Thanks for your opinions; now here’s mine on the Task Force’s grievous mistake

By David H. Kirkwood

Hearinghealthmatters.org has been drawing more and livelier comments recently in response to our weekly posts. I’m sure I speak for all my colleagues when I say thank you to all who share your thoughts with us and encourage other readers to do the same. All of us—editors and readers alike—appreciate and learn from your input.

A couple of recent posts on my two Blogs at HHM drew some interesting comments that, in turn, have stimulated me to take my turn in opining on the topic. You’ll find some of these comments at the end of my August 15 Hearing News Watch post that reported on a revised federal task force recommendation questioning the benefit of routine screening for hearing loss among older adults.

Other comments were submitted in response to last week’s Hearing View by Carole Rogin, president of the Hearing Industries Association, which addressed the same topic.

In addition to these and other comments published on the blog, I received a thoughtful e-mail on the subject from Mike Metz, a prominent audiologist, who, I’m glad to say, has never been shy about expressing his opinions.

 

RESULT: MORE UNTREATED HEARING LOSS

In her compelling Hearing View, Carole Rogin criticized the decision by the U.S. Preventive Services Task Force to reverse its long-established recommendation that primary-care physicians screen asymptomatic patients over age 50 for hearing loss.

The HIA leader warned, “Neglecting an easy and effective way to screen adults for hearing loss is certain to result in a higher incidence of untreated hearing loss. And, as we know all too well, the consequences of untreated hearing loss are neither cheap nor harmless to individuals at home, in their communities, and at work. In fact, the social, emotional, and productivity costs are enormous.”

I strongly agree with her sentiments. But rather than repeat the points she and others (e.g., Candy Sagon who wrote on an AARP blog “It just seems like common sense: Screening older adults for hearing loss is a cheap, effective, harmless way to determine if their hearing ability has worsened and might be helped with a hearing aid.”) have made so well, I’d like to address some of the comments that we received on this issue.

 

PUTTING THE RECOMMENDATION IN CONTEXT

In his response to Carole Rogin’s Hearing View, Dan Schwartz, one of our most prolific commenters, pointed out, quite correctly, “The U.S. Preventive Services Task Force’s opinion on hearing screening shouldn’t be viewed in a vacuum; but instead in the context of two other decisions regarding cutting back on testing for PSH levels for prostate cancer for men and mammograms for women.”

To those two decisions, I would add the Task Force’s recommendation, issued this week, to cease testing healthy women for ovarian cancer. Virginia Moyer, the chair of the panel explained that no existing screening method is effective in reducing deaths. She added that “a high percentage of the women” who are screened receive false-positive results and may be subjected to unnecessary harms as a result.”

Comparing the recommendation against routine screening of older adults for hearing loss (because the Task Force found insufficient evidence of its benefit) with its recommendations to reduce or eliminate testing for various types of cancer underscores how very different these cases are.

While I’m certainly not qualified to judge the validity of the panel’s recommendations on screening for breast, prostate, and ovarian cancers, there is no doubt that routinely conducting these tests on millions of people is extraordinarily expensive. When the screens result in false positives, they pose the risk of serious and unnecessary physical harm and emotional suffering for patients who undergo procedures for a condition they don’t have. If the tests produce false negatives, they create a false complacency, which can be deadly. Therefore, the Task Force is certainly justified in very carefully weighing the benefits of such screening against its very high costs.

Contrast that with the situation when a primary-care physician screens an adult for an undetected (or possibly an unacknowledged) hearing loss. Doing so takes just a few minutes and need not cost a penny. While there are various screening tools, one of the most popular is the Quick Hearing Check offered by the Better Hearing Institute as part of its free physician’s kit.

In view of how common hearing loss is among older adults and how often it is overlooked, routine screening undoubtedly detects many cases and leads to more patients getting help with their hearing sooner rather than later. Moreover, the very fact that a patient’s doctor includes this test in a routine physical sends the valuable message that hearing loss is a serious matter.

While no test is infallible, the consequences of a false positive (possibly an unneeded follow-up hearing test) or false negative (a possible delay in getting hearing help) are far less serious than the harm that can result when a test for cancer produces an inaccurate result.

 

THE EVIDENCE ISSUE

As I mentioned, Mike Metz sent me a letter that responded in part to our blog’s ongoing discussion of the Task Force recommendation. In his e-mail, he emphasized the importance of evidence-based practice in audiology. He also deplored the fact that there is so little empirical data available for practitioners to draw on.

He wrote, “Audiologists face ‘lack-of-empirical-data’ situations on a daily, clinical basis. And, the majority of hearing aid fitters—audiologists and dispensers—do not perform the necessary tests and investigations to define hearing loss and then do not perform the necessary tasks to demonstrate the benefits of their rehabilitative work.”

It’s hard to argue with Dr. Metz about the need for more research and more use of data-based hearing care. As noted earlier, the reason that the Task Force decided to revise its earlier recommendation of routine adult hearing screening is that, it found, there is no compelling evidence of its benefits. It also urged that researchers conduct studies to determine the effects of such testing among adults over 50 without known symptoms of hearing loss.

While such research is a great idea, I can’t accept that, pending the publication of its findings, it makes sense for primary-care physicians to eschew screening for hearing loss, especially since, as, the Task Force acknowledged, the possible harms of screening “are probably small to none.”

It seems to me that the place of hearing screening in a routine physical is somewhat analogous to, for example, weighing a patient. It does no harm, involves minimal time and cost, and produces important information. But has anyone ever conducted a study to prove its benefits? If so, let me know what they found (and how they came up with a control group). If no study has proven the benefit of weighing patients, should physicians quit doing it?

Or, one might compare it with the friendly chitchat that helps build the doctor-patient relationship but, I suspect, has never been scientifically proven to be beneficial.

Neither of these comparisons is exact, I admit.  But I think they are all examples of practices that physicians may logically take even in the absence of empirical evidence of their value.


2 Comments

  1. Great write David. This is something i have always wondered. As a HOH person, my loss started many years ago with a Cholesteatoma (i apologize if this is spelled wrong). It is so important for all of us to get hearing screenings. Frankly this should be done with yearly physicals. This is just my humble opinion.

  2. Unfortunately, in the primary care physician’s (PCP’s) office (of which I once had a dispensing practice located in), the problem of providing hearing screenings is also one of billing: Since very few PCP offices dispense hearing aids (and hence the attendant profit center), each test as part of a physical exam needs to be billable, in the new normal of healthcare rationing.

    Put yourself in the place of a busy PCP: It’s a pain in the ass to perform a billable hearing test, because that means time the too-busy nurse needs to spend, and it also involves (at minimum) a dedicated “quiet” room, when office space costs $25-$40 per square foot… All for a few extra bucks of billing.

    What’s more, this extra billing is only available to non-HMO patients — And one of the goals of ObamaCare is to push more people into Medicaid HMO’s.

    Welcome to the new normal of healthcare rationing.

    Dan Schwartz

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