by Melanie Ferguson, PhD
In a teleconference of the American Academy of Audiology (AAA) Strategic Documents committee last week, someone made a comment that if audiologists are charging insurance companies for a service, this needs to be supported by evidence and guidelines. Good point. In the UK about three years ago we had exactly the same discussion.
In 2015, a clinical commissioning group (CCG) announced that it was considering decommissioning hearing aid provision for adults with mild to moderate hearing loss (MMHL), and other CCGs followed suit. This was a big deal. One, CCGs pay for UK National Health Service (NHS) health care, including hearing aid provision. And two, hearing aids have been provided free on the NHS since its inception in 1947. We had a major clinical and political issue on our hands for the next couple of years.
But why? Hearing aids are the main intervention for people with hearing loss, with millions provided globally each year. And hearing professionals know that hearing aids ‘work’, right? But where was the evidence? This was provided by the systematic review by Chisolm et al (2007). This systematic review was ground-breaking, as it was new to audiology. However, the review showed a paucity of high-quality evidence on the effectiveness of hearing aids. There was only one randomised controlled trial (RCT), which is the highest level of experimental evidence. In addition, the review only included studies published up to 2004. In 2015, more than a decade later, the time was right to update the evidence from the published literature.
The very highest level of research evidence is a systematic review with a meta-analysis, and the ‘gold standard’ of systematic reviews are Cochrane Reviews. These are internationally recognised as the highest standard in assessing health care resources. Explicit methods aim to minimise risk of bias, such as selective reporting of the data, to provide reliable findings for use in clinical decision-making.
So, we rolled our sleeves up and decided it was time to do a Cochrane review on the effectiveness of hearing aids in adults with MMHL.
Following strict guidelines from the Cochrane Collaboration, the review team developed a protocol that underwent rigorous peer review. Only RCTs were included. Other predefined criteria were described, for example, how studies were selected, how risk of study bias was assessed, and how the treatment effect was measured. Believe me, nothing went undefined!
The review included five RCTs. Three studies up to and including 2005 recruited control patients from a waitlist group. Two further studies were published in 2017 within a few days of each other, and the control patients used placebo hearing aids (i.e. no gain, therefore acoustically transparent). So, it seemed that RCTs on hearing aids were like buses – you wait 12 years for one and two turn up at the same time!
The meta-analyses showed:
- Hearing-specific health-related quality of life (QoL), a large beneficial effect of hearing aids
- Listening ability, a large beneficial effect of hearing aids
- Health-related QoL, a small but still significant beneficial effect of hearing aids
- This evidence was all judged to be moderate quality, which is unusual, as most evidence in adult rehab systematic reviews are low or very low quality.
Figures 1 and 2 (below) summarize some of the details from the meta-analysis:
We concluded that:
“The evidence is compatible with the widespread provision of hearing aids as the first-line clinical management in those seeking help for hearing difficulties”.
The Cochrane review received a lot of interest on social media, invited interviews and articles, including a JAMA article, which was Sir Muir Gray’s Better Healthcare Value Paper of the Week in July. There was an NIHR dissemination video and an NIHR Signal, which are accessible summaries of recent, important health research.
But where was the real impact? The Cochrane review was used as the clinical evidence for the effectiveness of hearing aids in the NICE (National institute for Health and Care Excellence) Guidelines on Hearing Loss, which was published in June 2018. NICE has an international reputation and provides guidance to improve health and care in the NHS. NICE is very influential. The guideline made recommendations on clinical aspects across the adult patient pathways from referral, assessment, management and follow-up.
As part of the NICE guideline development, a health-economic analysis showed that hearing aids were also highly cost-effective. This led to the recommendation “Offer hearing aids to adults whose hearing loss affects their ability to communicate and hear…”. Offer indicates a strong recommendation and provides CCGs with the guidance they need for decision-making on hearing aids for people with MMHL. And note, no mention of the level of hearing loss. There remains only one CCG in the UK who still does not routinely provide hearing aids to those with MMHL. Watch this space.
So, back to the teleconference earlier this week. There is now clear, robust evidence and clinical guidelines that show that hearing aids are high-value and low-cost. What audiologists knew all along, right? But now we have it in writing and with the NICE stamp of quality and assurance.
It seems that NHS hearing aid provision in the UK is now future-proofed for at least the next five years, maybe more. And that can only be good news for the half a million people in the UK who use audiology services each year.
Editor’s Note: The important takeaway here is that Audiologists should routinely document the quality of life benefits of hearing interventions using one of the self report measures included in Dr. Ferguson’s meta-analysis. Perhaps if we routinely document and share these outcomes with stakeholders, we may be able to raise our credibility as a high value profession.
-Barbara Weinstein, PhD
This blog presents independent research funded by the National Institute for Health Research (NIHR) Biomedical Research Centre Programme. The guideline referred to in this blog was produced by The National Guideline Centre (NGC) for the National Institute for Health and Care Excellence (NICE). The views expressed in this article are those of the authors and not necessarily those of the NHS, the NIHR, the Department of Health and Social Care, or NICE.
National Institute for Health and Care Excellence (2018) Hearing loss in adults: assessment and management. Available from https://www.nice.org.uk/guidance/ng98
About the Author
Dr. Melanie Ferguson is a Consultant Clinical Scientist (audiology) and Associate Professor in Hearing Sciences at the NIHR Nottingham Biomedical Research Centre, UK. She leads a translational research programme on Mild to Moderate Hearing Loss that aims to promote healthy hearing by reducing activity limitations and participation restrictions. Her research focuses on (i) e-health and self-management, (ii) listening and cognition, and (iii) listening devices. She is currently the Vice-chair for the British Society of Audiology, member of the American Academy of Audiology Strategy Documents Committee. She is a member of the NICE Quality Standards Advisory Committee for Hearing Loss and was a full member of the NICE Guideline Development Committee for Hearing Loss. She can be reached at Melanie.firstname.lastname@example.org or on Twitter @Mel_Ferguson1 and @hearingnihr