Abstract
Background:
Behind arthritis and heart disease, hearing loss (HL) is the third most prevalent chronic condition in older Americans, with primary care providers playing a crucial role in its identification. Understanding the practices and perceptions of primary care providers in hearing health is key to understanding gaps in hearing health care for patients.
Methods:
We conducted a quality improvement study at an urban tertiary academic facility from January–June 2024. Primary care physicians, nurse practitioners, and physician assistants were surveyed on attitudes and practices regarding HL screening, diagnosis, and treatment. Data were analyzed using descriptive statistics to identify patterns and trends.
Results:
Of 695 subjects queried, there were 62 respondents (response rate: 8.9 percent), most aged 41–55 years (n = 27, 43.5 percent). Many respondents reported they did not routinely screen patients for HL (n = 36, 59 percent), with lack of time being the most cited factor (n = 22, 62.9 percent). Some respondents indicated they followed Medicare guidelines for HL screening (n = 8, 32 percent), though the majority indicated they did not use specific guidelines (n = 15, 60 percent). Many providers reported they did not feel comfortable in their knowledge about hearing aids (n = 39, 62.9 percent) or cochlear implants (n = 51, 82.3 percent); in fact, 62.9 percent of the cohort reported they had never been educated about cochlear implants.
Conclusions:
These responses identify potential gaps in the hearing health care pipeline, particularly the need for standardized HL screening protocols and increased interprofessional training and education on HL treatments. Future endeavors to target these gaps should be assessed to see whether these gaps can be closed.
Keywords: hearing loss, primary care, screening
INTRODUCTION
Behind arthritis and heart disease, hearing loss (HL) is the third most prevalent chronic condition in older Americans, with approximately 1 in 4 adults experiencing some form of HL (Goman and Lin, 2016; Nieman and Oh, 2020; Yueh et al., 2003). Risk factors for HL in adults include age, noise exposure, family history, exposure to ototoxic medications, smoking, and diabetes (Nieman and Oh, 2020). The prevalence of clinically significant HL doubles with each decade of life and is associated with adverse health outcomes such as cognitive impairment, social isolation, and increased health care use (Arlinger, 2003; Dawes et al., 2015; Goman & Lin, 2016; Nieman & Oh, 2020; Nordvik et al., 2018).
Despite its prevalence, however, HL often goes underdiagnosed and undertreated. According to a Forbes health survey, on average people with HL wait 7 years before seeking help; some sources indicate an estimated 80 percent of cases of HL are undiagnosed (Forbes, 2023) and as few as 9 percent of internists offer hearing testing to geriatric patients (Yueh et al, 2003). A survey from the Hearing Health Foundation states that although 80 percent of HL cases can be treated with hearing aids (HA), only one in four individuals who would benefit will pursue HA (Hearing Health, 2023). Similarly, the rate of uptake of cochlear implant (CI) devices is estimated to be less than 10 percent (Ebrahimi-Madiseh et al., 2020). There are no universal screening guidelines or suggested interval screenings in any age group, despite recommendations from most professional groups regarding screening of at-risk adults (Nieman & Oh, 2020).
The primary care provider is in a prime position for early identification and management of HL, with some studies estimating that the average provider sees four consultations per day related to HL (Easton & Leverton, 2018). Despite this frequency, due to the gradual nature of some types of HL (e.g., presbycusis), patients may experience significant delays in care, with one study showing up to a 10-year delay in adults (55–74 years) reporting HL in primary care (Easton and Leverton, 2018). Similarly, Bennett et al (2020) found that up to 85 percent of older patients state that they do not receive counseling from their primary care provider regarding hearing, and less than half of those seeking help received appropriate support. This support is crucial, however, with one population-based survey showing that patients are five times more likely to seek treatment when their primary care physician positively endorses hearing health care (Bennett et al., 2020).
Whereas primary care providers play a crucial role in identifying HL, barriers exist in the hearing health pipeline. These barriers include both providers’ and patients’ awareness of HL, low rates of patient self-referral and adequate screening in the office, low rates of referral and escalation of care to ear health experts such as otolaryngologists or audiologists, lack of providers’ understanding and counseling of treatments such as HA and CI, and ensuring adequate follow-up after treatment (Bierbaum et al., 2020; DeJonckheere et al., 2021; Ebrahimi-Madiseh et al., 2020; Rapport et al., 2018; Rapport et al., 2020; Tsimpida et al., 2024; Zazove et al., 2020). Understanding the practices and perceptions of primary care providers in hearing health is key to understanding potential gaps in hearing health care for patients. The primary objective of this study is to describe current practices and attitudes of primary care providers in our institution regarding HL screening, diagnosis, and treatment to better understand gaps in knowledge and care.
METHODS
This was a prospective cohort quality improvement study at an urban tertiary academic facility conducted between January and June 2024. Primary care providers, which consisted of physicians, nurse practitioners, and physician assistants, were emailed a survey consisting of 38 multiple-choice and free-response questions assessing attitudes and practices regarding HL screening, diagnosis, and treatment.
The survey was broken up into six general domains: general practice characteristics, consequences of HL/miscellaneous, screening/diagnosis, counseling, referral/treatment, and follow-up.
The screening and diagnosis domain included questions about the frequency and targets of routine screening for HL, frequency of self-reported HL, screening guidelines, tools used for screening, goals for HL prevention and treatment, and prioritization of hearing health. The counseling domain included questions about resources providers have to educate patients on HL, counseling on the neuropsychological effects of CI, provider knowledge and education on CI, and follow-up on patient HA use. The referral domain included questions about frequency of referral to ear specialists and other practices, barriers to referral, knowledge about referral practices, and provider recommendation of HL treatments. The follow-up domain included questions about the frequency of follow-up with patients with HL and follow-up after referral to an ear specialist. Data were analyzed using descriptive statistics to identify patterns, trends, and gaps.
RESULTS
Of 695 subjects queried, there were 62 respondents (response rate: 8.9 percent). Table 1 outlines general practice characteristics. Most respondents were between 41 and 55 years old (n = 27, 43.5 percent), and the next-greatest cohort was greater than 60 years old (n = 14, 20.8 percent). When asked to describe patient population composition, most providers indicated that their patients are primarily English-speaking (n = 47, 73.4 percent) and few identified their patients as largely immigrant or multicultural (n = 6, 9.4 percent). Most providers also identified their patients as low-income (n = 38, 59.4 percent) or underserved (n = 26, 40.6 percent). The majority of respondents strongly agreed or agreed that their patients would be culturally receptive to HA if they were clinically indicated (n = 54, 80.6 percent). The majority of respondents felt their patients sometimes (n = 27, 40.9 percent) or rarely (n = 20, 30.3 percent) brought up their hearing health in visits (Table 1).
Table 1.
General Practice Characteristics
| Question | n (%) |
|---|---|
| Which of the following best describes your age range? | |
| 20–25 | 0 (0) |
| 26–30 | 1 (1.5) |
| 31–35 | 7 (10.4) |
| 36–40 | 6 (9.0) |
| 41–45 | 10 (14.9) |
| 46–50 | 9 (13.4) |
| 51–55 | 11 (16.4) |
| 56–60 | 8 (11.9) |
| 61–65 | 7 (10.4) |
| 66+ | 7 (10.4) |
| Prefer not to say | 1 (1.5) |
| How would you describe the patient population you serve? (please select all that apply) | |
| Affluent | 26 (40.6) |
| Low-income | 38 (59.4) |
| Underserved | 26 (40.6) |
| Largely immigrant/multicultural | 6 (9.4) |
| Primarily English-speaking | 47 (73.4) |
| Other | 7 (10.9) |
| Do you feel your patient population would be culturally receptive to hearing aids if they needed them? | |
| Strongly agree | 11 (16.4) |
| Agree | 43 (64.2) |
| Neutral | 10 (14.9) |
| Disagree | 2 (3.0) |
| Strongly disagree | 1 (1.5) |
| How often do you feel your patients ask you about their hearing health? | |
| Always | 1 (1.5) |
| Often | 17 (25.8) |
| Sometimes | 27 (40.9) |
| Rarely | 20 (30.3) |
| Never | 1 (1.5) |
Table 2 outlines consequences of HL/miscellaneous. Providers overwhelmingly strongly agreed or agreed that they were aware of issues patients face from untreated HL (n = 55, 83.3 percent), with the vast majority citing social isolation (n = 65, 97.0 percent) and overall health outcomes (n = 55, 82.1 percent) as issues related to untreated HL. All respondents strongly agreed or agreed that they would use HA if they felt it could benefit them (n = 67, 100 percent). Providers’ familiarity with audiograms was largely heterogeneous, with nearly a quarter of respondents stating they had never seen an audiogram (n = 18, 26.9 percent) and nearly three quarters stating that they disagree or strongly disagree that they can read an audiogram (n = 39, 58.2 percent) (Table 2).
Table 2.
Consequences of Hearing Loss/Miscellaneous
| Question | n (%) |
|---|---|
| Do you feel that you are aware of issues patients may face from untreated hearing loss? | |
| Strongly agree | 13 (19.7) |
| Agree | 42 (63.6) |
| Neutral | 7 (10.6) |
| Disagree | 4 (6.1) |
| Strongly disagree | 0 (0) |
| Which of the following do you recognize as issues related to untreated hearing loss? (please select all that apply) | |
| Dementia | 40 (59.7) |
| Social isolation | 65 (97.0) |
| Health literacy | 51 (76.1) |
| Overall health outcomes | 55 (82.1) |
| None of these | 1 (1.5) |
| If you had hearing loss, would you be interested in a hearing aid if you felt it could benefit you? | |
| Strongly agree | 44 (65.7) |
| Agree | 23 (34.3) |
| Neutral | 0 (0) |
| Disagree | 0 (0) |
| Strongly disagree | 0 (0) |
| When did you last see an audiogram? | |
| Within 1–3 months | 15 (22.4) |
| Within 3–6 months | 8 (11.9) |
| Within the last year | 14 (20.9) |
| Not since residency | 6 (9.0) |
| Not since medical school | 3 (4.5) |
| Not since graduate school | 3 (4.5) |
| Never | 18 (26.9) |
| Can you read an audiogram? | |
| Strongly agree | 5 (7.5) |
| Agree | 10 (14.9) |
| Neutral | 13 (19.4) |
| Disagree | 22 (32.8) |
| Strongly disagree | 17 (25.4) |
Table 3 outlines screening and diagnosis. The majority of respondents indicated that they do not routinely screen patients for HL (n = 40, 60.6 percent), citing lack of time (n = 24, 61.5) and not enough options for screening (n = 25, 64.1 percent) as the most common reasons. Providers largely agreed that intake forms with specific questions addressing HL may be one way to mitigate time constraints (n = 31, 81.6 percent). Of providers who routinely screen patients, nearly half indicated they screen patients older than 65 years (n = 11, 42.3 percent), with the next-largest fraction indicating they screen all patients (n = 8, 30.8 percent). Over half of respondents stated there were no specific guidelines in place for HL screening in their practice (n = 15, 57.7 percent), with Medicare guidelines being the next-most-cited answer (n = 8, 30.8 percent). Most providers indicated they screen patients yearly (n = 21, 87.5 percent). Respondents indicate that their practice’s goals for hearing health are to refer patients to appropriate specialists (n = 19, 73.1 percent), with nearly all referring patients to otolaryngology (n = 27, 40.3 percent) or audiology (n = 38, 56.7 percent). Most providers do not have an audiometer in the office (n = 43, 67.2 percent) (Table 3).
Table 3.
Screening/Diagnosis
| Question | n (%) |
|---|---|
| Do you routinely screen patients for hearing loss? | |
| Yes | 26 (39.4) |
| No | 40 (60.6) |
| If yes, do you screen all patients? | |
| Yes; all patients, regardless of age | 8 (30.8) |
| Yes; some patients (age >50) | 5 (19.2) |
| Yes; some patients (age >65) | 11 (42.3) |
| Other | 5 (19.2) |
| If no, why don’t you screen? | |
| Lack of time | 24 (61.5) |
| Not enough options for screening | 25 (64.1) |
| No benefit in screening | 0 (0) |
| Lack of solutions if a patient screens positive | 5 (12.8) |
| Other | 10 (25.6) |
| If time is an issue, what would be a possible solution to increase screening? | |
| Intake form where patients can check a box if they are concerned about their hearing, and, if selected, will lead them to getting referred for an audiogram | 31 (81.6) |
| Previsit phone screening by ancillary staff | 8 (21.1) |
| Medicare wellness questionnaire | 17 (44.7) |
| Other | 1 (2.6) |
| What guidelines do you follow regarding hearing loss screening for your patients? (please select all that apply) | |
| Medicare guidelines | 8 (30.8) |
| American Speech-Language-Hearing Association guidelines | 0 (0) |
| World Health Organization Guidelines on Integrated Care for Older People | 1 (3.8) |
| Other | 3 (11.5) |
| No specific guidelines in place | 15 (57.7) |
| What questions do you ask patients to screen for hearing loss? (please select all that apply) | |
| Do you have hearing loss? | 11 (45.8) |
| Do you have trouble hearing others? | 21 (87.5) |
| Do you ask others to repeat themselves? | 14 (58.3) |
| Have others told you that you should get [your hearing] checked? | 14 (58.3) |
| Other | 3 (12.5) |
| What tools do you use to screen for hearing loss? (please select all that apply) | |
| Pure-tone audiometry | 6 (23.1) |
| Whisper test or finger rub | 14 (53.8) |
| Watch tick test | 1 (3.8) |
| Tuning forks | 4 (15.4) |
| Other | 2 (7.7) |
| I do not use physical tools to screen for hearing loss | 9 (34.6) |
| What questionnaires do you use to screen for hearing loss? (please select all that apply) | |
| I do not use questionnaires for screening | 20 (76.9) |
| Hearing Handicap Inventory for the Elderly (HHIE) | 0 (0) |
| International Outcome Inventory for Hearing Aids (IOI-HA) | 0 (0) |
| Satisfaction with Amplification in Daily Life (SADL) | 0 (0) |
| Other | 6 (23.1) |
| How do you identify which patients in your system to screen for hearing loss? (please select all that apply) | |
| Age | 22 (84.6) |
| Comorbidities | 7 (26.9) |
| Occupation | 11 (42.3) |
| Other | 5 (19.2) |
| How often are you screening patients for hearing loss? | |
| Every visit | 3 (12.5) |
| Every other visit | 0 (0) |
| Yearly | 21 (87.5) |
| I do not screen patients for hearing loss | 0 (0) |
| What are your clinic’s goals regarding hearing loss treatment and prevention for your patients? (please select all that apply) | |
| Identify all patients at risk for hearing loss | 5 (19.2) |
| Refer patients with hearing loss to appropriate specialists | 19 (73.1) |
| Our clinic does not have goals for hearing loss treatment and prevention | 7 (26.9) |
| Educate all patients on hearing loss prevention | 5 (19.2) |
| Other | 1 (3.8) |
| Do you have an audiometer in your office? | |
| Yes | 14 (21.9) |
| No | 43 (67.2) |
| Unsure | 7 (10.9) |
| What do you do with your patients who either self-identify or screen positive for hearing loss? | |
| ENT referral | 27 (40.3) |
| Audiology referral | 38 (56.7) |
| Nothing | 1 (1.5) |
| Other | 1 (1.5) |
| Do you feel that you prioritize your patients’ other health problems over their hearing health? | |
| Strongly agree | 12 (18.2) |
| Agree | 31 (47.0) |
| Neutral | 11 (16.7) |
| Disagree | 11 (16.7) |
| Strongly disagree | 1 (1.5) |
Table 4 outlines counseling. Most practices lacked resources or counseling materials (n = 53, 79.1 percent). Providers largely did not feel comfortable in their knowledge about HA (n = 42, 62.7 percent) or CI (n = 54, 80.6 percent), though they indicated that a 1-hour continuing medical education (CME) module (n = 28, 71.8 percent) and/or pamphlet (n = 25, 64.1 percent) would increase their comfort. The most familiar aspects of HA were what they are (n = 26, 38.8 percent), how they work (n = 20, 29.9 percent), and when they are indicated (n = 16, 23.9 percent). When patients struggle with their HA, nearly all providers refer them to otolaryngology or audiology (n = 65, 98.5 percent). The most familiar aspects of CI were what they are (n = 14, 20.9 percent) and how they work (n = 9, 13.4 percent), though most respondents indicated they had never received formal education on CI (n = 41, 62.1 percent) (Table 4).
Table 4.
Counseling
| Question | n (%) |
|---|---|
| What resources or education do you have to advise/counsel patients on hearing loss? (please select all that apply) | |
| Pamphlets | 3 (4.5) |
| Videos on our website | 0 (0) |
| Dedicated audiologist or nurse educator on staff | 4 (6.0) |
| No resources | 53 (79.1) |
| Other | 8 (11.9) |
| How are patients and patients’ families counseled on the effects of hearing loss? | |
| Coordination of care with neuropsychologist/mental health professional | 2 (3.0) |
| Realistic expectation and goal-setting | 12 (17.9) |
| Other | 6 (9.0) |
| We do not have resources in our office for this type of counseling | 49 (73.1) |
| Do you feel comfortable in your knowledge about the following aspects of hearing aids? (please select all that apply) | |
| What are they | 26 (38.8) |
| How they work | 20 (29.9) |
| How long they last | 10 (14.9) |
| When they are indicated | 16 (23.9) |
| Patient eligibility | 7 (10.4) |
| Cost | 12 (17.9) |
| Insurance coverage | 6 (9.0) |
| Clinical outcomes | 6 (9.0) |
| I do not feel comfortable in my knowledge about hearing aids | 42 (62.7) |
| If you do not feel comfortable talking with your patients about hearing loss, what would make you feel comfortable? (please select all that apply) | |
| A 1-hour CME module | 28 (71.8) |
| A pamphlet, either reviewed in person or via e-mail | 25 (64.1) |
| Other | 2 (5.1) |
| If a patient is struggling with their hearing aids, how do you counsel them? | |
| Referral to ENT/audiology | 65 (98.5) |
| Referral elsewhere (e.g., Costco, Sam’s Club) | 20 (30.3) |
| I do not address it | 0 (0) |
| For your patients with hearing aids, do you ask about their hearing aid use? | |
| Yes | 44 (65.7) |
| No | 22 (32.8) |
| Unsure | 1 (1.5) |
| If yes, what have you heard from patients about their hearing aid use and general experiences with hearing aids? | |
| Positive responses | 8 (18.6) |
| Negative responses | 2 (4.7) |
| Both positive and negative | 33 (76.7) |
| Other | 0 (0) |
| Do you feel comfortable in your knowledge about the following aspects of cochlear implants? (please select all that apply) | |
| What are they | 14 (20.9) |
| How they work | 9 (13.4) |
| How long they last | 2 (3.0) |
| Patient eligibility | 1 (1.5) |
| Cost | 2 (3.0) |
| Insurance coverage | 1 (1.5) |
| Clinical outcomes | 4 (6.0) |
| I do not feel comfortable in my knowledge about cochlear implants | 54 (80.6) |
| How have you been educated about cochlear implants? (please select all that apply) | |
| Academic conferences | 2 (3.0) |
| Continuing medical education courses | 5 (7.6) |
| In medical school/residency training | 16 (24.2) |
| In graduate school | 3 (4.5) |
| Other | 2 (3.0) |
| I have not been educated about cochlear implants | 41 (62.1) |
Table 5 outlines referral and treatment. Most respondents indicated they always or often (n = 54, 81.1 percent) refer patients to otolaryngology/audiology for HL management, with uncertainty about eligibility for referral and “other” being the most commonly cited reasons (n = 9, 13.6 percent and n = 10, 15.2 percent, respectively). Qualitative analysis of free-form responses reveals that patients’ declining and other social determinants of health such as lack of transportation comprise these deterrents. However, the majority of providers strongly agreed or agreed that they knew when to refer a patient for HL management (n = 57, 86.3 percent). Few providers prescribed HL treatments (n = 6, 9.2 percent), though among them HA and preventive measures such as avoiding noise exposure or using earplugs were most commonly cited (n = 4, 66.7 percent for both). Consultation from other providers (n = 6, 100 percent) and cost of treatments (n = 5, 83.3 percent) were large driving factors. Providers’ low confidence in knowledge of HL treatments was a leading factor in the decision not to prescribe HL treatments (n = 47, 79.7 percent) (Table 5).
Table 5.
Referral/Treatment
| Question | n (%) |
|---|---|
| When a patient is concerned about hearing loss, do you refer to an audiologist or otolaryngologist to further evaluate? | |
| Yes, otolaryngologist (ENT) | 40 (59.7) |
| Yes, audiologist, separate from an ENT office | 15 (22.4) |
| No | 0 (0) |
| It depends on the patient presentation | 12 (17.9) |
| How often do you refer to ENT/audiology for hearing loss management? | |
| Always | 23 (34.8) |
| Often | 31 (47.0) |
| Sometimes | 9 (13.6) |
| Rarely | 3 (4.5) |
| Never | 0 (0) |
| What prevents you from referring a patient to ENT/audiology? (please select all that apply) | |
| Unavailability of appropriate specialists | 6 (9.1) |
| Unsure of which practice to refer to | 4 (6.1) |
| Uncertainty about patient eligibility for referral | 9 (13.6) |
| Other | 10 (15.2) |
| Not applicable, as I refer patients regularly | 48 (72.7) |
| Do you feel you know when to refer a patient for hearing loss management? | |
| Strongly agree | 15 (22.7) |
| Agree | 42 (63.6) |
| Neutral | 9 (13.6) |
| Disagree | 0 (0) |
| Strongly disagree | 0 (0) |
| Do you prescribe hearing loss treatments? | |
| Yes | 6 (9.2) |
| No | 59 (90.8) |
| If yes, which ones? (please select all that apply) | |
| Hearing aids | 4 (66.7) |
| Cochlear implantation | 0 (0) |
| Preventive measures | 4 (66.7) |
| Other | 0 (0) |
| If yes, what factors influence your decision (please select all that apply) | |
| Cost | 5 (83.3) |
| Best practice guidelines | 3 (50.0) |
| Consultation from other providers | 6 (100.0) |
| Prior knowledge/training | 1 (16.7) |
| Other | 0 (0) |
| If no, what factors influence your decision? (please select all that apply) | |
| Cost | 4 (6.8) |
| Lack of insurance benefits | 5 (8.5) |
| Lack of resources in office | 17 (28.8) |
| Low confidence in knowledge of hearing loss treatments | 47 (79.7) |
| Other | 6 (10.2) |
Table 6 outlines follow-up. Over half of respondents indicated that they do not follow up with their patients who have HL about their HL (n = 36, 53.7 percent), with most stating there is no follow-up plan in place (n = 42, 64.6 percent). Among those that do, the most common timeframes are 3–6 months after treatment/diagnosis (n = 14, 20.9 percent) and yearly (n = 12, 17.9 percent). Providers cited reminders, such as automated messages through the electronic patient portal and text messages (n = 33, 49.3 percent) or verbal cues during visits (n = 30, 44.8 percent), as ideal methods to ensure appropriate compliance and adherence to treatment (Table 6).
Table 6.
Follow-up
| Question | n (%) |
|---|---|
| Do you follow up with your patients who have hearing loss? How often? | |
| Yes; 2–4 weeks after treatment/diagnosis | 1 (1.5) |
| Yes; 1–3 months after treatment/diagnosis | 4 (6.0) |
| Yes; 3–6 months after treatment/diagnosis | 14 (20.9) |
| Yes; yearly | 12 (17.9) |
| No, I do not follow up with these patients about their hearing loss | 36 (53.7) |
| What follow-up is in place after referral to an ear specialist to ensure patients’ appropriate compliance and adherence to treatment? (please select all that apply) | |
| Ancillary office staff calls to follow up with patient | 0 (0) |
| Reminders in electronic patient portal and other communication preferences (text, e-mail) | 3 (4.6) |
| Reminder at next in-person or telehealth visit | 18 (27.7) |
| Other | 3 (4.6) |
| There is no follow-up plan in place | 42 (64.6) |
| What follow-up would you ideally desire after referral to an ear specialist to ensure patients’ appropriate compliance and adherence to treatment? (please select all that apply) | |
| Ancillary office staff calls to follow up with patient | 23 (34.3) |
| Reminders in electronic patient portal and other communication preferences (text, e-mail) | 33 (49.3) |
| Reminder at next in-person or telehealth visit | 30 (44.8) |
| Other | 7 (10.4) |
DISCUSSION
Untreated HL is associated with numerous negative outcomes including depression, accelerated cognitive decline, and dementia (Davis et al., 2016). Studies have shown that HA use can improve impaired cognitive scores, which might indicate risk mitigation for cognitive impairment later in life (Sarant et al., 2024; Stropahl et al., 2024). Alongside otolaryngologists and audiologists, primary care physicians play an important role in the hearing health care pipeline (Bennett et al., 2020; Easton & Leverton, 2018). Though HL affects more than 40 percent of people over 70 years old, nearly 40 percent of people with HL do not report it to a provider, and almost 20 percent of those who do report do not receive a referral (Tsimpida et al., 2024). Existing literature suggests barriers include lack of regular hearing screening, providers’ difficulty interpreting the results of an audiogram, lack of referral to specialists, deprioritization of hearing health in general, lack of providers’ knowledge about HA, and lack of follow-up with the patient (Ebrahimi-Madiseh et al., 2020; Nieman & Oh, 2020; Ravi et al., 2023; Tsimpida et al., 2024). This study seeks to examine these barriers at our institution and propose potential avenues for intervention.
The data from this study align with previous literature regarding known gaps in the hearing health care pipeline and highlight several opportunities for improvement. One such gap is training with and access to audiograms. In our cohort, many providers had never seen an audiogram, and the vast majority did not feel comfortable in their abilities to interpret an audiogram. Furthermore, nearly three quarters of our cohort felt that patients sometimes or rarely discussed hearing health at visits. Although it is unreasonable to expect all providers to obtain audiometers, perhaps if they knew how to read an audiogram they would better prioritize hearing health inquiries from patients, potentially increasing conversations around hearing health. Thus, one potential intervention could be increasing supplies of audiometers in primary care offices and training providers and their staff on how to use and interpret audiograms. However, learning to read an audiogram may not actually address time constraints. Better alternatives include focusing on previsit screenings or using other low-cost screening tools. Examples include a portable device with both tympanometry and distortion product otoacoustic emissions to rule out possible middle ear pathology and gauge hair cell function, respectively. Another avenue is through smartphones apps, such as uHear, EarTrumpet, and hearScreen, which use a combination of smartphone hardware and the user’s personal earphones to screen for HL (Melo et al., 2022). These methods are low-cost and easily accessible, with some studies showing promising results in terms of sensitivity and accuracy (Abu-Ghanem et al., 2016; Barczik & Serpanos, 2018; Melo et al., 2022; Peer & Fagan, 2014; Szudek et al., 2012). Further research and validation, however, are necessary before these become mainstream adjuncts (Irace et al., 2021).
Another gap that we identified was time constraints. Providers indicated that they do not have enough time to routinely screen for HL. Whereas nearly half of our cohort suggested that automated messages through the electronic patient portal and text messages may help streamline screening, data on the efficacy of these measures are mixed, with several studies suggesting that without clear guidelines in place many of these notifications may go unaddressed (DeJonckheere et al., 2021; Menachemi & Collum, 2011; Zazove et al., 2017). Intake forms may be helpful adjuncts for prescreening. Using the screening question from the Medicare Annual Wellness Visit, such as the yes/no question “Do you think you have a hearing problem, or do others think you have a hearing problem?,” or adapting multiple questions from the Hearing Handicap Inventory for the Elderly may be a touchpoint to draft prescreening materials. Similarly, more than half of the providers in our study stated there were no specific guidelines in place at their practice regarding HL screening; another intervention could be implementing standard and specific guidelines such as Medicare, which mandate screening as part of the annual wellness exam for older adults, or the American Speech-Language-Hearing Association (ASHA), which recommends screening once every decade until the age of 50 years, and then every 3 years after (Nieman & Oh, 2020).
Lack of counseling materials for patients and their families in primary care offices was another gap identified. Respondents indicated that they do not feel confident in their knowledge of hearing treatments. This low confidence in turn influences providers’ decisions to prescribe treatments. This finding aligns with themes in the literature; Coleman et al. (2018), for example, found that audiology patients wanted more information about HL and treatments during their visits than their providers could supply, leading to lack of confidence in proper HA usage. Therefore, initiatives to address this knowledge gap and increase interprofessional education are crucial. Respondents felt that a 1-hour CME module or pamphlet may be helpful first steps in this education. Researchers have highlighted the utility of CME modules in longitudinal education for providers (Humphries et al., 2014), with Mazmanian & Davis (2002) suggesting that CME is most effective when it is self-directed by the physician and offers opportunities for critical reflection on practice and improvement measures.
Lack of follow-up for patients with HL was another barrier we identified. Several providers felt that this was not within the purview of primary care. Several studies in the literature suggest that otolaryngologic knowledge may be deficient in primary care providers (Domanski et al., 2010; Error et al., 2013; Hu et al., 2012), which may be a contributing factor. This sentiment highlights the opportunity for increased interprofessional collaboration between specialists and primary care physicians, especially given the overwhelming consensus in this survey about referring patients with HL out to specialists. A group of researchers at the Henry Ford Health System developed a set of referral guidelines between primary care physicians and otolaryngologists, finding that referral guidelines may be an effective way of improving specialty access (Benninger et al., 1995), though other studies have not found evidence for these guidelines in improving provider knowledge (Clarke et al., 2010). The use of the internet for disseminating information between specialties is another avenue, though there is currently no consensus on what material should be included (Tsikoudas et al., 2013). Scott et al. (2015) recommend further analysis of the referral preferences and consultation requests between primary care and otolaryngology.
This study has several limitations. It is the first step in a quality improvement study at a large multicenter institution and may not apply to practices at other institutions or in other geographic regions. The response rate was low (8.9 percent), which may indicate a selection bias in who chose to fill out the survey. Our cohort was homogenous in terms of older providers commenting on largely English-speaking patient populations. It is also important to note that some of our conclusions are based on smaller sample sizes of providers and represent an initial touchpoint for this research. We did not collect data on practice location, which would have enabled a more granular socioeconomic analysis of our cohorts’ practices. Furthermore, we did not specifically ask respondents their professional title (physician versus nurse practitioner versus physician assistant), which may have influenced responses. Future extensions on this work could improve on these survey questions and compare responses across multiple institutions, including a greater sample size to strengthen subsequent conclusions.
CONCLUSIONS
These responses identify potential gaps in the hearing health care pipeline, particularly the need for standardized HL screening protocols and increased interprofessional training and education on HL treatments. Future endeavors to target these gaps should be assessed to see whether these gaps can be closed.
Abbreviations
- CI
cochlear implant
- CME
continuing medical education
- HA
hearing aids
- HL
hearing loss
Footnotes
Conflict of Interest: None reported.
Any mention of a product, service, or procedure in the Journal of the American Academy of Audiology does not constitute an endorsement of the product, service, or procedure by the American Academy of Audiology.
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