BACKGROUND/RATIONALE:
Hearing impairment is one of the most common disabilities in veterans. The decreased ability to communicate is troubling in itself, but the strong association of hearing loss with functional decline and depression adds further to the burden on the hearing-impaired. Although hearing amplification improves quality of life, hearing evaluations are offered infrequently to older patients. Only 25 percent of patients with aidable hearing loss receive treatment. Up to 30 percent of patients who receive hearing aids do not use them. We contend that an effective formal screening program should identify hearing-impaired patients who are motivated to seek evaluation and who derive benefit from treatment.

OBJECTIVE(S):
The first specific aim is to determine if formal screening programs for hearing loss can increase visits to audiologists. The second specific aim is to determine which specific screening strategy leads to the most frequent audiology visits.

METHODS:
Our four-armed randomized clinical trial compares three screening strategies (physiologic testing, a self-report questionnaire, and combined use of both physiologic and self-report testing), against a control arm (usual care). Physiologic testing was done with the Audioscope, a portable otoscope that emits tones from selected frequencies at a variety of loudness levels. The self-report questionnaire was the screening version of the Hearing Handicap Inventory of the Elderly questionnaire (HHIE-S), which quantifies the social and emotional handicap from hearing loss. Patients aged 50 and older who did not wear hearing aids were recruited from the outpatient clinics at the VA Puget Sound Health Care System. Only patients who were eligible for VA-issued hearing aids were enrolled in this trial. Patients randomized to the control arm were not screened. Patients screened with both the Audioscope and HHIE-S were referred to the audiology service for evaluation if either of the tests was positive. All patients, regardless of screening status, were followed to determine how many patients in each arm subsequently visit an audiologist.

The primary outcome is the percentage of patients who contact the audiology service within 6 months of the date of screening. Secondary outcomes include: 1) the number of cases of hearing loss detected; 2) the number of dispensed hearing aids; 3) self-rated communication ability; 4) hearing-related quality of life; and 5) rates of hearing aid adherence. Costs of screening and subsequent treatment were collected. The study is not powered to determine cost-effectiveness, but to pilot calculations of the costs to implement the screening program will be made. An intention-to-screen analysis will be used to minimize bias due to subject self-selection.

FINDINGS/RESULTS:
Enrollment and one-year follow-up for 2289 subjects is complete. Baseline characteristics are representative of the older veteran population, and are evenly distributed between study arms. We observed substantial variation in failure rates between study arms: 18.6% with the Audioscope arm, 59.6% with the HHIE-S, and 64.0% with both techniques. The extent to which these different screening strategies yield positive long-term hearing outcomes will ultimately depend on which kinds of patients each screening strategy identifies. These data, including the number of subsequent audiology visits, the number of hearing aids dispensed, hearing-related function, the number of adherent hearing aid users, are needed to gain ultimate understanding of the effectiveness of community-based hearing screening,. These data are currently being analyzed.

IMPACT:
This trial directly addresses three of the VA’s designated research areas: sensory disorders, aging, and health systems. Improved detection and treatment of a common disease in veterans is the likely outcome of this study. This project will help VA leadership determine whether to screen veterans for hearing loss, provide preliminary insight into specific screening strategies likely to be effective, and produce valuable epidemiological and utilization data (frequency of audiological evaluations and treatment at non-VA facilities) about hearing impaired veterans that will assist VA leadership and planning.

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External Links for this Project

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PUBLICATIONS:

Journal Articles

1. Kezirian EJ, White KR, Yueh B, Sullivan SD. Cost and cost-effectiveness of universal screening for hearing loss in newborns. Archives of otolaryngology--head & neck surgery. 2001 Apr 1; 124(4):359-67. [view]
2. Yueh B. Digital hearing aids. Archives of otolaryngology--head & neck surgery. 2000 Nov 1; 126(11):1394-7. [view]
3. Yueh B, Collins MP, Souza PE. Effects of depression on self-report hearing outcomes. Journal of The American Auditory Society. 2007 Mar 1; 32(1):32. [view]
4. Collins MP, Souza PE, Yueh B. Effects of group versus individual hearing aid visits. Journal of The American Auditory Society. 2007 Mar 1; 31(1):34. [view]
5. Yueh B, Collins MP, Souza PE, Boyko EJ, Loovis CF, Heagerty PJ, Liu CF, Hedrick SC. Long-term effectiveness of screening for hearing loss: the screening for auditory impairment--which hearing assessment test (SAI-WHAT) randomized trial. Journal of the American Geriatrics Society. 2010 Mar 1; 58(3):427-34. [view]
6. Yueh B, Souza PE, McDowell JA, Collins MP, Loovis CF, Hedrick SC, Ramsey SD, Deyo RA. Randomized trial of amplification strategies. Archives of otolaryngology--head & neck surgery. 2001 Oct 1; 127(10):1197-204. [view]
7. Bogardus ST, Yueh B, Shekelle PG. Screening and management of adult hearing loss in primary care: clinical applications. JAMA : the journal of the American Medical Association. 2003 Apr 16; 289(15):1986-90. [view]
8. Yueh B, Shapiro N, MacLean CH, Shekelle PG. Screening and management of adult hearing loss in primary care: scientific review. JAMA : the journal of the American Medical Association. 2003 Apr 16; 289(15):1976-85. [view]
9. Yueh B, Collins MP, Souza PE, Heagerty PJ, Liu CF, Boyko EJ, Loovis CF, Fausti SA, Hedrick SC. Screening for Auditory Impairment-Which Hearing Assessment Test (SAI-WHAT): RCT design and baseline characteristics. Contemporary clinical trials. 2007 May 1; 28(3):303-15. [view]

Conference Presentations

1. Yueh B. Introduction to Evidence-Based Medicine in Otolaryngology. Paper presented at: American Academy of Otolaryngology - Head and Neck Surgery Annual Conference; 2001 Sep 11; Denver, CO. [view]
2. Liu CF, Collins MP, Souza PE, Heagerty PJ, Yueh B. Long-Term Cost-Effectiveness of Screening Strategies for Hearing Loss. Paper presented at: VA HSR&D National Meeting; 2008 Feb 14; Baltimore, MD. [view]
3. Liu CF, Collins MP, Souza PE, Heagerty PJ, Yueh B. Long-term Cost-Effectiveness of Screening Strategies for Hearing Loss. Poster session presented at: AcademyHealth Annual Research Meeting; 2008 Jun 9; Washington, DC. [view]
4. Yueh B, Collins M, Souza P, Heagerty P, Loovis C, Hedrick S. Long-term effectiveness in a randomized trial of hearing loss screening. Presented at: American Auditory Society Annual Meeting; 2005 Mar 22; Scottsdale, AZ. [view]
5. Collins MP, Souza PE, Yueh B. Subjective Hearing Complaints and Sentence Recognition Performance for Listeners with Posttraumatic Stress Disorder (PTSD). Poster session presented at: American Auditory Society Annual Meeting; 2006 Mar 6; Scottsdale, AZ. [view]

DRA: Sensory Loss, Aging, Older Veterans' Health and Care, Health Systems
DRE: Diagnosis
Keywords: Hearing, Quality of life, Screening
MeSH Terms: none