by Brian Taylor, AuD, and Kelly Tremblay, PhD
Two studies, published by JAMA Otolaryngology on November 8th are compulsory reads for hearing care professionals concerned about accessibility and affordability of hearing-related services. Both studies, which relied on insurance claims data from the OptumLabs Data Warehouse, a division of the for-profit UnitedHealth Group, add to the growing body of evidence demonstrating hearing loss is linked to several common, adverse conditions in older adults.
The pair of studies were conducted primarily by researchers at John Hopkins Bloomberg School of Public Health and sponsored by AARP. In the first study, Jennifer Deal and her colleagues examined the association of age-related hearing loss with dementia, depression, accidental falls, nonvertebral fractures, heart attacks and stroke. These researchers evaluated data from adults aged 50 years and older at two, five and 10-year follow up intervals. After ensuring participants with hearing loss were carefully matched to those with no evidence of hearing loss across a wide range of possible confounding factors, they determined adults with age-related hearing loss was significantly associated with an increased 10-year risk of dementia, depression, falls and heart attack.
In the second study, Nicholas Reed and colleagues looked at the relationship between hearing loss of adult onset and overall healthcare costs per individual. In their study they found an association between untreated hearing loss and higher healthcare costs and a higher risk for hospital readmission. Specifically, they found over a 10-year period, individuals with untreated hearing loss incurred an average of over $22,000 in additional healthcare costs compared to similar adults with normal hearing.
A summary of the studies cited above can be found here.
Collectively, the above-mentioned studies highlight the cost of hearing loss to the individual and to society. They help build the case that hearing loss should be a public health concern (Reavis, Tremblay, Saunders, 2016) which is important because hearing loss is not a common topic of discussion among public health policy experts.
Hearing Loss as a Public Health Issue
Typically, public health experts devote much of their time warding off infectious diseases and global pandemics, mainly because the consequences of these ailments can be life threatening on a massive scale. Recent studies, however, like the ones cited above indicate hearing loss warrant serious attention.
In an American healthcare system that is believed by many to be costly and inefficient, saving a potential $22,000 per person through early intervention and treatment of hearing loss, as these studies suggest, could be a game-changer. Over the next few years, it will be interesting to see if the UnitedHealth Group with many large commercial HMO and Medicare Advantage programs leverages these findings to provide more comprehensive hearing-related benefits for their members, including, perhaps, the coverage of hearing aids.
Considering age-related hearing loss is more prevalent than diabetes or cancer, it will be necessary for audiologists to play a key role in this public health mission. But here rests the problem, there are insufficient numbers of audiologists to meet the hearing health needs of our aging population (Windmill and Freeman, 2013). What is more, the solutions that have been proposed leave many clinicians struggling to understand their role in addressing this public health mission.
As the still-to-be-defined role audiology plays in public health evolves, it’s important to note the professional landscape has been changing, albeit slowly, for nearly a decade. Many believe the landscape began to shift with what is now considered a landmark report in a February 2010 Ear and Hearing editorial, authored by Amy Donohue, Judy Dubno and Lucille Beck. Their editorial, titled Accessible and Affordable Hearing Health Care for Adults with Mild to Moderate Hearing Loss, laid much of the groundwork that led to the detailed June 2016 National Academy of Science Engineering and Medicine’s (NASEM) Hearing Health Care for Adults: Priorities for Improving Access and Affordability.
Fast-forward to 2017 with the OTC Hearing Aid Act being approved, and adults with perceived mild-to-moderate hearing loss no longer needing to see a hearing professional to purchase over-the-counter (OTC) hearing aids. Congressional legislation also authorized the FDA to create a new category of OTC hearing aids by 2020. Although other key events and publications emphasize the role of audiology in meeting this public health mission, how rank and file audiologists can become more actively involved in public health initiatives can seem perplexing.
Are Audiologists the Glue that Holds Public Health Initiatives Together?
At a time when smartphone-based hearing screening apps and automated audiometry are readily available to the general public, what role is there for the audiologist?
Depending on whom you speak to, some audiologists see the implementation of automated hearing testing and the availability of OTC devices as posing a risk to the patient and a threat to our profession. This perspective is understandable given our commitment to patient safety and our gold standards of practice. It also rings true if we solely think of the hearing test and the amplification device as being synonymous with hearing “health.”
However, hearing health involves more than just technology and when viewed through a public health lens, Audiologists can choose to be the glue that holds these tools together.
Take, for example, the implementation of newborn hearing screening programs. If you were a practicing audiologist in the 1980s and ’90s the emotional tension that we’re experiencing now about OTCs might feel familiar. Decades ago, no one debated the importance and need for early identification of hearing loss. Who would provide these services, however, were hotly debated issues. Once again, a major dilemma was the fact that there were not enough audiologists across the country to conduct hearing screenings. And, many audiologists saw the use of trained volunteers and paid technicians, as affordable and accessible solutions, to be controversial. Non-audiologists were viewed as a potential threat to the profession, and a threat to patient care because of the potential for obtaining incorrect hearing screening test results. However, when viewed through a public health lens, and by recognizing that the effectiveness of an early identification program did not solely rest on the hearing-screening test itself, cost-effective methods for reaching more children are now in place around the world. The greater good of reaching more babies offset some of the risks of involving non-audiologists in the screening process.
Today, newborn hearing screening programs exist in many countries around the globe and audiologists continue to play a key role in establishing the guidelines upon which they operate so that follow-up audiological services are implemented.
When thinking about older adults, hearing tests and amplification devices are also key ingredients to identifying and managing age-related hearing loss. However, technology, on its own, is unlikely to improve someone’s quality of life. Therefore, audiologists can shape their practice in a manner that fills the gaps that technology leaves behind. We can draw upon the many support skills we learned in graduate school; skills like counseling, auditory training and education and consumer advocacy.
We can be the glue that holds together technology and person-centered support, so more people can benefit from affordable devices.
This public health mission also challenges us to move beyond the traditional four walls of the clinic by getting directly involved in person-centered care while dispensing high quality, non-custom amplification devices in places where improved communication with a medical professional or caretaker is imperative. Also, because tax-payer and insurance dollars will be saved by the option of OTCs, this opens the door to advocate for greater insurance coverage for auditory rehabilitation services, especially for people with moderate to severe hearing loss. Another opportunity for audiologists is to play an active role educating hospital and nursing home personnel about the link between hearing loss and several other common adverse chronic medical conditions as well as advocating for policy changes that broaden access to audiological care and amplification devices.
Beyond the provision of traditional hearing aids and hearing tests, across the board–the public, profession, and more importantly persons with hearing loss–benefit from earlier intervention and support.
Chang JE, Weinstein B, Chodosh J, Blustein J.
J Am Geriatr Soc. 2018 Nov;66(11):2227-2228. doi: 10.1111/jgs.15545. Epub 2018 Oct 5. No abstract available.
Wilson BS, Tucci DL, Merson MH, O’Donoghue GM.
Lancet. 2017 Dec 2;390(10111):2503-2515. doi: 10.1016/S0140-6736(17)31073-5. Epub 2017 Jul 10. Review.
Windmill IM, Freeman BA.
J Am Acad Audiol. 2013 May;24(5):407-16. doi: 10.3766/jaaa.24.5.7. Review.
Reavis KM, Tremblay KL, Saunders G.
Ear Hear. 2016 Jul-Aug;37(4):376-80. doi: 10.1097/AUD.0000000000000321.
Brian Taylor, AuD, is the director of clinical audiology for the Fuel Medical Group. He also serves as the editor of Audiology Practices, the quarterly journal of the Academy of Doctors of Audiology, and editor-in-chief of Hearing News Watch for HHTM. Brian has held a variety of positions within the industry, including stints with Amplifon (1999-2008) and Unitron (2008-2015). Dr. Taylor has more than 25 years of clinical, teaching and practice management experience. He has written and edited six textbooks, including the third edition of Audiology Practice Management, recently published by Thieme Press.
Kelly Tremblay, PhD, is an Audiologist and Neuroscientist at the University of Washington.