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. Author manuscript; available in PMC: 2022 Oct 1.
Published in final edited form as: J Aging Health. 2021 Apr 29;33(9):786–797. doi: 10.1177/08982643211014323

Near Vision but not Hearing Loss is Associated with Lacking a Usual Source of Health Care

Adam Simning 1,2, Thomas V Caprio 1,2,3, Yue Li 2, Yeates Conwell 1,4
PMCID: PMC8882359  NIHMSID: NIHMS1780835  PMID: 33914652

Abstract

Objectives:

Sensory loss may be a barrier to accessing health care services, and this study seeks to examine the association of sensory loss with whether older adults report having a usual source of health care.

Methods:

Our study included 7,548 older adults who participated in the National Health and Aging Trends Study in 2015. Having a self-reported usual source of health care was our outcome, and hearing and vision loss were our primary independent variables.

Results:

In multivariate analysis accounting for demographics, socioeconomic, health status, and environmental covariates, near vision loss but not distance vision or hearing loss was associated with decreased odds of having a usual source of health care.

Discussion:

That older adults with near vision loss were less likely to report having a usual source of health care is concerning. Examining barriers to care is needed to identify sensory loss-relevant processes to optimize and intervene upon.

Keywords: Functional loss, primary care services, health services utilization, epidemiology

Objective

Auditory and visual sensory loss are common worldwide and increase in prevalence with advancing age (Bourne et al., 2018; Goman & Lin, 2016; Guthrie et al., 2018; Stevens et al., 2013). These sensory losses can negatively affect physical, cognitive, and social functioning and are associated with poor health outcomes, worse quality of life and mental health, suboptimal care, and increased difficulties in accessing health services and information (Cupples, Hart, Johnston, & Jackson, 2012; Goman & Lin, 2018; Mikkola et al., 2016; Miller, Deere, & Cox, 2017; Pandhi, Schumacher, Barnett, & Smith, 2011; Pratt, 2018; Adam Simning, Fox, Barnett, Sorensen, & Conwell, 2019; Spencer, Frick, Gower, Kempen, & Wolff, 2009; Swenor, Lee, Varadaraj, Whitson, & Ramulu, 2020; Zheng et al., 2012). Sensory loss often goes unrecognized, and people with sensory loss may have to manage physical, communication, and procedural (e.g., completing forms) barriers to accessing primary care services (de Vries McClintock et al., 2016; Miller et al., 2017; Pratt, 2018).

Auditory and visual sensory loss can contribute to functional impairment and disabilities (Goman & Lin, 2018; Guthrie et al., 2018; Mikkola et al., 2016; Swenor et al., 2020). People with disabilities are at risk of having unmet health care needs, in part because they may have more difficulties in accessing primary care clinics, difficulties that are worsened among older adults (Popplewell, Rechel, & Abel, 2014). Similarly, worsening functional impairment is associated with increased difficulties in obtaining necessary health care (McClintock et al., 2017). Transportation issues and having medical offices that are accessible are particularly salient barriers for accessing health services among people with disabilities residing in rural communities who may live far away from their health care providers (Iezzoni, Killeen, & O’Day, 2006). Given the relationship between sensory loss and disability, there is concern that older adults with hearing and vision loss may have decreased access to routine medical care such as having a regular medical provider. The limited available survey data indicate, however, that sensory loss may not be associated with decreased access to general health services. For instance, other than increased use of mental health services, a Finnish survey from 2000–2001 did not find evidence that hearing loss was associated with general health services use among older adults (Mikkola et al., 2016). Additionally, data from the Medical Expenditure Panel Survey from 2002–2004 found that people aged 40 and older with vision loss in the United States did not have lower rates of having a usual source of health care compared to those without vision loss (Spencer et al., 2009). Whether the Finnish study findings are generalizable to other populations and health care systems is uncertain, however, and the United States study did not focus specifically on older adults. Because sensory loss may contribute to disability and, more than a third of people aged 65 and older in the United States have a disability (Kraus, Lauer, Coleman, & Houtenville, 2018), considering the potential impact of sensory loss on accessing health care services among older adults is warranted.

Identifying whether a person has a usual source of health care is a way to measure health care access (Tipirneni et al., 2020). This health care access marker is relevant because people with a usual health care provider are more likely to receive preventative services, have greater satisfaction with their care, receive better quality of care, and have lower health care costs (Friedberg, Hussey, & Schneider, 2010). For instance, adults with a usual source of care were more likely to receive treatment for hypertension and hypercholesterolemia and have lower mortality following an acute myocardial infarction (Spatz, Ross, Desai, Canavan, & Krumholz, 2010; Spatz et al., 2014). The presence of a usual source of care can be transitory, however, with one study finding that older adults can lose and regain a usual source of care over six years of follow-up (Nothelle, Boyd, Sheehan, & Wolff, 2018). This is potentially concerning because observational studies show that increasing continuity of care (from both generalist and specialist doctors) is associated with lower mortality rates (Pereira Gray, Sidaway-Lee, White, Thorne, & Evans, 2018). Although the presence of a usual source of care appears to have a meaningful effect on disease management and outcomes, we know relatively little about how auditory and visual sensory loss may affect whether older adults in the United States have a usual source of care.

To help address this gap, our study’s objective was to use a national cohort of older adult Medicare beneficiaries in the United States to examine the association of auditory and visual sensory loss with whether an older adult reported having a usual source of care to manage their health needs. We hypothesized that 1) the presence of auditory and visual sensory loss function as a barrier to health care access and are associated with decreased odds of having a usual source of health care, and 2) older adults with sensory loss rely more on others to access their usual source of health care.

Method

Participants and Study Design

The National Health and Aging Trends Study (NHATS) commenced in 2011 and longitudinally examines a nationally representative cohort of United States Medicare beneficiaries aged 65 years and older with annual in-person interviews (Kasper & Freedman, 2018). NHATS is administered in English and Spanish, recruits disproportionately higher levels of Black older adults and from older age groups, and is publicly available at www.nhats.org. For this article, we examined participants who were interviewed in 2015 (Round 5), which was when the original NHATS cohort was replenished with new participants. The 2015 interview year had an unweighted response rate of 76.8% (Kasper & Freedman, 2018). Of the 7,548 participants included in our study sample, 7,052, 423, and 73 were dwelling in the community, non-nursing home residential care settings, and nursing homes, respectively. NHATS was approved by the Johns Hopkins Bloomberg School of Public Health Institutional Review Board.

Usual Source of Health Care Variables

Our primary outcome (binary: present, absent) was determined by this question: “Is there a doctor that you think of as your regular doctor, that is, a doctor you usually go to when you are sick and need advice about your health?” (“National Health & Aging Trends Study,” 2020). Similar to others, we used this survey question to indicate whether a usual source of health care was present, the presence of which has been associated with the absence of depressive symptoms, more medical comorbidity, and Medicaid insurance (Nothelle et al., 2018). For participants who reported seeing their usual source of health care or another doctor in the past year, we examined whether these older adults drove themselves to their appointments or were driven by others and whether anyone sat in with them during their doctor visits. Among participants that had someone attend the doctor’s appointment with them, we examined the type of assistance they received (e.g., whether others helped them prepare for the physical exam, reminded them about things they wanted to tell or ask the doctor, asked or shared information with the doctor for them, and helped them understand what the doctor was saying)(“National Health & Aging Trends Study,” 2020).

Auditory and Visual Loss

Our primary independent variables were the presence of auditory and visual sensory loss (binary: present, absent), which we determined using sensory items available in the NHATS questionnaire (see Supplemental Figures 1 and 2 for operationalization of NHATS survey items). Hearing loss was present if the participant (even if a hearing aid was used) was unable to “hear well enough to carry on a conversation in a room with a radio or TV playing,” was unable to “hear well enough to carry on a conversation in quiet room,” was unable to “hear well enough to use the telephone,” or reported being Deaf (N=10). Near vision loss was present if the participant (even if glasses, contacts, or vision aids were used) was unable to “see well enough to read newspaper print” or reported being blind (N=51). Distance vision loss was present if the participant (even if glasses, contacts, or vision aids were used) was unable to “see well enough to recognize someone across the street,” was unable to “see well enough to watch television across the room,” or was blind (“National Health & Aging Trends Study,” 2020). Of note, self-reported hearing and vision loss are often under-reported when compared to objective auditory and visual exams, the underreporting of which can vary by sociodemographic characteristics (Goman, Reed, Lin, & Willink, 2020; Whillans & Nazroo, 2014).

Covariates

Study covariates included demographics, socioeconomic, health status, and environmental domains that may be associated with sensory loss or affect an older adult’s ability to access health care services (James et al., 2018; Riverin, Strumpf, Naimi, & Li, 2018; Adam Simning et al., 2019; A. Simning et al., 2020). Demographics included age (65–74, 75–84, 85+), sex (male, female), race and ethnicity (non-Hispanic White; non-Hispanic Black; Hispanic and other; other includes American Indian, Asian, Native Hawaiian, Pacific Islander, and other), marital status (married or living with a partner; separated or divorced; widowed or never married), and number of close social contacts (0 to 5). Socioeconomic status included formal education (high school degree or less, some college or vocational training, college degree or higher) and Medicaid status (present, absent)(Kasper & Freedman, 2018; “National Health & Aging Trends Study,” 2020). Health status variables included medical comorbidity, which was grouped by quartile (higher quartiles indicating worsening medical comorbidity) and consisted of the total number of the following conditions: heart attack, heart disease, high blood pressure, arthritis, osteoporosis, diabetes, lung disease, stroke, and cancer; dementia (probable, possible, no dementia)(Kasper, Freedman, & Spillman, 2013; Spillman & Skehan, 2013); instrumental activities of daily living impairment (IADLs; present, absent) that included preparing meals, doing laundry, doing light housework, shopping for groceries, managing money, taking medicine, or making phone calls; activities of daily living impairments (ADLs; present, absent) that included eating, transferring out of bed, transferring out of chairs, walking inside, going outside, dressing, bathing, or toileting; and a depression screen (PHQ-2; positive, negative)(Kroenke, Spitzer, & Williams, 2003). NHATS modified the PHQ-2 scale to assess the prior one month (rather than two weeks), which was scored from 2 to 8 (Kasper & Freedman, 2018), with scores of 5 or higher indicating a positive depression screen. Probable dementia was present when survey participants or proxies reported a doctor had told the participants that they had dementia or participants had scores on cognitive testing that met criteria for likely dementia. Possible dementia was present for those not reporting a dementia diagnosis who had cognitive testing that did not meet criteria for likely dementia but indicated some impairment was present (Kasper et al., 2013; Spillman & Skehan, 2013). Environmental variables included whether there were stairs (present, absent) or a ramp (present, absent) at the participants’ primary entrance.

Statistical Analyses

To examine differences in usual source of health care use, demographics, socioeconomic status, and health status domains by auditory or visual sensory loss status, we first conducted bivariate analyses and used the Rao-Scott F adjusted chi-square statistic (a statistic that is recommended for complex survey data because it yields a more conservative interpretation than the Wald chi-square)(National Center for Health Statistics, 2020). We also examined the association of doctor visit assistance with sensory loss across age groups due to concern that age could confound this association. To examine the association of hearing and vision loss with having a usual source of health care, we next conducted one unadjusted and one adjusted logistic regression analysis (models included hearing, near vision, and distance vision loss concurrently) with the presence of a usual source of health care (1=present, 0=absent) as our outcome. Adjusted regression analyses included all of the covariates in the demographics, socioeconomic status, and health status variables. We did not include those with proxy interviews (N=457) in the adjusted analyses because NHATS did not ask proxy respondents about close social contacts (Kasper & Freedman, 2018). Following NHATS technical guidance (Kasper & Freedman, 2018), we used SAS survey procedures (version 9.4, SAS Institute, Inc., Cary, NC) to account for sampling design and nonresponse and calculate population-weighted adjusted estimates, and all prevalence estimates are based on population-weighted data. To account for participants with missing data, we used SAS survey procedures’ “not missing completely at random” (i.e., nomcar) option.

Results

Bivariate Analyses

Among our cohort of older adult Medicare beneficiaries, 12.5% (N=1,051) reported hearing loss, 4.7% (N=488) reported near vision loss, and 6.5% (N=612) reported distance vision loss. Those with near vision loss but not hearing or distance vision loss were less likely to report having a usual source of health care compared to those without hearing or vision loss, respectively (Table 1). Additionally, older adults with either hearing or vision loss were much more likely to have others drive them to their doctor appointments and receive assistance from others during the visit. Of note, this association of doctor visit assistance with sensory loss largely persisted across age groups (Table 2). Those with sensory loss were also more likely to be older, non-White, widowed or never married, have fewer close social contacts, have less formal education, have Medicaid, have more medical comorbidity, have probable or possible dementia, be functionally impaired, have depression symptoms, and entrance ramps compared to those without hearing or vision loss, respectively (Table 1). The association of sex varied by sensory status, however, with disproportionately more males reporting hearing loss and disproportionately more females endorsing vision loss.

Table 1.

Usual Source of Health Care Services, Demographics, Socioeconomic Status, and Health Status Characteristics of Medicare Beneficiaries Aged 65 Years and Older Stratified by the Presence of Hearing or Vision Loss.

Hearing Loss Near Vision Loss Distance Vision Loss
Absent Present P value a Absent Present P value a Absent Present P value a
N % or mean SE N % or mean SE N % or mean SE N % or mean SE N % or mean SE N % or mean SE
Interview Type
Proxy, yes 284 3.1 0.2 189 13.3 1.4 <0.001 345 3.5 0.3 117 19.8 2.0 <0.001 297 3.0 0.3 151 20.2 2.1 <0.001
Usual Source of Health Care Services
Have usual source of health care, yes 6,144 94.7 0.4 984 94.3 0.9 0.614 6,697 94.8 0.4 451 91.6 1.8 0.032 6,538 94.7 0.4 569 94.3 1.0 0.666
Drove self to appointment, yes 4,043 75.5 0.7 438 53.8 2.0 <0.001 4,415 75.2 0.7 79 23.1 2.8 <0.001 4,370 76.0 0.7 118 27.8 2.5 <0.001
Others drove to appointment, yes 2,032 25.9 0.7 516 44.9 1.8 <0.001 2,220 26.4 0.6 330 67.8 2.9 <0.001 2,107 25.4 0.7 418 67.5 2.3 <0.001
Attended doctor appointment with others, yes 2,296 32.5 0.9 595 57.0 1.8 <0.001 2,567 34.0 0.8 323 67.9 3.4 <0.001 2,470 33.4 0.9 397 64.7 2.7 <0.001
Others helped prepare for doctor exam, yes 380 14.8 0.9 169 25.9 1.8 <0.001 441 15.5 0.9 105 32.7 3.3 <0.001 410 15.1 0.9 127 28.8 2.5 <0.001
Others reminded participant during doctor visit, yes 1,278 53.8 1.4 388 67.5 2.4 <0.001 1,462 55.9 1.3 205 64.7 3.3 0.016 1,411 55.7 1.3 245 63.7 2.6 0.006
Others asked or shared information at doctor visit, yes 1,311 52.1 1.3 425 68.8 2.5 <0.001 1,487 53.8 1.3 243 71.6 3.3 <0.001 1,419 52.9 1.3 293 71.7 3.1 <0.001
Others helped understand information at doctor visit, yes 1,221 46.3 1.4 454 73.9 2.1 <0.001 1,415 49.4 1.2 250 74.9 3.0 <0.001 1,361 48.7 1.1 289 73.5 2.8 <0.001
Demographics
Age in years <0.001 <0.001 <0.001
 65–74 2,559 57.9 0.6 237 41.1 1.7 2,704 56.8 0.6 99 35.6 2.9 2,669 57.2 0.6 128 37.2 3.0
 75–84 2,599 31.1 0.5 373 31.9 1.6 2,815 31.2 0.5 169 32.5 2.2 2,774 31.4 0.5 197 30.3 2.0
 85+ 1,322 11.0 0.3 441 27.0 1.1 1,541 12.0 0.3 220 32.0 1.9 1,454 11.5 0.3 287 32.5 2.4
Sex, Female 3,798 56.3 0.7 573 50.2 2.0 0.008 4,072 55.1 0.7 303 61.8 2.3 0.012 3,922 54.6 0.7 426 67.7 2.6 <0.001
Race and ethnicity <0.001 <0.001 <0.001
 White, non-Hispanic 4,383 80.7 1.0 742 76.7 2.1 4,893 81.0 1.0 250 64.3 3.4 4,740 80.9 1.0 373 70.4 2.8
 Black, non-Hispanic 1,426 9.0 0.5 132 4.5 0.6 1,406 8.1 0.4 148 14.4 1.6 1,416 8.4 0.4 130 9.2 1.2
 Hispanic or Other 513 10.3 0.8 157 18.8 2.0 598 10.9 0.9 74 21.3 3.2 579 10.8 0.9 93 20.4 2.7
Marital Status <0.001 <0.001 <0.001
 Married or living with a partner 3,180 57.3 0.8 453 51.8 1.9 3,491 57.6 0.8 156 38.4 2.7 3,447 57.9 0.8 186 39.3 2.0
 Separated or divorced 929 14.8 0.6 109 11.4 1.3 981 14.3 0.6 57 14.9 2.3 961 14.4 0.5 75 13.9 1.6
 Widowed or never married 2,366 27.9 0.6 488 36.8 1.4 2,584 28.1 0.6 273 46.7 2.4 2,484 27.7 0.6 350 46.9 2.3
Number of close social contacts 6,196 2.22 0.03 862 2.01 0.06 <0.001 6,715 2.21 0.03 371 1.79 0.06 <0.001 6,600 2.21 0.03 461 2.00 0.07 0.006
Socioeconomic Status
Education <0.001 <0.001 <0.001
 High school degree or equivalent or less 2,975 41.1 1.2 621 58.3 2.1 3,267 42.0 1.2 334 70.5 2.7 3,209 42.0 1.2 369 61.5 2.7
 Some college or vocational training 1,398 23.7 0.6 185 19.4 1.2 1,516 23.6 0.7 70 14.5 2.1 1,464 23.4 0.7 114 19.6 1.9
 College degree 1,950 35.2 1.2 218 22.2 1.6 2,111 34.4 1.2 65 15.0 2.0 2,062 34.6 1.2 108 18.9 2.1
Medicaid, present 885 11.1 0.5 212 20.8 1.7 <0.001 942 11.4 0.5 151 31.3 2.7 <0.001 940 11.4 0.5 151 25.6 2.2 <0.001
Health Status
Medical comorbidity <0.001 <0.001 <0.001
 1st Quartile 1,485 28.8 0.6 164 18.9 1.6 1,581 28.1 0.6 72 17.0 2.5 1,564 28.3 0.6 81 16.8 2.2
 2st Quartile 1,545 25.2 0.8 195 19.8 1.3 1,666 24.9 0.7 82 17.4 2.2 1,624 24.8 0.7 115 20.3 2.4
 3rd Quartile 1,495 21.9 0.6 223 22.8 1.5 1,607 21.9 0.6 111 22.3 2.2 1,592 22.2 0.6 123 19.2 2.0
 4th Quartile 1,878 24.2 0.5 449 38.5 1.8 2,115 25.1 0.6 216 43.3 3.0 2,033 24.7 0.5 281 43.7 2.6
Dementia or Alzheimer’s <0.001 <0.001 <0.001
 Probable 650 6.5 0.3 283 21.8 1.6 736 7.2 0.3 188 32.1 2.5 703 6.8 0.3 206 29.1 2.4
 Possible 632 7.7 0.3 138 11.4 1.1 682 7.8 0.3 93 17.8 1.8 680 7.8 0.3 86 12.8 1.2
 No dementia 5,176 85.8 0.4 618 66.8 1.8 5,619 85.0 0.4 197 50.2 2.8 5,494 85.4 0.4 309 58.0 2.1
IADL impairment, present 1,438 17.6 0.5 485 41.2 2.1 <0.001 1,595 18.3 0.5 327 66.4 3.3 <0.001 1,501 17.7 0.5 394 59.7 2.7 <0.001
ADL impairment, present 1,062 12.8 0.5 393 31.8 1.7 <0.001 1,204 13.5 0.4 248 48.4 2.7 <0.001 1,118 12.9 0.5 308 44.3 2.8 <0.001
Depression symptoms, present 777 10.7 0.4 254 25.6 1.5 <0.001 888 11.6 0.5 143 31.6 3.2 <0.001 843 11.2 0.4 182 31.3 2.6 <0.001
Environment
Entrance stairs, present 4,849 76.4 0.9 731 72.5 1.8 0.024 5,283 76.5 0.9 307 65.7 2.3 <0.001 5,192 76.7 0.9 386 65.9 2.3 <0.001
Entrance ramp, present 670 9.0 0.5 171 14.3 1.1 <0.001 745 9.3 0.5 96 17.5 2.1 <0.001 718 9.2 0.5 116 15.9 1.9 <0.001
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Note. SE = standard error; IADL = instrumental activities of daily living; ADL = activities of daily living. Prevalence estimates are based on population-weighted data.

a

P values determined by Rao-Scott F adjusted chi-square statistic for categorical variables or F-test statistic for continuous variables.

Table 2.

Health Care Services Assistance by the Presence of Hearing or Vision Loss Grouping, Stratified by Age Group.

Hearing Loss Near Vision Loss Distance Vision Loss
Absent Present P value a Absent Present P value a Absent Present P value a
N % or mean SE N % or mean SE N % or mean SE N % or mean SE N % or mean SE N % or mean SE
Health Care Services Assistance, Age 65–74
Drove self to appointment, yes 1,888 84.3 0.9 157 71.3 3.5 <0.001 2,018 84.4 0.9 30 36.1 5.9 <0.001 1,996 84.7 0.9 51 45.4 5.6 <0.001
Others drove to appointment, yes 478 17.3 0.9 68 29.7 3.3 <0.001 496 17.4 0.8 53 55.9 6.3 <0.001 477 16.8 0.8 68 55.3 5.4 <0.001
Attended doctor appointment with others, yes 616 24.5 1.2 97 46.3 3.3 <0.001 665 25.6 1.1 52 58.9 6.9 <0.001 651 25.3 1.2 62 53.6 6.3 <0.001
Others helped prepare for doctor exam, yes 82 12.5 1.5 20 22.5 4.0 0.005 90 13.0 1.6 14 32.5 7.3 0.002 85 12.8 1.6 16 25.3 5.4 0.012
Others reminded participant during doctor visit, yes 312 49.2 2.7 68 69.7 5.5 0.004 350 51.8 2.6 34 66.4 8.0 0.113 344 52.0 2.5 39 62.6 6.8 0.151
Others asked or shared information at doctor visit, yes 292 44.8 2.3 57 60.3 5.6 0.017 317 46.3 2.3 33 59.7 7.6 0.122 306 45.2 2.3 41 65.0 7.0 0.019
Others helped understand information at doctor visit, yes 241 34.8 2.6 61 64.2 5.2 <0.001 268 37.6 2.5 35 67.1 6.9 <0.001 261 36.6 2.2 41 72.0 6.6 <0.001
Usual Source of Health Care Services, Age 75–84
Drove self to appointment, yes 1,635 70.0 0.9 182 54.6 3.0 <0.001 1,789 70.1 1.0 35 25.7 4.8 <0.001 1,770 70.7 0.9 51 30.3 4.1 <0.001
Others drove to appointment, yes 851 31.6 1.0 170 46.6 2.7 <0.001 909 31.6 1.0 114 69.1 4.1 <0.001 885 30.9 1.0 131 69.3 3.8 <0.001
Attended doctor appointment with others, yes 974 39.0 1.3 194 56.3 3.0 <0.001 1,063 39.8 1.2 104 65.2 5.1 <0.001 1,041 39.3 1.2 119 65.2 3.7 <0.001
Others helped prepare for doctor exam, yes 147 15.1 1.2 47 22.2 3.8 0.054 163 15.0 1.3 29 32.0 6.7 0.004 162 15.1 1.1 30 26.4 4.9 0.007
Others reminded participant during doctor visit, yes 536 55.3 1.9 120 64.1 3.9 0.076 587 56.1 1.6 69 65.9 5.6 0.103 582 56.0 1.6 70 63.2 4.4 0.127
Others asked or shared information at doctor visit, yes 540 53.2 1.8 132 67.7 3.9 0.002 589 53.9 1.8 82 79.0 4.6 <0.001 578 53.7 1.8 87 73.3 4.9 0.002
Others helped understand information at doctor visit, yes 509 49.7 1.8 139 71.1 3.7 <0.001 563 51.4 1.8 83 76.8 5.3 <0.001 561 51.6 1.7 79 67.1 5.1 0.005
Usual Source of Health Care Services, Age 85+
Drove self to appointment, yes 520 45.7 1.7 99 25.8 1.9 <0.001 608 45.2 1.5 14 6.0 1.9 <0.001 604 48.2 1.6 16 5.6 1.6 <0.001
Others drove to appointment, yes 703 54.4 1.6 278 66.4 2.1 <0.001 815 54.5 1.6 163 79.6 3.1 <0.001 745 52.7 1.6 219 79.6 2.5 <0.001
Attended doctor appointment with others, yes 706 55.9 1.5 304 74.4 2.7 <0.001 839 57.9 1.4 167 80.7 3.2 <0.001 778 57.3 1.5 216 76.7 2.5 <0.001
Others helped prepare for doctor exam, yes 151 19.5 1.8 102 32.6 2.9 <0.001 188 21.7 1.5 62 33.4 3.4 0.002 163 20.4 1.7 81 33.5 3.2 <0.001
Others reminded participant during doctor visit, yes 430 61.3 1.7 200 68.3 2.7 0.033 525 63.9 1.7 102 62.3 4.2 0.730 485 63.3 1.7 136 64.9 3.7 0.703
Others asked or shared information at doctor visit, yes 479 66.7 2.2 236 78.0 2.4 0.001 581 69.0 1.9 128 75.3 4.0 0.178 535 68.2 1.9 165 75.6 3.2 0.051
Others helped understand information at doctor visit, yes 471 66.0 2.1 254 85.8 1.8 <0.001 584 70.2 1.8 132 79.7 3.1 0.017 539 69.4 1.9 169 79.7 2.5 0.001
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Note. SE = standard error. Prevalence estimates are based on population-weighted data.

a

P values determined by Rao-Scott F adjusted chi-square statistic for categorical variables.

Multivariate Analyses

In the unadjusted logistic regression analysis, hearing loss (odds ratio, OR=0.96, 95% confidence interval, CI: 0.67–1.38) and distance vision loss (OR=1.23, 95% CI: 0.80–1.88) did not have an association with having a usual source of health care, while near vision loss was associated with decreased odds of having a usual source of health care (OR=0.52, 95% CI: 0.30–0.91). A similar relationship was observed in the multivariate logistic regression analysis adjusted for covariates (hearing loss: OR=0.94, 95% CI: 0.59–1.49; distance vision loss: OR=1.63, 95% CI: 0.84–3.17; and near vision loss: OR=0.46, 95% CI: 0.25–0.83). Other characteristics also were associated with decreased odds of having a usual source of health care were younger age, separated or divorced marital status, fewer close social contacts, less medical comorbidity, possible dementia, and presence of depressive symptoms (Table 3).

Table 3.

Logistic Regression Analyses Examining the Association of Hearing and Vision Loss, Demographic, Socioeconomic Status, Health Status, and Environmental Characteristics with having a Usual Source of Health Care

Unadjusted Model, N = 7,441 Adjusted Model, N = 6,463
OR 95% CIa P value OR 95% CIa P value
Sensory Loss
Hearing loss, present 0.96 0.67–1.38 0.804 0.94 0.59–1.49 0.786
Near vision loss, present 0.52 0.30–0.91 0.022 0.46 0.25–0.83 0.012
Distance vision loss, present 1.23 0.80–1.88 0.348 1.63 0.84–3.17 0.145
Demographics
Age in years (ref=65–74)
 75–84 1.35 0.99–1.83 0.057
 85+ 1.66 1.15–2.38 0.007
Sex, Female 1.04 0.76–1.43 0.798
Race and ethnicity (ref=White, non-Hispanic)
 Black, non-Hispanic 0.69 0.47–1.01 0.054
 Hispanic or Other 1.44 0.90–2.30 0.123
Marital Status (ref=married or living with a partner)
 Separated or divorced 0.65 0.45–0.95 0.026
 Widowed or never married 0.77 0.55–1.09 0.141
Number of close social contacts 1.15 1.00–1.31 0.046
Socioeconomic Status
Education (ref=college degree)
 High school degree or equivalent or less 0.80 0.56–1.15 0.228
 Some college or vocational training 0.81 0.54–1.20 0.287
Medicaid, present 0.97 0.65–1.45 0.875
Health Status
Medical comorbidity quartile (ref=1st quartile)
 2nd Quartile 2.94 1.96–4.41 <0.001
 3rd Quartile 4.11 2.72–6.23 <0.001
 4th Quartile 5.12 3.19–8.20 <0.001
Dementia or Alzheimer’s (ref=no dementia)
 Probable 0.99 0.54–1.82 0.977
 Possible 0.56 0.37–0.83 0.005
IADL impairment, present 0.80 0.51–1.24 0.307
ADL impairment, present 1.21 0.73–2.02 0.449
Depression symptoms, present 0.56 0.37–0.86 0.008
Environment
Entrance stairs, present 1.11 0.77–1.60 0.562
Entrance ramp, present 0.86 0.53–1.41 0.542
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Note. Unadjusted model includes both hearing and vision loss concurrently; proxy respondents are excluded in the adjusted model. SAS survey procedures accounted for sampling design and nonresponse to calculate population-weighted adjusted estimates.

a

Intervals based on 95% Wald confidence limits.

Discussion

Approximately 1 in 10 the cohort of 7,548 Medicare beneficiaries reported hearing loss and about 1 in 20 reported near and distance vision loss. Consistent with concerns that vision loss may increase difficulties in accessing health care services (Cupples et al., 2012), and in partial support of our hypothesis, near vision (but not hearing or distance vision) loss was associated with decreased odds of having a usual source of health care. More specifically, older adults who were unable to see well enough to read newspaper print (even with visual aids), had 54% decreased odds for having a usual source of health care, even after accounting for potentially confounding demographic, socioeconomic status, health status, and environmental factors. Our findings suggest that the type of vision loss matters because distance vision loss (unable to recognize someone across the street) was not associated with decreased odds of having a usual source of health care. That hearing loss had no association with having a usual source of health care is congruent with findings that the use of non-mental health medical services did not vary by hearing loss status among a Finnish cohort of older adults (Mikkola et al., 2016).

In support of our second hypothesis (i.e., that older adults with sensory loss relied more on others to access their usual source of health care), compared to those without sensory loss, older adults with either auditory or visual sensory loss were much more likely to have others drive them to their doctor appointments and receive assistance from others during the visit. Perhaps unsurprisingly, those with near vision loss (67.8%) and distance vision loss (67.5%) relied even more heavily on others to drive them to the appointment than those with hearing loss (44.9%). People with near vision loss also were more likely to have others join them at the appointment compared to those with hearing loss (67.9% versus 57.0%). These findings suggest that the support of others in accessing a usual health care provider is important for both hearing and vision loss, but especially so for those with vision loss. Additionally, transportation issues (e.g., ability to drive or public transportation accessibility) may be important environmental factors to consider that could affect the ability of a person with sensory loss to access health care.

In addition to vision loss, other characteristics were associated with not having a usual source of health care such as having fewer close social contacts and depressive symptoms. That having fewer close social contacts was associated with a higher risk of not having a usual source of health care is pertinent to people with vision loss with our data suggesting that these people have smaller social networks and because they may be more reliant on their support networks in accessing health care services (Cupples et al., 2012). That depressive symptoms were associated with a greater risk of not having a usual source of health care is concerning in the context of hearing and vision loss because these sensory losses are associated with an increased risk for depressive symptoms (Guthrie et al., 2018; Swenor et al., 2020).

Worsening severity of auditory and visual sensory loss is associated with substantially increased medical and non-medical costs, with heavy reliance on informal caregiving (Chuvarayan, Finger, & Köberlein-Neu, 2020; Deardorff et al., 2019; Köberlein, Beifus, Schaffert, & Finger, 2013). Although there are increased costs associated with higher utilization of some medical services, evidence suggests that access to and satisfaction with healthcare services is inadequate for many with sensory impairment (Assi et al., 2020; Cabral, Muhr, & Savageau, 2013; Nolan, Mathos, Fusco, & Post, 2015; Sharts-Hopko, Smeltzer, Ott, Zimmerman, & Duffin, 2010; van der Aa et al., 2015). To help address issues related to healthcare access and satisfaction with care among people with sensory impairment, there are a variety of approaches that medical offices could implement to better serve their patients with sensory loss. These approaches include training staff on the prevalence and impact of sensory loss, systematically flagging patients’ medical records to help identify sensory loss and alert staff and providers, environmental modifications (e.g., improved signage and lighted walkways), improved use of sensory assistive devices (e.g., hearing aids), using larger font on paperwork provided to the patients, and community outreach (Miller et al., 2017; Pratt, 2018). Although many approaches have been suggested, research on organizational approaches to improve access to primary care services among vulnerable populations is limited and empirical evidence is lacking (Khanassov et al., 2016). An additional challenge to addressing sensory loss is that doing so can be expensive, especially since most insurance programs do not cover hearing aids and vision care (e.g., to pay for glasses) often requires supplemental insurance in the United States (Goman & Lin, 2018).

Study Strengths and Limitations

Notable strengths of our study include the examination of a nationally representative population of older Medicare beneficiaries, concurrent examination of three different groupings of sensory impairment, and accounting for many characteristics spanning demographic, socioeconomic status, and health status domains. Our study also has several limitations. First, reliance on the term “doctor” in identifying a usual source of health care is a narrow descriptor that excludes other primary care providers such as nurse practitioners and physician assistants. Second, the identification of having a usual source of health care was based on participant self-report and not determined by examination of medical records, which could introduce error into the analyses. An examination of the NHATS dataset, however, found that older adults were able to accurately report the use of medical services (rehabilitation use) over the past year (Freedman, Kasper, & Jette, 2018). Third, we did not examine the participants’ use of specialist medical services (e.g., perhaps some participants had a team of specialists that deliver “usual care” while lacking a single usual care provider?). Fourth, these analyses were based on cross-sectional data, which makes examining causal relationships difficult. Fifth, our determination of hearing and vision loss was based on self-reported sensory functional measures rather than objective auditory and visual examinations, which therefore represents the prevalence of self-reported sensory loss rather than the prevalence of objective hearing or vision loss. Although older adults typically under-report sensory loss, another concern is that people with moderate or good sensory function may report sensory loss (Zimdars, Nazroo, & Gjonça, 2012). We suspect that these misclassification errors could weaken the association between sensory loss and usual care providers in our analyses and bias our findings toward the null hypothesis. Possible options to address this issue could be to use medical diagnoses of sensory loss or objective sensory assessments. However, as screening for sensory loss is highly variable and incomplete (National Center for Health Statistics, 1997), we would recommend that future studies consider relying on objective sensory assessments to reduce issues related to misclassification error. Sixth, our study had potential power limitations. For instance, we did not have sufficient power to examine those with more severe sensory loss (e.g., only 91 were unable to hear well enough to carry on a conversation in a quiet room) or to examine people with dual sensory loss. We believe this is a topic worthy of future investigation as people with dual sensory loss may have more barriers to accessing healthcare services than those with single or no sensory loss. Lastly, our study did not account for the use of American Sign Language (10 participants identified as being Deaf) and only partially considered possible compensatory strategies that older adults with sensory loss may rely upon to access healthcare services and are issues that could be more rigorously examined.

Conclusion

Auditory and visual sensory loss are common among older adults. Our finding that those with near vision loss were less likely to report having a usual source of health care is concerning because having a regular care provider is associated with better health care quality, improved patient satisfaction, and reduced costs (Friedberg et al., 2010). It is unclear what factors were contributing to this reported lack of a usual source of health care (e.g., perhaps text-based outpatient communications and information are ineffective for older adults with near vision loss?). We also found that older adults with any sensory loss were more likely to rely on others to help them travel to doctor appointments and to assist them during these appointments, which suggests that the presence of a caregiver and informal support networks may be especially important to older adults with sensory loss. Future efforts examining potential barriers such as medical office accessibility, including issues with transportation, handicap accessibility, and communication (e.g., are accommodations made for patients who are unable to read?), may identify sensory loss-relevant processes to optimize and intervene upon.

Supplementary Material

Supplemental Figures 1 and 2

Acknowledgments:

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: The National Health and Aging Trends Study (NHATS) dataset is publicly available at www.nhats.org and was funded by the National Institute on Aging [grant number U01AG032947] through a cooperative agreement with the Johns Hopkins Bloomberg School of Public Health. Additionally, AS was supported by the National Institute on Aging [grant number K23AG058757]. The funders had no role in our article’s design, data analysis, decision to publish, or manuscript preparation. Lastly, the authors would like to thank the reviewers for their thoughtful comments, which improved this manuscript.

Footnotes

Declaration of Conflicting Interests: YL serves as an editor for Springer and a consultant for BCG Inc. and Intermountain Healthcare. The authors otherwise declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

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Supplementary Materials

Supplemental Figures 1 and 2
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