for some adults with age-related hearing loss.”
However, USPSTF added that the study “nearly exclusively evaluated white male veterans with moderate hearing loss and moderate to severe perceived hearing impairment, more than one third of whom had been referred for evaluation of hearing problems.” For that reason, it said, “these findings were of limited applicability to a hypothetical asymptomatic, screened population.”
The task force’s statement continued, “The only randomized trial that directly evaluated the effect of screening for hearing impairment—rather than the effect of treatment alone—was not primarily designed nor had sufficient statistical power to detect differences in hearing-related function.”
It concluded, “The evidence is inadequate to assess the benefit of screening and early treatment in an unselected screening population.”
RISKS SEEN AS “SMALL TO NONE”
Screening of asymptomatic adults for hearing loss is not the first routine test that the task force has raised doubts about. In May 2012, it recommended against routine PSA-based screening of men for prostate cancer. In 2009, the task force recommended biennial rather than annual mammograms for women aged 50 to 74, and it declined to make any general recommendation on mammograms for younger or older women.
However, unlike some other routine tests where it perceived a risk of actual harm resulting from their use, the USPSTF sees minimal risk from routine screening for hearing loss.
It wrote: “Because of a lack of studies, evidence to determine the magnitude of harms of screening for hearing loss in older adults is inadequate; however, given the noninvasive nature of both screening and associated diagnostic evaluation, these harms are probably small to none. Adequate evidence shows that the harms of treatment of hearing loss in older adults are small to none.”
In its new recommendation, the task force points to “research needs and gaps.” This suggests that if better evidence is found about the benefits of hearing screening, the USPSTF might rethink its position.
Specifically, it said, “Adequately powered studies are needed to better evaluate the effect of screening for hearing loss on health outcomes, such as emotional and social functioning, communication ability, and cognitive function, rather than intermediate measures, such as hearing aid use or satisfaction, particularly among adults without self-perceived or established hearing loss at baseline.
It added, “The incremental benefits and costs of screening asymptomatic adults compared with only testing and treating those who seek treatment of perceived hearing impairment are unknown. Knowledge of specific factors or patient characteristics associated with increased and sustained use of hearing aids, once prescribed, could permit testing and treatment targeted to those most likely to benefit.”