Public Health and Hearing Loss: Interview with Nick Reed, AuD

Brian Taylor
Welcome to This Week in Hearing everybody, this is Brian Taylor. And with me this week is Dr. Nicholas Reed. Nicholas is a professor at John Hopkins University School of Medicine, a Professor of Epidemiology, even though by training, you’re an audiologist, I believe, Nick, right. Yeah. Yeah. And you’re also on the faculty of the Cochlear Center for what is it, for hearing and public health.

And last time I checked on PubMed, you were the author or co author of about 50 to 70 articles. So you’re prolific researcher and writer, and you bring a lot of great value to the table, I think, for all clinicians. And that’s really what I want to focus on today with you first, I want to welcome you to our to our webcast. Thanks for being here.

Nick Reed
Thanks for having me. I’m a big fan so far.

Brian Taylor
Yeah, no, this is a unique format. I thought a good place to start would be just to kind of overview. We don’t see a lot of professors of epidemiology that have an AuD, you’re probably the only one. Maybe talk a little bit about your journey to being in that position.

Nick Reed
Yeah, yeah, I’m happy to talk about that. I guess I should also just say, I’m an Assistant Professor, you know, there’s the Assistant, Associate, Full. I don’t want any of the full professors out there to be like, “this guy is..

No, it’s no worries. I don’t think anyone would notice. Yeah, so I, you’re right. It is rare. I, you know, we were opining earlier about how I feel like I’m on an island sometimes. But in a weird way. It’s not. It’s not all completely rare, because, you know, there’s other clinical fields, physicians being the primary one, and various medical professions, sub specialties, that are professors or tenure track faculty, in departments of epidemiology all over the country. I think the difference was just audiology hadn’t seen as much breakthrough of the silos of people going over to that side. And for me, you know, it’s a sort of a very personal journey, and that I had no intention to fall into this level. I did a T 35 experience at the NCRAR in Portland. And that was the Dawn Conrad-Martin and Marilyn Dille. And, you know, the work was sort of quasi-public healthy. It was a matched cohort of veterans looking at diabetes and hearing loss. And they had me present that at a AAAS meeting. And I just happened to get next to Frank Lin. And I walked him through my poster. And then he walked me through his and then he was like, do you like this? And I was like, yeah, and he was like, I don’t mean a lot of people that care about this. And this is, this is like 2013 or 2014. So it several years ago, we’re in the back corner of the conference. And there were like three posters under the epidemiology umbrella. And Frank, he literally said, before the conference ended, we had we had a beer or something. And he was like, you’re gonna come work in my lab after you finish? And I was like, okay, because I was like, a third year. So I was like, oh, yeah, he’s not gonna remember me. And then we stayed in touch. And he brought me in, and I worked on the ACHIEVE pilot, which we’ll talk about that ACHIEVE study today. But you know, I just fell in love with it. I, I saw quickly that we can do something when we look at things on the population level that we can’t do when we look at individuals. And we can see things that aren’t always clear to us see trends. And I just think

I find this to be a fascinating area. And I think it’s where it’s where we can make a difference. And I think you’re seeing that right now with I mean, you talk about this all the time in your show — audiology is changing so rapidly. And I think it has a lot to do with the influence of the onslaught of public health based studies around hearing science that happened in the past decade or so

Brian Taylor
we’re starting to learn more for sure. Well, I really, there’s a couple things here I want to touch on. One is I know that about maybe 2017, you wrote a paper. And the reason I know it well is because I have in my slide decks where you compared a handful of PSAPs to a hearing aid into the unaided condition. So he did research in that area. And now you seem over the last couple of years to be shifting into, like pure policy, Medicare, Medicare, Medicaid benefits, those kinds of things. So maybe you can kind of explain that journey or that transition from one part of the field to the other.

Nick Reed
Yeah, I mean, I guess a part of it is natural progression of training, maybe, you know, when I started in, at Johns Hopkins, obviously, I was coming from just a clinical standpoint, and the only thing informing me at a research level was what I had seen in the clinic. And the reason that we did that PSAP study

was quite literally, when I was at Georgetown University Hospital doing my fourth year, we would have people come in and they were at this sort of transition point in their lives where you know, they were 26 and rolling off of their parent’s insurance and needed to get, you know, another set of hearing aids

To get them over the hump, or they were just, you know, in their early 30s, late, you know, late 20s. And

they had, you know, they just happen to have progressive hearing loss, you know, you see a different population in the clinic than what you see in the general population and, or even, you know, early 50s. And they were not, you know, keen on getting a hearing aid because of cost barriers. And that came up over and over again. And, you know, I just happen to have the right kind of mentors at the time on the clinic side, that we would do whatever we could define somebody, something and this is, you know, this is the early stage of PSAPs, there’s not a lot of options out there. But we looked through all of our, you know, everything in our tool bag. And, you know, we found some things that were not that bad. And we would basically connected with them, and then teach them to use them in very specific situations that they were having problems. And we would overcome their problems. At the moment. I’m not saying that we solved all their problems for the long term, but it sort of spurred the question that if you create a rigorous design study where you’re isolating the technology, or the technology is relatively equivalent, when it comes to, you know, big picture outcomes, we know what an electro acoustic level, not equivalent, but we also know from research that a lot of stuff that we do in the labs for, you know, processing and the electro acoustic differences, they don’t translate to speech, understanding differences, and they don’t translate the quality differences. We knew that from Robin Cox’s work so, so we sort of sat down and did that work. And then you’re absolutely right, that we started to, I’ve started to change, I’ll be honest with you, it’s very driven by personal stories where in 2018, one of my closest friends von, von Hippel Lindau syndrome is essentially he doesn’t have the ability to suppress tumors, and even dealing with this for a long time, lung cancer, you know, had half a lung removed, had tumors in his spine, brain tumors, and it was coming to appointment, his body couldn’t handle it anymore. And this is a, you know, 36 year old at the time, cognitively normal. He had a heart attack and ended up in the hospital. And when he was in the hospital, and he was finally pulled back out of the ICU, and he’s in, you know, recovery and just the general medical inpatient unit, I drove to Pittsburgh to see him and, you know, he just didn’t make sense. Everything was, you know, off, he seemed withdrawn, he was not there. He was not with us, you know, he was with us, but not and it just did not make sense. And it was actually his wife who pointed out to me that they had just told me not long before that, but he had tumors pushing up against his IACs, he basically had a conductive hearing loss. And well, actually probably sensory at that point, just depending on how big the tumor was. But you know, what I mean, hearing loss is present. And I had my lab in Baltimore, actually overnight ship, just the basic, you know, handheld amplifier, and we put it on him, and we saw him come back to us within 28 or 48 hour period, like he’s, he was sharp as a tack, again, able to make jokes, you know, despite his condition, and he wore that every single day, the rest of his life. And what I after talking with some of my mentors at Hopkins, particularly in geriatrics, Esther Seunghee Oh at Hopkins, and then Sharon Inouye, who I later was connected with at Harvard, you know, it’s classic delerium. And, you know, delirium is not just something that happens to older adults. And it’s also not just something that happens to adults with dementia, as we might think, or something like that. This is, you know, other pathways when we block communication in the clinic can cause this. And, you know, to me, I don’t know, this was just an injustice on a level that I couldn’t comprehend, especially when I think we know delirium is associated with worse health outcomes. And so for him to experience that we are, we already knew he was in hospice-like situation. But you know, we may have extended those three months into six months, who knows, or maybe you’re, and when I think that we can study this area and do something about a hospital based interactions with hearing loss. It’s very personal for me, and it’s something that I’ve sort of dedicated now, my research towards and by happenstance that also falls into the policy side of how we can make sure at a policy level we’re addressing hearing loss, and we’re getting people devices they need. So yeah, I think it’s fair to characterize that I’ve sort of changed maybe evolved, but you know, the truth is, like a lot of people in life, it’s personally driven for me, it’s not, you know, I don’t even know if there’s more research money in one space or the other or something like that.

Brian Taylor
Right. Right. It’s really something you’re keenly interested in. And I think the really interesting thing, or one of the interesting components, a lot of the work you do is you’re interacting with epidemiologists, other areas. I mean, think of a lot of the studies you’ve co authored with. Jennifer Deal. I have an Amber willick. Willink, Willink.

So and I know that, Franklin, I think he’s the founder for lack of a better term for the Cochlear Center. So maybe explain how that came into into fruition? What are the goals of the Cochlear Center, how you all work together? It seems like a really dynamic place.

Nick Reed
Yeah, it is. It’s a it’s a fantastic entity. So the Cochlear Center is sort of it’s it’s

born out of Frank Lin’s research, I think and he had already started to form this team of Jennifer Deal, myself, Josh Betts from biostatistics, Carrie Nieman, who’s another otolaryngologist Adele Goman, who is a psychologist, actually, by training, but very much was looking at population level health. And, and then amber came sort of at the founding of the center as well. And, you know, I don’t know the full background story, but essentially Cochlear, from Australia, Cochlear – the company, I think that they had a really healthy view of how we needed to go and research from a public health standpoint. And they basically provided this private gift of $1 million a year, over 10 years to Johns Hopkins Bloomberg School of Public Health, and that funded the center. And our mission is it’s vast, we have different pillars of research, where we’re looking at population level associations between hearing loss and health, health outcomes, and healthy aging, really, we are really trying to focus and establish ways to talk about and understand hearing loss. So sort of public health intervention on the societal level of, you know, let’s get beyond just saying there’s mild, moderate, severe hearing loss and get into something that’s meaningful for people to anchor against to, you know, take action on, you know, intervention level, we’re thinking about, like task sharing, and this is Carrie Neiman’s, HEARS project. And then for me, it’s addressing hearing loss in hospitals. And then also becoming sort of a Policy Center where we don’t have a lot of bias. And our goal is to make sure that we match the needs of the healthcare system, as well as audiology, the manufacturers of the world but you know, the hearing care space and create policy that works for the public. I mean, in the end, that’s our goal is to make sure that everybody has access to hearing care via major policy initiatives, the United States and so the center has been extremely fruitful I think, in the researchers brought in over the years, Esther Seunghee Oh, who’s from geria – she’s a geriatrician at Johns Hopkins has become a core faculty member, Bonnie Swenor, who’s an expert in disability and particularly vision has become a core faculty member. I think those are the two major additions in the past years, but we’ve also trained two PhD students have graduated we have I think, two currently studying a dozen or so masters students at this point, yeah, we, we really pride ourselves on providing scholarships to bridge the gaps where most of our students, our public health students who we have them focus on hearing loss. We also bring in audiologists who we then train into public health. And we’ve done that a few times and and physicians who we train into, you know otolaryngology students who we train into public health. And so we sort of run the gamut in that space of just trying to break down that silo. And I guess, I guess what really does make it unique to is, we’re focused on age related hearing loss only. And we don’t focus on cochlear implants. Despite the name being named after Cochlear, we don’t we don’t touch cochlear implant research really

Brian Taylor
Right, no, it’s really interesting. I know, one of the things that resonated with me that I heard from Frank Lin years ago is that we focus on infants, or not infants, but children and language development. And it’s such a big deal for obvious reasons that you want to treat that loss early, when an adult has hearing loss, we just sort of make a joke about it, you know, it’s normal for your age to deal with it. And that’s, you know, a wrong assumption. And I think a lot of the work that you guys are doing is changing the mindset, not only as professionals, but also of the public, which is great.

Nick Reed
Yeah, I can’t I can’t agree with you more. I think there’s an interesting tidbit, too. at Johns Hopkins, in particular, the School of Public Health actually had a center focused on hearing in the 70s. And it was only pediatric hearing loss. Right. And it makes perfect sense, because that’s the area we cared about. And then once those questions, I’m not saying they’re all answered, but you know, audiology, to their credit, audiology has done a great job.

Brian Taylor
Yeah, we’ve reached a consensus on it for sure.

Nick Reed
We’ve, I mean, we’ve, you know, audiology actually deserves a pat on the back, we we actually from public health standpoint, have done phenomenal things. Universal newborn hearing screening is a gold standard for among public health of some intervention that occurred in the United States, right? Driven by audiology.

Brian Taylor
I remember in the 90s, when audiologist spot for that, right

Nick Reed
yeah, and, you know, it’s, it’s wild to me that I’m not again, we haven’t answered all the questions, but then like the research from a public health standpoint, starts to kind of just wane off after we went after in the 70s 80s, you know, parts of the 90s we really hit this like zenith of public health, audiology research in the pediatric area, and then it starts to wane off and now I think we’re seeing like a second wave where we’re focusing on aging now. And, you know, perhaps it’s sort of like you just mentioned perhaps it’s just sort of a justice issue to where, unfortunately, we ignored hearing loss in older adults, not audiology, but as a society for and now we’re seeing the interest there.

Brian Taylor
I think a lot of it’s written by the baby boomer generation, there’s just so many of them and they’re very vocal and proactive about things and so it’s bound to happen. It’s a good thing. So you use this term population based

Health a few times, public health. And I think, as a clinician, you know, for 25 years or so seeing patients on the individual level, I think it’s sometimes hard to kind of wrap your head around what it means or how do you focus on population based health? And why why is that important? When I’m seeing dozens of individuals every week in my clinic? So what, what do audiologists need to know about public health or population based health to make them more effective in the clinic?

Nick Reed
Hmm, that’s a good question. I think so. You know, without trying to, like use terms in the title, but you know, public health is, is looking at health at a population level, it’s, it’s, and there’s some fundamental differences. Here, we I sort of I said this earlier to you get this idea that you can see trends at a population level that you can’t necessarily see in the individual, right. And they’re hard to tease out in the individual where you may see somebody who has hearing loss and dementia, and you don’t really put two and two together that they might be related. But then when you look at many, many individuals, we can pull out that association. And what’s important about that association, though, those numbers that we see, and this is this is something that literally everybody gets wrong, the estimate of risk is at the population level. So when you see numbers, like, you know, like the big Lancet analysis, 9% of dementia is attributable to hearing loss. It’s not that in a given individual, like 9% of dementia is attributed to hearing loss or that like they have a 9% increased risk or something like that, it’s that if you wiped out hearing loss on the global scale, 9% of dementia would also disappear, right? So the same thing for all these studies, you see where hearing loss contributed to five times the odds to develop dementia, or you know, a 36%, higher risk of dementia, none of that is individual. So when you’re looking at that research, as an audiologist, it’s always important to keep that in the back of your mind that we create the associations at a population level, but we treat the individual right. And so there is increased risk at a macro level, but it doesn’t necessarily create like a one to one. Right, right. I think that’s hard actually, to do that. You hear these numbers thrown around. And it’s so much easier, just say like, Oh, yeah, twice the risk.

Brian Taylor
But yeah, no,

I know. And I think and I really want to if we can maybe dig at this point a little bit, because I think I see this all the time in marketing material, you know, audiologist, hearing care professionals want to do the right thing. And they want to use data to make a claim or in marketing, but I think it’s almost it’s an apples and oranges thing, because to your point, these studies, the beauty of these studies is they’re having the data points from 1000s of people, so you get some really powerful analytics, but they may not apply to the individual. So I guess, how do you navigate that as a clinician? How do you how do you talk to the data speak to the data when you have an individual in front of you in the clinic? Or you’re developing a marketing piece? How do you do it in an accurate, responsible, ethical way?

Nick Reed
Yeah, I mean, so when, when trying to, you know, put that data out there, I think it is completely ethical to cite and, you know, talk about the data, I think where it becomes unethical is when we use it. And, you know, I’m not saying people do this, but inadvertently, we use it like as a scare tactic like, we’re almost saying, you know, you have hearing loss than your increased risk for dementia- is not necessarily true. Instead, I think it’s like healthy to think about it, as you know, almost like talking about heart disease or obesity, think other areas of public health that we’ve done a lot of work in, you know, we talk about soda consumption, for example, increases risk, you know, smoking increases risk, eating red meat increases risks, but we also know that, you know, one sandwich of, you know, cured meats, one, one steak, one soda, you know, I don’t, I don’t want to, I’m not telling anyone to go smoke a cigarette, but one cigarette not necessarily, like, we know that there’s sort of accumulation of these items at increased risk. And just because one person does something does not always mean that that individual is going to do something and maybe maybe people can resonate with that a little bit easier. Just because you have hearing loss does not mean you will develop dementia. And again, population level. Absolutely. Sure, we can measure that. But we don’t have individual level risk. And it doesn’t mean like I people want to know, they want you to say like, Okay, I have hearing loss, what does that mean for me, and I think your job as a clinician is more to say, Well, at a population level, there’s an association between the two. And that would mean that you are at higher risk as well. But it doesn’t mean that you have some set number at this point where, okay, you have hearing loss, you’re at 50%, higher risk, you’re you’re a complete person, and all these different things go into it and matter. And so it’s all about living a healthy lifestyle overall, because for that given individual, you know, the hearing loss could be completely counteracted. And then I also think it’s important audiologists always dig into what we think the mechanistic pathways are. And if we think it has a lot to do with social isolation and loneliness, for example, then we need to remind people that that is part of the mechanism we see there. It’s not just that hearing loss creates this out of thin air, there’s a pathway and so we want To make sure that you know, you as an individual are staying active and getting out there. And this is, this is fundamental to humans. You know, you can always talk about I think all people resonate with this, like we are creatures that love our species, right? We are we like to be in groups, we need that interaction we crave at a societal level interaction. Right, right. I think people get that.

Brian Taylor
Yeah, no. And I think that’s a great point about you’re increasing, the odds are maybe a little bit greater because you’re doing these things. But the individual level, there’s too many other variables to know for sure. So but you’ve already mentioned social, social isolation, loneliness, I know that you and your colleagues there have done an awful lot of young literature reviews, you’ve done studies that look at the association between some of these other conditions and how they’re related to hearing loss. So maybe we can kind of take a look at some of them, I social isolation and loneliness, maybe what’s the difference between those two concepts? How do they relate to hearing loss?

Nick Reed
Yeah, I mean, it’s a it’s actually a great question. Most people just use those interchangeably. social isolation really is the way I sort of think of it at a very lay-level, right? social isolation is a, you know, objective measure of how many people you’ve interacted with, loneliness is your perception of how lonely you are. So it is very possible to interact with dozens of people and still be lonely, right? Your social isolation could be, you know, quote, unquote, normal, no different than anyone else, but you could still be lonely.

Brian Taylor
Yeah, it’s like

your emotional reaction to it.

Nick Reed
Yeah. Yeah, you could think of it that way. Absolutely. And so they are different concepts, they correlate 100.. Like they do have a strong correlation. So you know, the, but they are fundamentally different. We have, like you said, there’s been a ton of research in this area, I think, lately, and I still actually will say there’s not enough social isolation, loneliness are also those kind of areas that they’ve got, they’ve come a good public health attention, but at the same time, they feel also sort of been ignored among older adults, just like you were just like hearing loss. You know, there’s, there’s sort of an ageism in research, and that we haven’t treated adults with the same sort of justice that I think we’ve given towards the other older adults towards other groups, just adults, pediatrics, adolescence, and we’ve sort of ignored them thinking like, Oh, well, that’s just that’s, ah, you’re just getting older. And that’s it. But this is a part of it. AARP did this huge report that Charlotte Yeh, the Chief Medical Officer will talk about where social isolation, loneliness actually are the highest predictors of morbidity and mortality among older adults, and they cost more per year to Medicare than anything else, really. So they’re incredibly important. And for us, as audiologists, I think this becomes important, because this is a pathway hearing loss increases risk. And so that’s the area of risk for social isolation, loneliness, that’s the area that people have started studying the data is, it’s not great at a macro level. And to be honest, this has to do with a lack of good data. And what I mean by that is, a lot of the studies out there that associate one with the other are using measures of self report, for example, and you can imagine there’s sort of a measurement, there’s sort of a bias and that kind of approach in that if you’re lonely, you may be more or less likely depending to report accurately your hearing loss, right. Just like with depression, and dementia, and hearing loss, the association, the the exposure measure, in that sense matters. And so, you know, it’s it’s one of those areas where it’s important that we get, you know, quote, unquote, objective measures. I say that because we know that pure tones are not objective. They’re a behavioral measure, still, but something that at a population level is much more clinically gold standard measure, and whether it’s pure tones, whether it’s speech in noise measures, whether it’s a better questionnaire that can sort of tease apart just like a yes, no, I have hearing loss type question, whatever it is, you know, I’m not saying there’s a there’s a gold standard, but the the main thing, I think, is that we need better measures to then associate with these, because then we can do a better job of estimating the actual risk change. But to that point, at a macro level, if you look at the meta analyses that we’ve done, or the systematic reviews, our big thing was looking at the UCLA loneliness scale, and seeing how many studies had used it and looked with hearing loss. And when we aligned it at a meta analysis level, I think, I think we identified like nine studies, you know, essentially, we found found that there was a lot of homogeneity and agreement between all of the studies and there isn’t, you know, increased risk in the presence of hearing loss.

Brian Taylor
You know, it’s more likely

on the population level, if a person is hearing loss, that they’re going to be socially isolated and lonely.

Nick Reed
Yeah, loneliness was easier for us to find social isolation almost non existent in the literature, because it’s a lot harder to get somebody to tell you how many people they’ve interacted with lately.

Brian Taylor
Yeah, that makes sense. Well, I know. I wanted to talk a little bit about the it’s I think it’s about 10 years old. Now the study that looked at the relationship between cognitive decline and hearing loss and the dosage effect. You can maybe you know, like you’re at much higher odds of having or acquiring dementia or cognitive decline, whatever you want to describe it, I’ll let you do that if you had a much more significant hearing loss relative to a mild loss, and I also know that there’s work now that Justin Golub subclinical hearing loss, so maybe you could speak to how that all fits together.

Nick Reed
Yeah, yeah. So I know exactly what you’re talking about the dose response, one that we often talk about, it’s Baltimore longitudinal study of aging, it’s Frank Lin’s work. And essentially, he looked- it’s survival analysis, in a sense that at baseline, nobody has dementia, and then we look forward in time. And we look at, you know, risk of developing dementia for each individual. And then we look by hearing level and so when you when you do it, that way, you use the World Health Organization categories for frequency PTA, those with mild hearing loss have twice the, it’s its hazard ratio, but you can interpret it as odds, basically- twice the odds. And then those with mild have three times the odds, and then those with severe or sorry, moderate three times the odds, and then severe was actually five times the odds. But you know, I also put a little bit of caution on that, because there’s not a lot of adults with severe hearing loss in that study. So the, the precision of that estimate is wide, and that the confidence interval was really wide. So, you know, I do think though, that the the moderate with three times the odds is even the mild with two times, that’s nothing to sneeze at. I mean, people, people don’t know how to interpret odds. And that’s because odds are sort of uninterpretable. And risk is a better way to think of things because then we can say, like, with precision that like, you know, 23% risk equates to a very specific thing, whereas the odds are sort of, you know, relative, it’s all relative, and it’s harder to get, but, you know, in epidemiologic literature, when you get anytime over, like 20% odds, so and you’re, in this case, we’re looking at 100% and 300% odds, we are well into, like, you know, significant, clinically meaningful areas, like these are your numbers, and then Justin’s work. Oh, that’s, so I love Justin’s work, really like Justin Golub, Columbia at Columbia and he has been focusing on Okay, so if you look at, you know, we see this dose response and all these other studies, right, and a lot of the work that that Frank Lin has done, for example, and Jennifer, they’ve looked at continuous measures of PTA as well. And we always see, you know, that, you know, we see these dose responses essentially, where the, the higher your hearing loss, the the more various different outcomes, the worst things are, the higher the risk for the outcome, Justin looked at those under four frequency PTA of 25. And saw an association with cognition and subclinical hearing loss, and essentially now you’re saying that, okay, we stratified to this group of quote, unquote, normal hearing, and we still see the higher your PTA within that group, the more likely to have, you know, poorer cognition, based off I can’t remember the measure he used, I think he use the NHANES data. So it might have been digit symbol substitution. I don’t quote me on that. But the papers in JAMA otolaryngology for anyone who wants to read it. And I think it just gets at this idea that, you know, maybe this is a little philosophical, but, you know, perhaps we don’t have perfect cut points for hearing loss. And also just this is the difference between clinical and epidemiologic work where at the epidemiologic level, we have to define hearing somehow, and we use the four frequency pure tone average, that’s pretty standard, but at the clinical level, you know, we know that you might not have a PTA that goes over 25, but you might still have clinical complaints of hearing, because you have more hearing loss over, you know, 4, 6, 8000 level frequency levels, right? or, you know, perhaps there’s something here where we need to think more about where somebody is, you know, original baseline is and where they’ve moved from there.

Brian Taylor
Yeah, exactly. It’s a huge range, right?

Nick Reed
If you, you know, if you start at a PTA of negative five, and you move to 20, versus somebody who was, you know, around like a 20, that moved to a 25. Well, we label one person with hearing loss, and we call the other normal still, despite over their life course having a massive change. And so this could be part of, you know, I think, I think what Justin, his work is sort of telling us is that probably the same pathways exists things like cognitive load, things like sensory changes to the causing structural sensory input, causing structural changes to the brain, and then perhaps even communication, causing social isolation and loneliness, to get to cognitive decline. But, you know, it may not just be a phenomenon of these arbitrary measures of hearing loss, it it really might be more important to think about PTA as a continuous thing and any individual change any, you know, loss at any level could be, you know, right is important.

Brian Taylor
A couple

thing, I think that he also has a paper that looks at subclinical hearing loss and depression. So there’s more than just cognitive decline going on. But I think the point I wanted to make here is as a clinician, you can’t just look at somebody thresholds and make a determination about intervention. You need some other tool like some type of scale self report, that’s validated to help you determine me I can think of all kinds of people that I’ve seen over the years that had to do a case history and you think the person is a, you know, a hearing aid candidate and put them in the booth to do the test, you find out they have normal hearing, then you’re kind of stuck. But you know, if he did, he took it a step further, you could, you know, by doing some type of a scale, like the HHIE we could determine what their auditory wellness is, I think the gap is we don’t have real solid intervention strategies beyond stay out of the background noise, you know, find the least reverberant place in the restaurant there. I think that things are changing, though. If you’re going to see more things come to the table – devices that help

Nick Reed
I wholeheartedly agree with you, I

think that we are seeing a real, like the tool belt is expanding drastically, very, very rapidly. And yeah, I think that’s the perfect way to think about it too. And that, you know, there’s a way to measure peripheral hearing loss. And that’s what we’re using in a lot of these epidemiologic studies. But there’s a way to actually measure difficulties associated with hearing that translates more toward the idea of intervention than just the peripheral side. Right? Right. It’s, it’s an important distinction to make. It’s, you know, we this, this gets at to, you know, again, philosophically, like, we talk about these things, and they don’t make any sense to the public. And we’ve, we’ve got to do a better job of, you know, this is hearing, right, this is hearing over here, but this is your difficulty. And this is what translates to the hearing aid side, right. And this is where or hearing aid intervention in general, like this is where you got to do something, perhaps. And, you know, it goes back to what you asked them the beginning, actually, public health versus the way you treat the individual. And, you know, the next step with a lot of this research, is making more of what we might call clinical epidemiology, which is how do you take this population based data, and turn it into individual level risk factors and actually create algorithms to say that this person truly is now at this level of high risk for something and you need to do something or, you know, these are cut points where you need to triage them into different areas? And

Brian Taylor
so where are we as a profession in that?

Nick Reed
I think we’re actually I think we’re pretty nascent in that area. I think there’s a lot of really great audiologists out there. And I think most of the time, we we mean, well, but a lot of times we throw the whole test battery at people, for example. And I think when we start to think more about almost like precision, audiology, so using clinical epidemiology to inform precision audiology, we are going to get closer to, you know, picking and choosing our test batteries based off of clinically set cut points based on the data. Right. And I think audiology, I’m not saying it’s, you know, at the, you know, it’s behind or anything, I think a lot of fields are like this, where we’re just getting to this nascent stage of now we’re being informed by data, and we’re doing a better job of taking that population data and starting to figure out attributable risk within an individual. And yeah, you know, if you if you really wanted to dig into this kind of literature, I would always say go look at the cardiology literature, because they always seem to be 20 years ahead of the rest of kind of makes sense, right?

Brian Taylor
Yeah. Let’s get to that. I wanted to put a plug in for you’re, you were the guest editor for this. Don’t know people can see that real well. This last issue, or man, not the first issue this year of Seminars in Hearing, right, there’s way there’s, this is a great if anybody wants to know more about the relationship between audiology and public health, I would have you take a look at that. But there’s one study in there that I wanted you to maybe speak about a little bit it was, wasn’t by you is maybe by some researchers in Michigan preventative care. And I thought this is really interesting. People that had hearing loss were more likely to not do the things they needed in this respect to preventative care. So

Nick Reed
is this Nicholas Fierro Montes? Yes, I think so. So Nick is fantastic. He’s a, he’s a med student at University of Maryland. And he worked with Lama Assi who is my former mentee. Now she is, uh, she did her MPH with me and now she’s at University of New, LSU in New Orleans, and she’s a ophthalmology resident actually. And Lama’s done a few studies in this, there’s actually a relatively large follow up study to this that I think your audience might be interested in coming out in American Journal of Preventative Medicine, where we look at something very similar, except on a much, much larger scale. So the long and the short of it is exactly what you said adults with sensory loss are, hearing loss in this case, are less likely to engage in preventative care activities. And those are screenings. You know, in the other study, we looked at things like vaccinations, screenings are, you know, across the board. I think the big one, though, in this study, I may be mixing up the studies, this one might have been mammograms, and we’ve also done sort of heart attack knowledge, which is a big thing that’s been measured out there among the public. And what we believe is happening is we’re looking at the other literature that we’ve done, where we’ve seen associations between hearing loss and various healthcare utilization outcomes. And you know, you don’t just get from one to the other via just communication, right. There’s a lot going on in this pathway. And so in this particular pathway, what we think is going on is hearing loss potentially leading to poor communication with patients and providers. And those barriers, change your actual utilization of these, you know, preventative measures these healthy interactions with the healthcare system. And it’s twofold. We don’t just think that, you know, people with hearing loss are doing a bad job of reporting things, we actually think that when you have poor communication, the physicians may not be doing as much as they should be doing, because they’re 1) potentially becoming, you know, frustrated, and they’re not moving as quick. And you know, these levels of frustrations are two waves, and then maybe 2) they just, you know, don’t get to it. And so our, our theory is actually that it’s not just pure access, you know, it’s not just that you have trouble calling or something like that, or getting through on the system it is a lot of just, you know, when you have those conversations, you may end up not getting to the next level, and maybe the physician not even recommending it because of the communication breakdowns.

Brian Taylor
That’s really interesting.

Nick Reed
I go ahead Brian,

Brian Taylor
I just, you know, just the value of early intervention with people that need help with hearing, I think we take it for granted, when we have good hearing that it’s easy for those that don’t hear very well to just kind of tune out easily. And we don’t

Nick Reed
Yeah, you don’t doubt them. Exactly. Like, you know, again, this is this ageism in society where you have an older adult, and they have hearing loss, and, you know, they start saying, hmm, and what and you’re so likely to almost like I say you as in like the societal level, like we as a society are so likely to start to ignore them and sort of not think as much about their needs. And maybe again, in this case, from a healthcare standpoint, not push them to various preventative measures. And vaccines are the big ones for us screening as well. But and I’m not even talking about just like, you know, COVID vaccines, but just, in general, this is something that, you know, an appointment of a doctor, a physician really has to push that and get that set up, right, and to see it not happening at the same clip as those without hearing loss. And, you know, this is after accounting in the population, then for, you know, vaccine hesitancy, which we have no reason to believe one would be higher than the other in these groups. You know, this is this is an important area, I think that we discount hearing loss among communication. I know this sounds crazy to audiologists, but if you actually dig in on the literature, but there’s a whole literature on patient communication, and hearing loss is almost never mentioned. And it’s just, it’s wild to me. And I really do mean, it’s like wild like I can’t wrap my head around it that people say this, and I I tell this story from a few years ago, I have this paper published now in Health Affairs, we actually it’s just published this past May and it’s on unmet healthcare needs among adults with hearing loss. And the first time I submitted it to a different journal, it was a it was rejected for another journal Health Affairs is a very good journal ended up in a better journal in the end, but one of the reviews that came back was this person keeps mentioning communication, but they’re not measuring communication at all, like hearing loss is not communication. And I almost spit out my coffee. I was like: What are you talking about? Communica- hearing loss is literally a fundamental technical barrier to or orally presented communication. I know that verbal communication includes written and oral, but we know that the vast majority communication that occurs in this country is oral, and we need to ensure access to it. And whether that is ensuring that there’s written access to that’s a different story. But that the point for me is that it’s fundamental to communication, you know, for someone to disregard it like that.

I just read it. That’s crazy. Couldn’t believe it?

Brian Taylor
Well, there’s a couple other things, I wanted to talk about it with some of the work that you’ve done there. One is the acronym is ACHIEVE. And I know this, in our in our profession, this has gotten a lot of traction over the last few years. I know this is a longitudinal study. So maybe you could update our viewers on what you’re what you’re looking at in the ACHIEVE study, and what we can look forward to when it’s when it’s published.

Nick Reed
Yeah, I think so. The ACHIEVE study is a large randomized control trial of best practice hearing care on cognitive decline among adults with mild and moderate hearing loss. And so it’s about 1000 individuals half randomized to hearing care half randomized to sort of a healthy aging equivalent there, they essentially sit down with a nurse and discuss various issues, healthy aging. This is I think this is very much the culmination of Frank’s you know, entire career to this point to a certain point. I mean, it’s not to use too much hyperbole, but it really is one of these studies that I don’t think will ever get redone at the same level, you’re, you’re gonna have a hard time convincing the NIH or other funding agencies to give you that much money to actually do this study again. So I do think it’s sort of a once in a lifetime study that we’re seeing right now. And at this point, we are done recruitment, we’ve been done with recruitment for a while. It’s a three year study. So individuals, you know, they’re randomized, there’s intervention, and then we follow them for three years and we’re looking at cognitive decline. From baseline to three years, and we have individuals at this point who are coming in for their three years, and so, you know, we’re getting closer and closer to the wrap up of this study, which will probably be in 2023. And then we’ll have a hopefully, you know, as far as evidence goes, this is pretty much the definitive answer on the protective effect of hearing aids. And, you know, it’s important, again, that our field – audiologists, we understand public health literature, because, you know, we go back to thinking about interpreting studies, but also just understanding the basics where just because you find an association between X and Y does not mean that getting rid of X or addressing x is actually going to fix this necessarily. Right. So what that means is, you know, just because we found that hearing loss, you know, has this what we propose as a causal association with cognitive decline, did not mean in any sense that hearing aids would then change that. And this goes for all fields, like, you know, you find that association between hypertension and dementia, it does not mean reducing hypertension necessarily would reduce dementia. I mean, it does. But, you know, that didn’t mean that definitively. So now, this is how we answer that question with a

Brian Taylor
right oh,

that’s why it’s so important. Right? And I’ll tell you a little bit of a sidebar here, I refer to there’s the clinical protocol that’s used in the study of the lead author is Sanchez. I don’t remember her first name.

Nick Reed
So I always say, Vicki Sanchez, Michelle Arnold’s and Terry Chisholm are the the group we partnered with, at University of South Florida to develop the intervention.

Brian Taylor
And then in about a year, or maybe your maybe a year ago was published in Ear & Hearing. And so when people ask me about what’s a good clinical protocol that I can use to make sure that I’m on the forefront with respect to how I practice that we say, you know, do what they did in the ACHIEVE study, because that’s very rigorous and cutting edge, and you’re not going to go wrong if you just adapt that into your own clinic. So

Nick Reed
she’ll appreciate that.

Brian Taylor
Anyway, the last thing about all of your work in this area wanted to touch on was, maybe this is another example of the dosage effect, but it has to do with expenses, or expenditures. I think it was a couple years ago, you published in one of the non audiology journals over time, how much a person with hearing loss cost the system relative to somebody of a similar age that has normal hearing you talk a little bit about that?

Nick Reed
Yeah. So in that study, we use a large clinical database, essentially Optum Labs database. So it’s a it’s a claims analysis. And what we did was, you know, we matched individuals with likely hearing loss of those without likely hearing loss. And I say that because we use claims to find this. And so we very much looked for age related hearing loss. This was a long process, I won’t bore you with it. But we think that we had developed an algorithm that was probably highly specific, but probably low sensitivity. And what I mean by that is, if we found somebody very likely, they had age related hearing loss, it’s very unlikely that it was something like, you know, Meniere’s or some other, or some ear disease that was miscoded, or something like that. But we know we did not get all the hearing loss. So this will come up in a second, when we interpret this Actually, I’ll jump right to the 10-year conclusions we did 2-year, 5-year and 10-year looks because you can get a lot more people in a two year analysis, just because it’s hard to get continuous claims on somebody. But in the 10 year analysis, we have 2300 individuals with hearing loss, 2300 without. We matched them on everything under the sun, you can think of including their baseline utilization metrics. So these are as close to the same individuals with and without hearing losses we can get, and then over a 10 year period, those with hearing loss, incur on average $22,000 more in health care expenditures. And it’s very much not due to some like hearing loss expenditure. There’s just nothing in there barely. And we excluded hearing aid use but when you actually and we also found you know, the other things that people I think are intrigued to hear is higher rate of hospitalization, 46% higher risk of a 30 day readmission, longer length of stay more likely to have an ED visit. What’s important when you interpret that to, again, the importance of getting the fundamentals of public health, when we have that high specific, low sensitive, relatively low sensitivity identifier like that, that means that there’s people with hearing loss also in the control group. And if we think that the association is that hearing loss is what’s driving it, then that is actually a conservative bias. So in reality, the difference might be much bigger if we had a better exposure where we were actually able to really truly identify hearing, right. So it’s a relatively conservative estimate. And I think that’s what the most important thing actually that people gloss over in that study is, is adults with hearing loss are incurring much more healthcare expenditures, and I don’t interpret it necessarily as like a hit to the system. I think it’s unfair to the individuals. I think the individuals are getting bad healthcare to a certain extent because the system is not accommodating their needs. It’s I mean, it’s a justice issue in the end to certain extent.

Brian Taylor
Yeah, I know, it

make sense. Which leads me to the last thing I wanted to talk about with you. I would think that insurance companies, government policymakers would pay attention to the numbers like that. So can you share with us sort of at the policy level? I know there’s a lot of talk right now about maybe Medicare being expanded. How does your research fit into some of these changes that we might have anticipated in policy?

Nick Reed
Yeah, that?

Yeah, that’s a great question. I think I think the work of the center fits in in two levels. One, I think that we have helped to inform the conversation and show them these kind of numbers and show them the potential cost-benefit of, you know, addressing hearing loss. The problem, though, is that the CBO, the Congressional Budget Office, cannot assume that. so we don’t have, you know, until the ACHIEVE trial comes out, we don’t have strong rigorous evidence saying that hearing aids actually reduce costs. So instead, we’re left with the assumption that, you know, perhaps if you did something, it would, but it doesn’t, it doesn’t actually translate to anything in the financial estimates. The second part of this is, our team, led by Amber Willink, myself and Frank Lin are the three who really do this work. We think a lot about what a Medicare policy might look like and trying to find a sweet middle ground to a certain extent. And what I mean by that is, the Medicare is.. it’s very unappealing for Medicare, to say, “we’re going to cover hearing aids and hearing care services for everyone with hearing loss,” because that is, as you know, when we break down those numbers, you’re looking at, like 20 million, 25 million Medicare beneficiaries. And that’s using a conservative estimate of hearing loss, not even including unilateral losses. And that number is astronomical. And so you saw this play out in the last Congress, where they had the Medicare hearing aid act now from Lucy mcbath, it had from Georgia, and that was pulled into the Elijah Cummings HR three. And the idea there was, we would cover hearing care services for everyone. And hearing aids specifically would be for those with severe greater hearing losses, what was in there, and I think this plays into a nice, you know, again, finding that middle ground where they’re acknowledging the over the counter hearing aid act technically covers the mild and moderate group. And they’re also acknowledging that not everyone in that group gets hearing aids, it’s a very, I mean, the uptake of hearing aids in the mild group is really low, we’re looking at like, less than 5%, right? And the sort of acknowledge that and say, let’s take those numbers out of the equation, then from population level of, because they have to assume everyone’s going to get hearing aids, if they, you know, cover them, right that the, the algorithms like front blows the Congressional Budget estimates out of the water. But then if you only address, you know, more severe hearing loss who are not covered under the OTC hearing aid act, then you’re covering devices for them. But then I think a key aspect of this is everybody gets services. And this is something that our team wrote about. I wrote a JAMA article several years ago, that was the foundation for this. And you may have actually seen to Franklin just re You know, he sort of took those points and put them into another article in stat news. But we we established this early on that we think the fundamental piece here is don’t worry about devices as much right covered devices for you know, the high end, higher degree of hearing loss group because they’re not covered under the OTC side. But perhaps the market is going to shift the way we deliver hearing care, the accessibility of devices, let that cover on one side and it gives people some skin in the game to they’ve they’ve done something, but cover the services, cover audiology services cover hearing aid dispenser services, that if we as a field really want to move forward, and we believe we matter, then that’s what matters. And that’s the hill that we can die on. It’s it’s so I mean, you’ve written about this before. It’s the same thing as the unbundling conversation. When you unbundle you show your own value. And I think that I think that at a public health level, we’ve moved Medicare just enough to get them to see the value of the services that that’s what they’re focusing now in on these bills. And we’ll see what the next version looks like. We don’t have a bill actually, right now, there’s, there’s the MAASA bill, but that’s a different, that’s a different thing. Then Medicare actually covering hearing aids, really, but we do know that there’s a lot of discussion going on, because in the proposed budget, coverage of dental vision and hearing care is in there. And the estimates are all based off HR 3 Elijah Cummings act, but we’ll see. We’ll see what it really looks like. I think I think there are some important questions out there right now. I think that there’s questions around, we’re hearing instrument specialists vs audiologists get linked up and put under Medicare, and I’ll say upfront for your audience that you cannot exclude one side at all. We don’t have enough people to go around to service everyone, right. It’s urban versus rural issue too. a serious issue. And then there’s these issues of DME versus prosthetic, which is getting in the weeds a little bit. But essentially the idea that is it all custom? Or can we bid as durable medical equipment to buy a bunch of hearing aids from for Medicare at once? And then I think there’s also sort of a, an issue I hear a lot about, and we discuss macro level, you know, well, what is what does the hearing aid look like? Is it top of the line? Are we giving people the option to upgrade out of Medicare? And that, that turns that that turns Medicare from covering a hearing aid to actually covering an allowance? And, you know, does Medicare want to go down that path? And are there really, are there really examples of us to follow in that, and I don’t, I don’t really see that in Medicare too much. There’s Medicare Advantage, obviously, which is sort of an upgrade. That’s a different thing if people want to do Medicare Advantage and get different hearing aids, and that’s totally different. But Medicare itself allow doing an allowance, and then giving people essentially, doesn’t really exist.

Brian Taylor
Yeah, as I say, not in this country. I know in other parts of the world. They have a system like that, but not here. Now. It’s good information. So I’ve taken too much of your time. And I really appreciate all the all this great conversation. Just maybe in closing, if you could share with us, you know, what are some things like a take home message for clinicians, based on all the work that you and your team have done at Johns Hopkins?

Nick Reed
Oh, man?

Brian Taylor
That’s a big question.

Nick Reed
I know. I mean,

I guess, you know, honestly, I would leave it as more of, you know, for clinicians, I would encourage people to start to search into public health, for thinking about the next, how they can improve themselves from a career standpoint. And what I mean by that is, you know, read not just these pieces and just take away that Oh, hearing loss causes x y&z but you know, in that Seminars in Hearing issue, read Jennifer Deals article on how to interpret epidemiologic studies start to look into things like implementation science and health behavior in society. And I think that if we can start to break down our silo and audiology and become more cross disciplinary, we can move our field much, much further. And there are a lot of leaders out there doing this right now. I, I very much like the current, you know, AAA president, or incoming president, Sarah Sydlowski, who, you know, has gone out and got an MBA, and she’s versed herself more on like this economic side of business and business side. And that’s the kind of leadership that audiology has to do. And I’m not saying everybody has to go get a master’s in public health or an MBA, but becoming more public health literate, I think could really, really help push our field further, that that would give a take home message.

That’s it.

Brian Taylor
Yeah I know, I mean I think our field if I could speak about it, I think I just think that from the device standpoint, we’re pretty good at, like innovation and breakthroughs. But we’re not so good at like, follow through, follow up, you know, I mean, like seeing people back doing the simple things, right. We don’t really do that very well as a profession sometimes. And so getting insight from individuals like yourself is really helpful. Looking at the big picture. So anyway, Nick, I can’t say enough, you know, thank you for being with us. All the great work that you and your group have done. Keep it up. We want to see more of it.

Nick Reed
Thanks, no

It’s, it’s phenomenal to sit down and talk always good to see you personally. But

Brian Taylor
likewise, hopefully next time in person. Yeah, we’ll take care and we’ll catch up some more down the road. To our viewers, bye