Otolaryngology and Public Health—Lessons in Hearing and Aging

Most individuals in the US have conditions that could benefit from treatment by an otolaryngologist—hearing loss alone affects nearly 1 in 10 individuals in the US over 12 years and nearly two-thirds of adults older than 70 years.¹ Many of these conditions are associated with communication barriers and decreased quality of life on the individual level but also have critical downstream consequences to the health system on a broader societal scale.

Traditionally, otolaryngology as a field has focused predominantly on individual patient-level models of care and research, while population-level models have only more recently started to emerge. Yet, these approaches are critical to identify solutions that serve diverse communities, make data-driven decisions that promote equitable care, and reduce the economic burden on the health care system at large. Here, we call for a stronger investment in population-level research in otolaryngology and greater presence of otolaryngologists in policy and advocacy efforts by exploring key examples in hearing loss.

A Need For Higher-Quality Research

At present, population-level research in otolaryngology lags behind other specialties,² where high-quality data have been more readily available in large longitudinal cohort studies (eg, Framingham Heart Study, Nurses’ Health Study, and the Whitehall Studies). Indeed, there is a relative lack of high-quality studies in the otolaryngology literature compared to other medical and surgical subspecialties, perhaps due to funding or the inherent challenge of studying difficult-to-standardize and costly surgical interventions.² Moreover, some measures used by otolaryngologists to understand disease processes at the individual level may simply be unsuitable for population-level research. For example, the auditory brain response (ABR) is an objective test that evaluates an individual’s auditory pathway from the cochlear nerve to the brain stem. The ABR provides critical detail on hearing pathways but is extremely difficult to conduct on a population level. On the other hand, portable audiometry is a subjective behavioral test that may lack the information provided by an ABR but can be conducted on a broad scale with high internal validity.

A Case Study in Self-Reported Hearing Loss

To further illustrate the need for quality research measures, consider the use of self-reported hearing loss, which is commonly used in epidemiologic studies examining the associations of hearing loss with aging outcomes. However, these studies underscore the fundamental question—is self-reported hearing loss a valid measure? While quick and cost-effective, self-reported hearing loss is a poor hearing measure in research for several key reasons. Self-reported hearing loss relies on an individual’s perception of their hearing ability, which can vary widely from person to person. Prior studies suggest a discordance between self-reported and objective measures of hearing because one’s perception can be influenced by a range of contextual factors unrelated to actual hearing ability.³ Older adults often underestimate and deny hearing loss due to gradual nature of age-related hearing loss, broader issues of ageism, and associated stigma of hearing loss and its treatment options.^1,3 Nevertheless, studies routinely use self-reported hearing loss to study outcomes including dementia and cognitive decline, even though dementia may impact an participant’s very ability to answer questions regarding their hearing loss and its downstream consequences.

The relative lack of high-quality, scalable, objective hearing measures can lead to ambiguous and inconsistent findings. Improving the quality and accessibility of population-level research in otolaryngology will require concerted effort to develop new research tools and add high-quality measures to existing key longitudinal studies. For example, the Atherosclerosis Risk in Communities study was initiated in 1987 and added audiometric hearing assessments for the first time in 2016,⁴ while the National Health and Aging Trends Study started in 2011 and added audiometric data in 2021.⁵ Of note, a central priority in these efforts should be to collect data that adequately reflects the diversity of the population and permits researchers to robustly consider how important demographic and socioeconomic factors impact individual patients and their communities.

Involvement in Advocacy and Policy

Another primary challenge in advancing population health initiatives in otolaryngology is the underrepresentation of clinicians in policy development, advocacy, and funding decisions. While otolaryngologists, audiologists, speech-language pathologists, and other related health care professionals bring a valuable ecological perspective to healthcare, their expertise is often not fully used in shaping public health policy. Clinicians possess a unique, ecological perspective and can provide valuable insight and context to research findings, help inform data-driven policy changes, and lead collaborative discussions that engage the full spectrum of stakeholders and resources.

For example, the passage of the Over-the-Counter Hearing Aid Act of 2017, finalized in August 2022, allowed hearing aids to be sold directly to patients without a required medical examination. Between 2015 and 2016, the President’s Council of Advisors on Science and Technology and the National Academies of Science, Engineering, and Medicine each released reports that detailed the burden of untreated hearing loss, highlighted the economic/financial barriers preventing treatment, and identified a need to reform the current hearing aid market.^1,6 These consensus reports were motivated by and relied on the relatively recent, at the time, emergence of epidemiologic research on health behaviors related to hearing care and the importance of hearing in aging. It is plausible the adoption of public health methods was more easily relatable and understood by the broader scientific community and helped open the door into the rich patient-level clinical research in hearing care. While over-the-counter hearing aids were polarizing in the field, the success of the movement demonstrated the power of a transdisciplinary approach that includes population research methodologies.

What’s Next? A Call to Action

It is time to redirect our focus and resources to support high-quality, multidisciplinary population-level research for clinicians. Clinical training programs should provide foundational education in epidemiology, biostatistics, social and behavioral health sciences, community engagement, health systems, and policy analysis into their core curriculum. By incorporating these principles, trainees will be better equipped to engage in meaningful research that directly informs patient care and policy decisions. Federal funding opportunities along with professional society- or foundation-sponsored grants can help recruit and support a diverse group of individuals across varying stages of training. Additionally, multidisciplinary research centers can serve as valuable examples of hubs for collaboration among clinicians, public health researchers, and trainees. These educational initiatives and collaborative opportunities will provide clinicians with the skills necessary to advocate for policies that improve access to care, enhance treatment quality, and ultimately drive better health outcomes.

However, of paramount importance is recognizing the importance of a bidirectional collaborative relationship between otolaryngologists, clinicians in related fields, public health researchers, policy makers, and community stakeholders. Recognizing the limitations of our own training, otolaryngologists must prioritize recruitment of diverse teams and emphasize outreach to public health professionals that can impart their own expertise. These efforts will be necessary to elevate population-level approaches to research, policy, advocacy, as well as to incorporate important insights to patient care.

Conclusions

In the face of a growing demand for specialized care, we need to prioritize population-level approaches to address the field’s diverse challenges. Similar needs exist across various otolaryngologic conditions, for example, where current research is clarifying the relationships between vestibular or olfactory dysfunction and aging outcomes. Examples in hearing loss teach us that high-quality, collaborative research is the foundation for effective advocacy and intervention. Prioritizing public health approaches and investing in a workforce equipped with the necessary skills is the critical first step.