Gaps in Evaluating, Managing Hearing Difficulties

In 2018, hearing loss remains one of the most prevalent chronic conditions in the United States. Despite its significant burden on patients’ physical function and quality of life, hearing difficulty may not be properly recognized and managed in the community, and patient access to hearing amplification or cochlear implantation may be limited for various reasons.

We recently investigated the National Health Interview Survey (NHIS) dataset to analyze the epidemiologic features and management patterns of hearing difficulty in the United States (JAMA Otolaryngol Head Neck Surg. 2017 Nov 22). The NHIS is annually conducted on a nationally representative sample of households, and data are collected on various health topics. The clustered design of the surveys allows researchers to produce national estimates for different conditions. Our analysis of the hearing-related section of the 2014 survey revealed some interesting findings. Hearing difficulty was self-reported by over 40 million adults (16.8%), which was similar to a previous national estimate of 16.1 percent by audiometric data (Arch Intern Med. 2008;168[14]:1522). One in five adults reported seeing a physician for a hearing-related problem within the past five years. Of those seen by a physician, only one-third were referred to an otolaryngologist or audiologist. Notably, of the 40 million adults with hearing difficulty, one-third had never seen a physician for a hearing problem, half were never referred to an otolaryngologist or audiologist, and one-third never had a hearing test.

Another question in the survey assessed an individual's functional hearing. Of those who stated that they were unable to appreciate shouting in their ear in a quiet room (lowest functional level), only 17.7 percent were recommended to obtain hearing aids and 5.3 percent were recommended to receive a cochlear implant. In the latter group, 22.1 percent actually got cochlear implants. Overall, about 7 million (3.1%) reported using hearing aids at the time of the survey. These estimates were consistent with previously reported estimates on hearing aid and cochlear implantation utilization rates (Hear Rev. 2009;16(11):12; Cochlear Implants Int. 2013; 14(Suppl 1):S4).

The etiology for these gaps is likely multifactorial, with several explanations described in the past. Low utilization rates for hearing aids have been attributed to degrees of hearing loss, financial limitations, and potential stigma associated with wearing hearing aids. In a 2013 survey of primary care physicians in Southern California, most respondents indicated lack of adequate familiarity with cochlear implants and their coverage by health insurance plans (Otol Neurotol. 2013;34(4):593). Another survey in 2008 revealed that only 14.6 percent of patients received hearing screening as a part of their physical exam in that year (Hear Rev. 2009;16(11):12).

All in all, our findings, in addition to those of other studies, indicate that hearing loss, despite its high prevalence, may be an underdiagnosed and undertreated condition. Improving awareness of hearing loss and its treatment options among the public and health care providers, as well as facilitating access to hearing evaluation, can help minimize the identified gaps. Otolaryngologists and audiologists undoubtedly have a central role in the evaluation and management of hearing loss and can assist in educating the public about this condition.

Hossein Mahboubi, MD, MPH
Hossein Mahboubi, MD, MPH

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