20Q: Hearing Loss and Public Health Initiatives

From the Desk of Gus Mueller

You regular 20Q readers might recall that back in 2019, Dr. Nick Reed visited these pages and provided us with insightful companion articles on Hearing Loss and Dementia, and Hearing Loss and the Health Care System. The second of these articles addressed an area we don’t think of too often (or enough) regarding the general health care system—the issue of how a hearing loss might impact a person’s relationship to patient-provider communication, health care costs, perception of care, and health care outcomes.

Well, as you might guess, Dr. Reed and the team at Johns Hopkins’ Cochlear Center have been busy the last three years, and Nick is back with us to provide an update on some of their most recent findings. For example, one area relates to a large survey of ~12,000 Medicare beneficiaries, in which additional documentation was collected revealing the structural barriers and inequities built into the health care system that make it more difficult for adults with hearing loss to access and engage in health care and information. You’ll see that the impact is much greater, and extends into more areas than what we would expect. Dr. Reed also reports on the new “Know Your Hearing” campaign from the Cochlear Center. Their group believes that the public needs a clear and efficient way to discuss their hearing—something better than the common normal, mild, moderate, and profound classifications. Check out what they have in mind.

Our guest author, Nicholas Reed, AuD, is an Assistant Professor in the Department of Epidemiology at Johns Hopkins Bloomberg School of Public Health with a joint appointment in the Department of Otolaryngology-Head and Neck Surgery (Audiology) at Johns Hopkins School of Medicine. As you know from his many publications, Dr. Reed’s research focuses on direct-to-consumer hearing care, understanding trends in hearing aid use in the United States, the relationship between hearing loss and health care outcomes/interactions, and whether interventions targeting hearing loss can mitigate these associations. Among his many current research projects, he is a co-investigator in the Aging and Cognitive Health Evaluation in Elders (ACHIEVE) trial where he is a member of the hearing intervention subcommittee and co-chairs the recruitment subcommittee.

Dr. Reed’s work over the past few years has been pretty amazing, and for this, he recently was honored by the American Auditory Society with the 2021 Early Career Development Award.  We’re pleased to have Nick back as a  “20Q Regular.”

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 Public Health Initiatives

Learning Outcomes 

After reading this article, professionals will be able to:

• Explain how hearing loss is associated with health care seeking behaviors and unmet health care needs.
• Describe the new public awareness of hearing loss campaign.
• Describe public health training initiatives open to audiologists.

Nicholas S. Reed

1. It’s good to get a chance to talk again! I enjoyed our conversations a few years back regarding Dementia and Hearing Loss as well as Hearing Loss and Health Care Interactions. Since then, it seems like you and your colleagues have continued to be busy.

Absolutely, very busy! The Johns Hopkins Cochlear Center for Hearing and Public Health is a unique place. To refresh your memory, our primary mission is to focus on age-related hearing loss but from a public health perspective. In fact, we’re housed in the Department of Epidemiology at Johns Hopkins Bloomberg School of Public Health rather than in the traditional home of hearing science in Communication Sciences Departments or Medical Schools. Uniquely, our core faculty and team members represent a broad array of disciplines including otolaryngology, audiology, health economics, epidemiology, biostatistics, psychology, geriatrics, health services research, and disability studies scholars.

Many people see our name and assume we do cochlear implant research but it’s actually not an area we invest any academic efforts into. Our Center is named after a large gift from Cochlear Ltd, but it is very much to focus on public health and hearing loss rather than specifically on implants. Our mission revolves around training. In fact, we hope to be a core pillar in training the next generation of researchers, clinicians, and public health experts who can study the impact that hearing loss has on public health, develop and test strategies to address hearing loss, and help implement effective policies for hearing loss at the local, national, and global levels. To that extend we’ve recently started some really exciting new training programs at our Center.

2. Thanks for the review. What can we talk about today that applies directly, or at least indirectly to my day-to-day clinical activities?

Yes, the Center has been busy. There have been several projects since we last talked. It’s honestly too much to name it all. I think some of the broad topics you might be interested in are how hearing loss impacts health care seeking behaviors and our new public health hearing loss awareness work.

While not a new project, I suspect you’d also like to hear an update on the ACHIEVE clinical trial, which we started back in 2017. This research examines the impact of hearing care on cognitive decline. As you might recall, the ACHIEVE clinical trial is the Aging and Cognitive Health Evaluation in Elders Study and sets out to examine the effect of best-practice hearing intervention on cognitive decline among older adults with mild to moderate loss.

I’m happy to report that this randomized control trial is still moving along smoothly. The final recruitment was 977 individuals with mild to moderate hearing loss, randomly allocated to a hearing intervention arm or a health aging equivalent arm. The majority of the main intervention visits in both arms and several of the larger data collection visits occurred just before the COVID 19 pandemic shut down data collection. During the height of the pandemic, virtual and phone visits as well as leveraging mail and drop offs for hearing aid needs kept things moving along. Now, everything is back in person again and we’re steadily moving towards the magic three-year mark for all participants to get the final results.

3. Exciting stuff! Those highly anticipated results will answer a burning question for audiologists and policy makers. You mentioned you’ve recently done work on hearing loss and health care seeking behaviors?

My work in this area focuses more broadly on health care in general, rather than just hearing care. Health care seeking behavior is a somewhat contested term. There are various definitions of what the conceptual model of help-seeking behaviors that include everything from problem recognition to coping strategies to selecting different services to actually engaging services. I’m broadly talking about attitudes towards health care as well as how people decide to pursue, access, use, and engage in health care. This includes things like seeking treatment as soon as one feels sick, maintaining a usual source of care, or obtaining preventative care such as vaccines.

4. How does an individual’s hearing relate to this?

That’s the right question isn’t it. I see this work as filling an important gap in the literature. As we discussed the last time we spoke, there is evidence that adults with hearing loss are less satisfied with health care. In addition, we talked about our work showing adults with hearing loss incur higher health care expenditures and increased health care utilization (e.g., higher risk of a 30-day readmission, longer length of stay during hospitalization, higher risk of emergency department visit). It is plausible that poorer satisfaction and negative care experiences could change a person’s attitudes towards seeking care in the future. This might mean that adults with hearing loss don’t engage in preventative care or don’t obtain care when they first notice an issue. Instead, they may delay care which can lead to more serious issues down the road. For example, not getting the flu vaccine and then ignoring a cough and fever during flu season could lead to a severe case that requires a costly hospitalization that was completely preventable. Understanding whether hearing loss is associated with changes in help-seeking behavior may explain how hearing loss is directly related to increased health care spending rather than indirectly related via something like hearing loss causing other health conditions (e.g., dementia, depression) which increase health care spending.

5. Fascinating. What have you found?

In Summer 2021 we published a piece looking at help-seeking behaviors of approximately 12,000 Medicare beneficiaries (Lin et al., 2021). Study participants were asked whether the following statements were true or false:

1. You will do just about anything to avoid going to the doctor.
2. Usually, you go to the doctor as soon as you start to feel bad.
3. You worry about your health more than other people your age.
4. When you are sick, you try to keep it to yourself.

In models adjusted for demographic, socioeconomic, and general health determinants, we found that Medicare beneficiaries who reported a lot of trouble hearing were significantly more likely to say they would do anything to avoid seeing the doctor and less likely to say they go to the doctor as soon as they feel bad. However, there were no differences when it came to worrying about health or keeping sickness to oneself.

6. Some of those statements sound like they’re talking about different things, can you elaborate?

Yes! You’re spot on. The first two (e.g., avoiding doctors, delaying seeing a doctor) actually reference the health care system while the second two (e.g., worrying about health and keeping sickness to oneself) do not reference anything in the health care system. This is a stark difference in terms of the interpretation of the statements and captures both caring about one’s health versus actually engaging the health care system. Admittedly, our team was really intrigued by these findings as it seems that Medicare beneficiaries with trouble hearing are essentially reporting they are more likely to avoid health care but don’t care any more or less about their health relative to those without trouble hearing. It’s impossible to make any conclusions off just one study, but perhaps poorer previous health care experiences have caused those with hearing difficulties to not engage in the health care system out of either frustration or perhaps they’ve even just lost faith in the system if, for example, the individual had repeated readmissions.

7. Could there be other underlying mechanisms on why adults with hearing loss may be less likely to seek care?

Sure. I think at a broad level there are structural barriers and inequities built into the health care system that make it more difficult for adults with hearing loss to access and engage in health care and information. These barriers include presenting information in oral formats such as face to face communication in the doctor’s office, requiring to make appointments or even just communicating basic health information via tele- and video-communication formats. In fact, we’ve actually shown that hearing loss is associated with higher odds of reporting difficulty understanding Medicare. In an analysis of 10,510 Medicare beneficiaries, we saw that a little and a lot of trouble hearing were associated with 18% and 25% higher odds of reporting greater difficulty with understanding Medicare, respectively (Willink and Reed, 2020). The models were adjusted for variables that could confound the association, including demographic, socioeconomic, additional insurance, and general health status. We’ve also found that sensory loss (hearing and/or vision) is associated with reduced knowledge of heart attacks (Assi et al. 2021). In addition, I think it’s important to keep in mind that everything here is synergistic. What I mean by that is poor health outcomes from not seeking care right away, like a readmission to the hospital, may also cause an individual to further delay seeking care in the future.

8. Are you saying that adults with sensory loss have reduced health knowledge?

Well, yes and no. Yes, we did find that sensory loss (vision, hearing, and dual sensory loss) was associated with higher risk of not having appropriate knowledge of heart attacks symptoms in the National Health Interview Survey. However, we don’t believe this is a reflection on the individual’s knowledge so much as a reflection of those barriers in accessing information that we talked about earlier. We went even further in this study and noted that at a broad population level, this suggests lower health literacy among adults with hearing loss which, honestly, corroborates much of Mike McKee’s work at the University of Michigan, who has long studied hearing and health literacy, particularly among the Deaf community. I think we often forget that the concept of health literacy includes the capacity to obtain, process, and understand basic health information needed to make appropriate health decisions. That part about ‘obtaining’ knowledge is just as important as anything else, yet much of the health literacy work focuses on processing or understanding information from a cognitive, education, and language viewpoint. 

9. You’ve made a case for hearing loss and help-seeking being related but do you have evidence beyond attitudes towards care?

We went back to the Medicare Current Beneficiary Survey to look at whether hearing trouble was associated with more ‘tangible’ metrics of help-seeking. Among 10,422 beneficiaries, we created models to look at the association of hearing trouble with having a usual source of care, not obtaining needed medical care, and not filling a prescription. Our models were adjusted for age, sex, race/ethnicity, educational attainment, income-to-poverty ratio, marital status, Medicare Advantage plan, general health, functional limitations, and comorbidity count. We found that relative to those without any hearing trouble, those with a lot of trouble hearing had 49% higher odds of not having a usual source of care, 85% higher odds of not obtaining needed medical care, and 56% higher odds of not filling a prescription (Reed et al. 2021). A really interesting sub analysis of reasons for not obtaining needed medical care showed that those without trouble hearing were actually more likely to report cost as a barrier while those with hearing trouble were more likely to report that they ‘thought the doctor couldn’t do much about it.’ Again, these results aren’t conclusive but how telling is it that cost doesn’t seem to be the barrier as much as a simple lack of faith in the health care system.

10. I get the points of obtaining care and filling prescriptions, but what about usual source of care? How is that an aspect of help-seeking behavior?

Having a designated usual source of care, that isn’t an emergency room, is a sign of a health relationship with the health care system. Primary care is especially important. Much of the preventative care that we encourage (e.g., vaccines, regular check-ups, etc) has its foundation in the primary care setting. Without an identified usual source of care, individuals may be more susceptible to poorer health care outcomes that weren’t caught early or prevented.

11. So what’s the Big Picture here and how does this all start to fit together?

I’m probably overly excited about this work but I think these findings help clarify what we’ve previously seen in work showing adults with hearing loss incur higher health care expenditures and have increased health care utilization. In that work, we’ve explained the potential pathway between hearing loss and higher health care spending as either:

5. Hearing loss is associated with changes in engagement in the health care system that leads to poorer outcomes
6. Hearing loss is associated with poorer overall health (i.e., development of dementia) that leads to poorer outcomes
7. There is unmeasured confounding in our models

Despite the fact that we went through great lengths to try to adjust and control for confounding from the concept that hearing is associated with poorer overall health, we can’t discount it. However, this new work does give us more confidence in the pathway that hearing loss changes how one engages with the health care system. Between you and me, I think many of us didn’t need the data to realize this but, nonetheless, we always need the hard data to show the people who make policy that change is needed.

12. What can audiology do with this information?

Similar to the crucial role audiology has played in thinking about classroom acoustics and accommodations for children, I think audiology should take on more of a role as a leader here in changing the way health care is designed for people with hearing loss. Audiologists have to be better allies to adults with hearing loss and play a role that lifts up their voices requesting accommodations and back it up with the science. Creating a world designed to accommodate hearing loss is just as important for our field as providing amplification to an individual.

13. Alright. Switching gears a little, you mentioned another thing at the beginning of our conversation about a hearing loss awareness campaign?

The Know Your Hearing campaign is a newer initiative from the Cochlear Center for Hearing and Public Health. The concept stems from what we see as a need for the public to have a clear and efficient way to discuss hearing. Right now, when we discuss hearing, we tend to use vague terms like normal, mild, moderate, and profound. In the clinic, we make things even more complicated by discuss the shape of the hearing loss. We need something simpler that ideally has a numeric value. In the opinion of our team, we believe the 4-frequency pure-tone average (i.e., 500, 1000, 2000 and 4000 Hz) is the best option at the moment. It is a simple scalar value that the public can use with relatively easy interpretation of the direction (e.g., higher values are worse).

14. But the PTA really isn’t a full representation of hearing ability, is it?

Completely agree, but the goal isn’t to give a complete diagnosis or full understanding of an individual’s hearing, it is to simply have an easy starting point for public consumption. I hate to use the vision analogy because it’s overdone between our professions, but the optometry appointment is a great comparison. Visual acuity is a common metric that we use to discuss our vision. For example, the term 20/20 vision is something that even lay people understand as “good” vision. However, if you’ve been to an optometrist, you know it’s much more complex and there is a complete test battery run to characterize vision. What we want to do is find that 20/20 number for hearing.

15. How does a measure like you describe help with public awareness?

At a basic level, we want to simplify things to this singular measure that people can walk away with, so they aren’t left completely confused with their eye’s glazed over when we explain the audiogram in detail and say things like “your hearing slopes from mild to moderate.” This also offers an easier to interpret single metric for our colleagues in other health and medical fields. I mean, let’s be totally honest, are primary care physicians reading detailed audiometric reports? Of note, we’re not saying that that kind of detailed description isn’t necessary during counseling, but we still give them that singular metric to walk away with. The simplicity of that metric is key as the important thing to remember is that this kind of campaign isn’t for audiologists or professionals, it’s for the public.

But importantly, while simplifying, the PTA also offers much more precision for an individual to understand their own hearing and clears the murkiness of terms like normal, mild, moderate, and severe hearing loss. Consider that an individual could go from a PTA of 26 to 40 over a 10- or even 20-year period. This might be a huge shift in peripheral auditory function but with our current labels, we would continue to call it “mild loss.” This might actually be confusing for an individual or even another health care professional as it suggests the loss is, well, “mild” and unchanged over a long period. By using the scalar PTA, the patient can see the incremental change.

Another important aspect of the PTA is that it is the standard metric used in epidemiologic research (i.e., the association of hearing loss and cognitive decline). We talk a lot about hearing loss being a risk factor for important aging outcomes and those findings should push the health care system to take hearing loss more seriously but the way we talk about it in the clinic and present it to others (e.g., patients and health care colleagues) doesn’t necessarily add up with the way it is measures in those risk factor analyses. Primary care physicians and geriatricians have told us they don’t understand when to do something because of the confusing language we use (e.g., normal, mild, moderate, severe). We have to try a different approach, so others know when to act on hearing loss. Standardization will have implications for easier policy communication and creating risk cut points for aging outcomes, like dementia, down the road.

16. But PTA doesn’t necessarily relate to seeking hearing care – I seem to recall that others have pointed out that the HHIE self-assessment scale would be better (Humes and Weinstein, 2021).

That’s a great point and I totally agree with the sentiment. However, I think this is a misconception of the premise of the Know Your Hearing Campaign. At a fundamental level, we aren’t necessarily hoping to push people to hearing care or gauge the effectiveness of the hearing care so much as changing awareness of hearing in a meaningful way. In the end, our final utopia is a world where people realize they each have a unique audio fingerprint and actually know their hearing numbers similar to how many people can spout off their visual acuity. Importantly, we do believe that if we change awareness then we will move more people into addressing hearing loss earlier.

17. What’s next for this campaign?

We’ve started by engaging health professionals across audiology, otolaryngology, primary care, and geriatrics as well as industry stakeholders. In addition, we’ve started working with a communication firm that has previously assisted with CDC public health campaigns. We’re now on a path to building out an informational campaign in partnership with stakeholders. Our aim is to make sure we align with the timing of over-the-counter hearing aids hitting the open market to take advantage of a moment where there will undoubtedly be plenty of news and excitement around hearing care.

18. This has already been a lot of info. But you mentioned in the beginning that your Center has started some new training programs?

That’s right. In the past year, we’ve added a new summer one-day course available to anyone. The course is part of the Johns Hopkins School of Public Health Summer Institute series and will be held on a Saturday in June (undetermined as of this time). The course is titled ‘Epidemiologic Approaches to Hearing Loss and Public Health’ and is actually a more condensed version of standard course for Johns Hopkins University students that I teach with Jennifer Deal called ‘Epidemiology of Sensory Loss in Aging.’ We specifically chose to do a one-day course to make is accessible to professionals who might be interested in getting their feet wet in the topic area.

In addition, last summer we held our inaugural Summer Cochlear Center Hearing & Aging Mentoring Program (Summer CHAMP). This was an intensive, one-week program designed for pre-doctoral audiology, medical, or public health doctoral students to gain a foundation in concepts and methods that will lead to research careers addressing hearing loss, aging, and public health. Last year, we took four students paired into two teams and assigned them to a mentorship team to work through an epidemiology-based project. Mornings were spent in didactic lectures with various Center faculty members with the afternoons filled with hands on labs to complete the project.

19. You mentioned that these are new, does that mean you had some other training programs already ongoing?

Yes! The Center already took trainees and fellows from across the globe in various capacities (e.g., Master of Public Health students, postdoctoral fellows, students taking a research elective, etc). In addition, in the summer of 2019, we launched an international training program where we invited ~30 international professionals in audiology, otolaryngology, geriatrics, and public health to Johns Hopkins University for a week of training on hearing loss and public health. The pandemic forced us to move the program online but it has actually resulted in an accessible set of lectures we want to make available to those interested in the topics. Keep an eye on our website or contact us for more information.

20. I have to ask, why are you guys doing all this?

Great way to wrap this up. We believe interdisciplinary training at the nexus of hearing and public health is key to moving our understanding of hearing loss and aging as well as novel methods to address hearing loss forward. This is in line with the purpose and forethought behind the initial gift that established the Center from Cochlear Ltd. We’ve made mentoring and teaching a core mission of the Center. In fact, we make it clear on our website that the impact of the Center “will ultimately be measured by the accomplishments of the individuals and trainees who comprise the Center and whose research, advocacy and academic pursuits will advance Center mission areas.”

References

Assi, L., Karam, E. S., Swenor, B. K., Deal, J. A., Willink, A., & Reed, N. S. (2021). Association of sensory loss with the knowledge of heart attacks. American Journal of Preventive Medicine, 62(2), 265–269. https://doi.org/10.1016/j.amepre.2021.07.003

Assi, L., & Reed, N. S. (2021). Patient-centered care inequalities identified for adults with hearing loss. The Hearing Journal, 74(10), 20-21.

Fioravante, N., Deal, J. A., Willink, A., Myers, C., & Assi, L. (2021). Preventive care utilization among adults with hearing loss in the United States. In Seminars in Hearing, 42(1), 37-46.

Humes, L. E., & Weinstein, B. E. (2021). The need for a universal hearing metric - is pure-tone average the answer? JAMA Otolaryngology–Head & Neck Surgery, 147(7), 588–589. https://doi.org/10.1001/jamaoto.2021.0417

Lin, F. R., & Reed, N. S. (2021). The pure-tone average as a universal metric - knowing your hearing. JAMA Otolaryngology–Head & Neck Surgery, 147(3), 230-231.

Lin, H. Y. H., Willink, A., Jilla, A. M., Weinreich, H. M., Oh, E. S., Robertson, M., ... & Reed, N. S. (2021). Healthcare-seeking behaviors among medicare beneficiaries by functional hearing status. Journal of Aging and Health, 33(9), 764–771. 10.1177/08982643211011799

Reed, N. S., Assi, L., Horiuchi, W., Hoover-Fong, J. E., Lin, F. R., Ferrante, L. E., ... & Willink, A. (2021). Medicare beneficiaries with self-reported functional hearing difficulty have unmet health care needs: Study examines the level of access to a usual source of care for Medicare beneficiaries who reported hearing loss. Health Affairs, 40(5), 786-794.

Willink, A., & Reed, N. S. (2020). Understanding Medicare: hearing loss and health literacy. Journal of the American Geriatrics Society, 68(10), 2336-2342.