20Q: Hearing Loss and the Health Care System

From the Desk of Gus Mueller

You’ve probably all heard the idiom from the early 1700s, made famous by Benjamin Franklin later that century: “Tis impossible to be sure of anything but Death and Taxes.”  While not ranking quite as high on the “certainty scale” as death and taxes, if you live into your 70s and 80s, as most Americans do today, you can be quite sure that you will have a hearing loss and also have increased hospital visits. On the surface, this doesn’t sound like too much of a big deal, until we start looking at the data and see that individuals with hearing loss have an increased risk of an emergency room visit, a much higher rate of hospitalization, and spend more days in the hospital when admitted.

Studying hearing loss and the health care system is complex, as it includes many different areas and layers of services.  Fortunately, we have an expert to tell us all about it. We didn’t have to look far, as we are bringing back Nick Reed, who you met last month here at 20Q. Fortunately for us, he is not only an expert on dementia and hearing loss, but is involved in researching the big picture of hearing loss and health care in general.

Nicholas Reed, AuD, is an Assistant Professor of audiology at Johns Hopkins School of Medicine. He is core faculty at the Cochlear Center for Hearing and Public Health at the Johns Hopkins Bloomberg School of Public Health. As evidenced by this month’s excellent 20Q article, much of his research focuses on the relationship between hearing loss and patient-provider communication, and the relationship between hearing loss and health care utilization patterns. 

Dr. Reed is funded by an NIH-supported K12 award, and work from his research has been featured in the Journal of the American Medical Association (JAMA) and the Journal of the American Geriatrics Society (JAGS). 

I think you’ll find the information and research findings presented here to be compelling, as they clearly show how audiology can assume a greater role in overall health care. As Nick states:  “. . . it is important that audiologists take the research being conducted and present it to health care providers and administrators. It carries a powerful message as it relates hearing loss to outcomes that they are more accustomed to reviewing.”

Gus Mueller, PhD
Contributing Editor

Browse the complete collection of 20Q with Gus Mueller CEU articles at www.audiologyonline.com/20Q

20Q: Hearing Loss and the Health Care System

Learning Outcomes 

After this course, readers will be able to:

• Explain how hearing loss may impact a person’s interactions with the health care system in general.
• Describe how hearing loss may be related to patient-provider communication, dementia, delirium, health care costs, perception of care, and health care outcomes.
• Discuss how accessing hearing care services may impact healthcare costs, and initiatives underway to address hearing loss on a broader scale.

           Nicholas Reed       

1. Thanks for sitting down with me again. As we were finishing last month’s discussion on hearing loss and dementia, you mentioned that you had another topic that would be interested to discuss?

Yes - I thought we could talk about an area that I think is of the utmost importance: studying hearing loss and the health care system. Interacting with health care is a nearly universal experience of adults in the United States and of course, the likelihood of hospitalization increases with age. Concurrently, the incidence of hearing loss also increases with age, such that two-thirds of adults over the age of 70 years have hearing loss. However, despite this large population of Americans navigating health care with a hearing loss, there is relatively little research and information in this area. 

2. Interesting. But that sounds like a wide-ranging topic?

You are absolutely correct. This area of research encompasses several layers of health services research from interactions with the health care system to health care outcomes. It includes help-seeking behaviors such as knowingly or unknowingly delaying care, perceptions of providers, interactions with the health care system such as patient-provider communication, the need for accommodations, patient safety and quality indicators such as incidence of falls or delirium during hospitalization, satisfaction with health care, utilization of health care (e.g., hospitalizations, 30-day readmissions, length of stay), and cost of health care. For simplicity sake, I like to think of it in three broad areas of pre- (e.g., delaying care), peri- (e.g., patient-provider communication), and post-interaction (e.g., health care cost). 

3. That’s a lot! So hearing loss affects all of these areas? ​

I believe it does. However, it is a complicated relationship. It is important to consider that the potential relationship between hearing loss and these health care outcomes is both direct and indirect. Moreover, it isn’t a linear relationship. To clarify, hearing loss may directly impact some outcomes. For example, hearing loss directly limits patient-provider communication. However, hearing loss could also indirectly impact some areas via mechanistic pathways. For example, via the poor communication from hearing loss, hospitalized patients with hearing loss may not understand their discharge treatment instructions and end up readmitted to the hospital due to poor treatment adherence. Another indirect example could be that hearing loss contributes to social isolation and psychosocial alterations resulting in a change in the help-seeking behaviors (i.e., seeking health care when needed) of persons with hearing loss. 

4. Communication seems to play a key role here? 

Communication between patients and providers is key to building rapport, coming to an appropriate diagnosis, decision-making, and understanding treatment and rehab instructions. In a systematic review our lab completed, hearing loss had a ubiquitous adverse effect on patient-provider communication among hospitalized patients (Shukla et al., 2018). However, the 13 studies identified in the review represent a small fraction of the patient-provider communication literature. The truth is that most patient-provider communication studies do not focus on hearing loss. A review from Cohen et al. (2016) revealed “hearing loss” was mentioned in less than a quarter of all papers studying patient-provider communication. Notably, it was included in the analysis in even fewer studies. Despite hearing loss’ obvious impact on communication, it is rarely included in patient-provider communication – likely meaning an important confounder in the relationship is often missing.

5. Why the lack of inclusion of hearing loss? Can audiologists do anything to correct it? 

Well, perhaps it is obvious to the audiology crowd that hearing loss would play an important role in patient-provider communication but the research suggests that for other professionals, this isn’t the case. I believe that hearing loss has been relegated to consideration as a benign aspect of aging by the greater medical community for so long that it tends to be simply overlooked. However, this viewpoint is changing. Research relating hearing loss to important health outcomes such as dementia is opening up eyes to the importance of hearing loss for overall health among the greater medical community. Moreover, I think audiologists need to be proactive and leverage their roles as experts on hearing loss to educate the rest of the health care system about hearing loss’ role in patient-provider communication. 

6. Agreed. Speaking of hearing loss and dementia, do relationships like that play a role in the health care utilization outcomes you study? 

I think it does play a role. It is plausible that hearing loss’ causal relationship with outcomes such as dementia contributes to increased health care utilization and cost. However, in much of the research our team has conducted, we have adjusted for covariates such as dementia, health status, and other comorbidities either by matching or including covariates in the analysis. Thus, we generally conclude that hearing loss is impacting these outcomes via the other mechanisms discussed above (e.g., communication). 

7. Regarding your other studies, what have you found regarding hearing loss and health care utilization?   

One way to study this is to look at medical claims data from insurance, allowing researchers to look at patient-encounter information like diagnoses (International Classification of Diseases [ICD] codes), hospital stay, treatments (e.g., prescriptions and referrals), billed amounts, paid amounts, etc. In addition to claims data, electronic health record data can offer insight into information not captured in claims such as physician notes on an encounter or undiagnosed concerns (e.g., previous conditions noted but not reported using ICD codes).

Our team has been active using this type of information. In a large claims dataset, the OptumLabs Data Warehouse, we matched adults with and without hearing loss on variables including age, race, sex, region, insurance, education, baseline spending and utilization metrics, and comorbidities and examined health utilization outcomes at 2-year (N=154,414), 5-year (N=44,852), and 10-year (N=4,728) time points. Over a 10 year period, compared to those without hearing loss, those with hearing loss:

• Had a 47% higher rate of hospitalization
• Spent 2.5 days longer, on average, during hospital stays 
• Had a 17% increased risk of an emergency department visit
• Had a 44% increased risk of experiencing a 30-day readmission. 

8. This all must translate into higher costs? 

Absolutely, the burden of hearing loss on health care costs were astounding. Compared to those without hearing loss, those with hearing loss spent, on average, $3,852, $11,147, and $22,434 more in health care at 2-years, 5-years, and 10-years, respectively. Importantly, costs directly related to hearing loss (e.g., diagnostic testing) accounted for less than $500 in total costs. Moreover, in our analyses, we eliminated those individuals with hearing aids. Thus, the spending differences do not include the cost of hearing aids. In fact, any hearing aid cost would have been unreported out-of-pocket spending. These data confirm earlier findings from the Simpson et al. (2016) piece that also reported higher health care spending among those with hearing loss using the Truven MarketScan database, another large claims database.

9. How do you identify hearing loss when you are working with such a large database? 

Working with claims data poses several difficulties. We used a relatively narrow approach to identify likely age-related hearing loss whereby we required multiple claims for hearing loss and limited claims to only a handful (i.e., we excluded any central hearing loss, conductive hearing loss, etc.). Further, we eliminated those with evidence of hearing loss and otologic conditions and/or chemotherapy which could represent hearing loss of an etiology other than typical age-related hearing loss. Given the limitations of claims data, it is likely that we underestimate the incidence of hearing loss. Although, propensity matching removes some of the issue of underestimating hearing loss. However, it is also likely there are persons with hearing loss in the normal hearing group, although, in theory, this would bias the results in a conservative direction (i.e., the persons with hearing loss in the normal hearing group incur higher costs). 

10. What do these hearing loss interactions also affect the patient’s perceptions of health care? 

We used the Atherosclerosis Risk in Communities study data to examine the relationship between objectively measured hearing (i.e., pure-tones obtained in a sound booth, measured as a 4-frequency pure-tone average) and self-reported satisfaction with care over the past 12 months. Satisfaction was measured as a binary variable, either satisfied or less than satisfied with care. In a regression model adjusted for age, sex, education, comorbidity count, and cognitive status, we found an interaction between age and hearing loss such that older adults with hearing loss were more likely to report being less than satisfied relative to other older adults the same age compared to younger adults with hearing loss relative to other adults the same age. For example, in a 75-year-old participant, every 10 dB increase in hearing loss, the odds of being less satisfied increased 0.94 (95% CI:0.74-1.20) relative to another 75-year old participant. However, in an 85-year-old participant, for every 10 dB increase in hearing loss, the odds of being less satisfied increased to 1.33 (95% CI:0.96-1.83) relative to another 85-year old participant. Importantly, this data suggests the same degree of hearing loss impacts adults differently based on age. We theorized that the interaction was due to older adults with hearing loss not being able to overcome their hearing loss during patient-provider communication while a relatively younger adult with the same hearing loss may be able to rely on cognitive reserve to compensate for hearing loss. 

11. I noticed you snuck in the word ‘delirium’ earlier, what exactly is delirium and is it also related to hearing loss? 

The definitions of delirium vary. However, it is an acute change in mental status and inattention. Many think of delirium as a hyper delirium (i.e, nonsensical vocalizations, aggravation, etc) but most cases are hypo-delirium which is characterized by withdrawal. It is an important patient safety and quality indicator in health services research as it is associated with poor outcomes including increased likelihood of developing dementia. Delirium is experienced by more than 2.6 million patients over 65 years of age each year and accounts for $164 billion in annual health care expenditures. Hearing loss is considered a risk factor for delirium in some delirium assessment methods. However, research exploring the relationship between hearing loss and delirium is limited and to date, few have examined the association in-depth. Using available data it is estimated that delirium incidence rates among persons with hearing loss are higher, ranging from 36% to 61.7%, while those without hearing loss experience delirium lower rates between 12% to 38.2% (Balas, Happ, Yang, Chelluri, and Richmond, 2009; Inouye, Viscoli, Horwitz, and Hurst, 1993). 

12. How exactly is hearing loss related to delirium? 

Delirium is multi-factorial and due to several risks that likely occur in combination. Like the association between hearing loss and cognitive decline, hearing loss plays just one part in a larger picture. Mechanisms through which hearing could impact delirium risk include sensory deprivation from hearing loss leading to a diminished ability to make sense of and interact with the environment. Moreover, poor communication may result in confusion and agitation. In tandem, sensory deprivation and poor communication as a result of hearing loss may contribute or exacerbate the behavioral symptoms associated with delirium.

13. Do hearing aids help with any of these health care outcomes?

I’d like to think so, however, I think that remains to be known. An important issue with this type of research is that many of the same factors associated with hearing aid use (e.g., income, education, etc.) are also associated with better health care system outcomes. It makes it difficult to tease out whether the socioeconomic variables or hearing aid use account for the improved outcomes. Nonetheless, studies of cohort data do suggest hearing aid use is associated with a reduction of hospitalization and emergency department visits (Mahmoudi, Zazove, Meade & McKee 2018). Moreover, work led by Amber Willink, PhD, from our research center suggests that among those who have hearing aids, those who visit an audiologist (or other hearing care provider) seem to have better outcomes. 

14. Can you expand upon that? 

Absolutely. Using the Medicare Current Beneficiary Survey, a nationally-representative survey of Medicare Beneficiaries in the United States, Willink et al. (2018) matched hearing aid users who reported using hearing care services in the past 12 months to those who did not use hearing care services. The groups were matched on demographic (e.g., age, education), socioeconomic (e.g., income, insurance), health status, and perceived degree of hearing trouble. After matching, those who did not use hearing care services spent, on average, $2513 (95% CI = $150‐$4876) more in health care costs over the previous year. 

15. This is all interesting. Are you doing anything else in this area? 

Of course. We are leveraging this evidence to try to create sustainable programs to address hearing loss in the hospital inpatient setting. Based in our belief that communication is a mechanism by which hearing loss directly relates to these outcomes, we are trying to improve hearing in this environment. Our program called ENHANCE (Engaging Health care to Address Communication Environments)  is being used in quality initiatives to identify and address hearing loss. In early quality initiatives, we’ve found adults with and without hearing loss report satisfaction with communication. 

16. What exactly are you doing to identify hearing loss that is so different from before? 

Good question. There are few examples of successful hearing screening programs. Unfortunately, hearing loss can be difficult to objectively measure as it requires equipment, time, and training. Moreover, many programs rely on one person to do all the screening. In ENHANCE, we integrate a simple self-report hearing question into the admissions process. I understand self-report hearing is not perfect. However, it allows us to reasonably conduct universal hearing screening. More importantly, in ENHANCE, we link screening for hearing loss to an immediate intervention that is meaningful to hospital providers, nurses and staff (e.g., patient-provider communication).

17. Are you doing anything different to address hearing loss when it is identified? 

First, we actually supply the different floors of the hospital with several handheld amplification devices (specifically, we use the SuperEar SE 9000) and dispense them to individuals to keep rather than only placing one per unit. This prevents issues when that one device is already in use or eventually is lost. Secondly, and more importantly, rather than rely on devices only, we focus most of our efforts on educating providers, nurses, and staff on communicating with persons with hearing loss. These simple tips like reducing background noise can go a long way in improving communication. Moreover, these strategies can improve communication for those with and without hearing loss.

18. You seem rather passionate about this area?

My interest in this area stems from three areas. First, I believe that we could impact health care for the millions of adults with hearing loss. It is a low-risk endeavor with potential high-reward. Second, I believe this area is of importance for the field of audiology. By better understanding how hearing loss impacts health care, we are raising audiology’s importance in the health care system. Since the passage of the affordable care act, patient-reported outcomes have taken a more prominent role in value-based care strategies. For example, under Medicare, reimbursement rates are now dependent on satisfaction with care surveys sent to Medicare Beneficiaries who were admitted to a hospital. Hospitals with better scores compared to other in their region, receive higher reimbursement rates. The third reason is extremely personal, and I believe others may relate. One of my closest friends, Scott C. Sutton, passed away in the past year from complications due to Von Hippel-Lindau (VHL) syndrome which is characterized by tumor and cyst growths. Due to the tumors in his external auditory canals, my friend lost his hearing during his final months. While in the hospital, he became extremely withdrawn and experienced acute confusion episodes. These are hallmarks of hypo-delirium. Amazingly, when I brought him a simple handheld amplifier, he perked up and seemed able to re-engage with family, friends, and health care providers. He relied on the device during his final months. To see, firsthand, the difference hearing can make on the health care experience completely refocused and energized my research in this area. 

19. Understand. How can we all work to educate others about this?

I think it is important that audiologists take the research being conducted and present it to health care providers and administrators. It carries a powerful message as it relates hearing loss to outcomes that they are more accustomed to reviewing. Imagine how powerful it is to relate hearing to satisfaction with care in the described value-based reimbursement system. 

20. What’s coming up next? 

We’re working right now to execute early pilot cluster trials comparing how ENHANCE impacts satisfaction with care measures in inpatient floors and are planning larger scale trials. Importantly, we’re also working to integrate objective hearing measures into existing cohort studies with Medicare linked claims data. By integrating these measures, we are able to dig deeper into the relationship between hearing loss and health care outcomes. Lastly, we’ve begun proactively objectively measuring hearing (and vision) and delirium in the hospital setting to better understand how sensory loss impacts delirium. I have a great team of collaborators and mentors as I pursue this research that deserve acknowledgement. At Johns Hopkins, Frank Lin MD PhD, Amber Willink PhD, Jennifer Deal PhD, Josef Coresh MD PhD, and Esther Oh MD PhD have been extremely supportive. Across the United States, Sharon Inouye MD MPH (Harvard Medical School), Kevin Franck PhD MBA (Harvard Medical School-Massachusetts’s Eye and Ear), Margaret Wallhagen RN PhD (University of California, San Francisco), Malaz Boustani MD (Indiana University) and Catherine Palmer PhD (University of Pittsburgh) have been instrumental in helping develop this line of research.

References

Balas MC, Happ MB, Yang W, Chelluri L, Richmond T. Outcomes associated with delirium in older patients in surgical ICUs. Chest.2009;135(1):18-25.

Cohen, J. M., Blustein, J., Weinstein, B. E., Dischinger, H., Sherman, S., Grudzen, C., & Chodosh, J. (2017). Studies of physician‐patient communication with older patients: How often is hearing loss considered? A systematic literature review. Journal of the American Geriatrics Society, 65(8), 1642-1649.

Inouye SK, Viscoli CM, Horwitz RI, Hurst LD, Tinetti ME. A predictive model for delirium in hospitalized elderly medical patients based on admission characteristics. Annals of internal medicine.1993;119(6):474-481.

Mahmoudi, E., Zazove, P., Meade, M., & McKee, M. M. (2018). Association between hearing aid use and health care use and cost among older adults with hearing loss. JAMA Otolaryngology–Head & Neck Surgery, 144(6), 498-505.

Reed, N. S., Altan, A., Deal, J. A., Yeh, C., Kravetz, A. D., Wallhagen, M., & Lin, F. R. (2019). Trends in health care costs and utilization associated with untreated hearing loss over 10 years. JAMA Otolaryngology–Head & Neck Surgery, 145(1), 27-34.

Reed, N. S., Betz, J. F., Kucharska‐Newton, A. M., Lin, F. R., & Deal, J. A. (2019). Hearing loss and satisfaction with healthcare: An unexplored relationship. Journal of the American Geriatrics Society, 67(3), 624-626.

Simpson, A. N., Simpson, K. N., & Dubno, J. R. (2016). Higher health care costs in middle-aged US adults with hearing loss. JAMA Otolaryngology–Head & Neck Surgery, 142(6), 607-609.

Willink, A., Reed, N. S., & Lin, F. R. (2019). Cost‐Benefit Analysis of Hearing Care Services: What Is It Worth to Medicare?. Journal of the American Geriatrics Society.