To the Editor
Hearing loss (HL), a chronic condition that affects nearly two-thirds of older adults in the United States,1 has been independently associated with dementia, poor health outcomes and mortality.2 HL could potentially interfere with patient-physician communication, and thus quality of healthcare. We investigated, in a nationally representative sample of adults, the associations between HL and 1) patient perceptions of quality of patient-physician communication, and 2) patient perceptions of quality of healthcare.
METHODS
Pooled data were derived from years 2002–2011 of the Medical Expenditure Panel Survey Household Component (MEPS-HC), a nationally representative survey of the US civilian non-institutionalized population.3 Participants were included if they were 18 years or older and visited a physician at least once in the previous year. Data were collected through computer-assisted personal interviews. HL was based on self-report and summarized as a binary variable (“No hearing loss” versus “Any hearing loss” [excluding deafness]). Perception of patient-physician communication was assessed with the Consumer Assessment of Healthcare Providers and Systems (CAHPS) composite measure developed for the Agency for Healthcare Research and Quality.4 Participants indicated how often their doctor(s) explained things clearly, listened carefully, showed respect for what they had to say, and afforded the madequate time (never (1), sometimes (2), usually (3) or always (4)). Responses to the 4 items were summed and averaged for each participant.5 The CAHPS quality of healthcare item asked participants to rate their care overall from 0 (worst possible) to 10 (best possible).
The associations of HL with ratings of patient-physician communication and healthcare were analyzed with logistic regression (rating scores > versus ≤ 50th percentile). We adjusted for potential demographic and health confounders including sex, age, race/ethnicity, education level, income, hearing aid use, physical health status (Short Form-12 version 2 physical component summary), mental health status (Short Form-12 version 2 mental component summary), and histories of hypertension, diabetes, stroke, hypercholesterolemia, myocardial infarction, coronary heart disease, other heart disease, and smoking. Multiplicative interaction terms were included to determine if age, sex, hearing aid use or self-reported vision impairment (any versus none) modified the associations. Analyses accounted for the complex sampling design. Missing values due to non-responses, refusals, and the survey skip pattern were excluded. Analyses were performed with STATA 12.0 (StataCorp).
RESULTS
Our analytic cohort was comprised of 122,556 participants (9,747 with HL; 112, 809 with normal hearing). Individuals with HL were more likely to be older, male, of lower socioeconomic status, and in poorer health (Table 1). In fully adjusted models, individuals with HL versus those with normal hearing had significantly lower odds of having ratings of patient-physician communication (Odds ratio [OR] 0.906, 95% confidence interval [CI]: 0.858, 0.957; p<0.001) and overall healthcare (OR 0.939, 95% CI: 0.890, 0.990; p=0.021) that were greater than the median. Sex, age, hearing aid use, and self-reported visual impairment did not significantly modify these associations (data not shown).
Table 1.
Study participant characteristics according to self-reported hearing loss (HL) status.
| Characteristic | No HL Col % |
Any HL Col % |
p-value1 |
|---|---|---|---|
| Male | 40.5 | 57.1 | < .001 |
| Age, mean (SE) | 47.2 (0.062) | 62.6 (0.19) | < .001 |
| Race | < .001 | ||
| White | 83.2 | 91.2 | |
| Black | 10.7 | 4.9 | |
| American Indian/Alaska Native | 0.7 | 0.7 | |
| Asian | 3.9 | 1.5 | |
| Hawaiian/Pacific Islander | 0.3 | 0.1 | |
| Multiple races | 1.3 | 1.6 | |
| Education | < .001 | ||
| Less than high school | 12.5 | 16.3 | |
| High school or GED | 30.6 | 35.4 | |
| Some college or university | 25.8 | 24.1 | |
| College/university graduate | 31.1 | 24.3 | |
| Family income | < .001 | ||
| Poor or negative | 9.8 | 10.2 | |
| Near poor | 3.5 | 5.3 | |
| Low income | 11.5 | 14.2 | |
| Middle income | 29.6 | 29.7 | |
| High income | 45.6 | 40.6 | |
| Physical health, mean (SE)2 | 48.9 (0.04) | 41.2 (0.15) | < .001 |
| Mental health, mean (SE)3 | 50.5 (0.03) | 49.2 (0.13) | < .001 |
| Diabetes | 9.6 | 18.4 | < .001 |
| Hypertension | 33.2 | 54.5 | < .001 |
| Angina pectoris | 2.6 | 8.4 | < .001 |
| Coronary heart disease | 4.9 | 14.5 | < .001 |
| Other heart disease | 9.5 | 21.7 | < .001 |
| Myocardial infarction | 3.6 | 10.7 | < .001 |
| Stroke | 3.1 | 9.8 | < .001 |
| Smoker | 17.2 | 17.7 | > .05 |
P-value for test of no difference between HL groups, determined using Chi-square test for categorical variables and 2-sided Student’s t-test for continuous variables
Physical component summary score of the Short-form 12 version 2 (higher is better)
Mental component summary score of the Short-form 12 version 2 (higher is better)
DISCUSSION
In this nationally representative study of adults in the United States, self-reported HL was independently associated with lower ratings of patient-physician communication and overall healthcare. On average, individuals with HL had a ~10% and 6% lower odds, respectively, of having more favorable ratings of their patient-physician communication and healthcare experiences compared to individuals with normal hearing. Patients with HL may have greater difficulty understanding or engaging in discussions with their physicians, especially in the context of noisy environments or unfamiliar medical concepts/terminology. Doctors may also become frustrated or unaware of effective communication strategies when conversing with patients with HL. These factors could plausibly impact the quality of patient-provider communication and overall rating of healthcare.
Effective communication is necessary for patient-centered care that is respectful and responsive to individual preferences, needs, and values, and facilitates knowledge transfer, shared decision-making, and patient autonomy.6 It is an important predictor of how patients perceive quality of care.5 Good communication may improve health outcomes in certain situations. In a systematic review of randomized controlled trials and observational studies that occurred in a variety of healthcare settings, 16 of 21 studies showed positive correlations between patient-physician communication and outcomes like emotional health, symptom resolution, pain control, functional status, blood pressure and glucose control.7
Limitations of our study are the use of self-reported assessments of HL, which may have resulted in exposure misclassification, and the possibility of residual confounding. Future research should investigate whether HL is associated with objective measures of healthcare quality and how patient-physician communication could be improved for patients with HL. Physicians should ensure that their patients with HL fully understand healthcare discussions.
ACKNOWLEDGMENTS
Funding/Support: This study is supported by grants from the National Institute on Deafness and Other Communication Disorders (K23DC011279), Triological Society and American College of Surgeons through a Clinician Scientist Award, and Eleanor Schwartz Charitable Foundation.
Sponsor’s Role: The sponsors had no role in the design and conduct of the study; in the collection, analysis, and interpretation of the data; or in the preparation, review, or approval of the manuscript.
Footnotes
Conflict of Interest Disclosures: Dr. Lin serves as a consultant to Cochlear Americas, on the scientific advisory board of Pfizer and Autifony, and has been a speaker for Med El and Amplifon. No other author reported any disclosures.
Author Contributions: All authors had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.
Study concept and design: Mick, Lin
Acquisition of the data: Foley
Analysis and Interpretation of data: Mick, Foley, Lin
Statistical Analysis: Foley
Drafting of the manuscript: Mick, Foley
Critical revision of the manuscript for important intellectual content: Mick, Foley, Lin
Obtained funding: Lin
Administrative, technical or material support: N/A
Study supervision: Lin
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