This cross-sectional study uses data from the National Health and Nutrition Examination Survey to examine the associations of hearing loss severity and hearing aid use with hospitalization among US adults aged 65 years or older.
Key Points
Question
Is hearing loss severity associated with hospitalization among individuals aged 65 years or older, and is hearing aid use associated with fewer hospitalizations among patients with hearing loss?
Findings
In this cross-sectional study of data for 2060 US adults aged 65 years or older from the National Health and Nutrition Examination Survey, moderate and severe hearing loss were associated with hospitalization. Hearing aid use was not associated with hospitalization among patients with hearing loss, even among those with at least moderate hearing loss.
Meaning
The findings suggest that hearing loss severity is associated with increased risk of hospitalization among older adults and that hearing aids are not associated with mitigating this risk.
Abstract
Importance
Hearing loss is associated with higher hospitalization risk among older adults. However, evidence on whether hearing aid use is associated with fewer hospitalizations among individuals with hearing loss remains limited.
Objective
To assess the association between audiometric hearing loss severity and hearing aid use and hospitalization.
Design, Setting, and Participants
This population-based cross-sectional study used audiometric and health care utilization data for respondents aged 65 years or older from 4 cycles of the National Health and Nutrition Examination Survey from 2005 to 2016. Data were analyzed from February 23, 2021, to March 22, 2022.
Exposures
Audiometric hearing loss severity and participant-reported hearing aid use.
Main Outcomes and Measures
The main outcome was respondent-reported hospitalization in the past 12 months. Multivariable logistic regression was performed to assess the association of hearing loss severity with hospitalization. To assess the association of hearing aid use with hospitalization, propensity score matching was performed with 2:1 nearest neighbor matching without replacement.
Results
Of 2060 respondents (mean [SD] age, 73.9 [5.9] years; 1045 [50.7%] male), 875 (42.5%) had normal hearing, 653 (31.7%) had mild hearing loss, 435 (21.1%) had moderate hearing loss, and 97 (4.7%) had severe to profound hearing loss. On multivariable analysis, moderate and severe hearing loss were associated with hospitalization (moderate hearing loss: odds ratio [OR], 1.50; 95% CI, 1.01-2.24; severe hearing loss: OR, 1.71; 95% CI, 1.03-2.84). Of 1185 respondents with at least mild hearing loss, 200 (16.9%) reported using a hearing aid. Propensity score–matched analysis showed that hearing aid use was not associated with hospitalization (OR, 1.17; 95% CI, 0.74-1.84), including among respondents with moderate or severe hearing loss (OR, 1.17; 95% CI, 0.71-1.92).
Conclusions and Relevance
In this cross-sectional study, hearing loss was associated with higher risk of hospitalization, but hearing aid use was not associated with a reduction in hospitalization risk in the population with hearing loss. The association of hearing aid use with hospitalization should be evaluated in larger prospective studies with reliable data on the frequency of hearing aid use.
Introduction
Hearing loss affects more than two-thirds of individuals older than 70 years in the US,1,2 and the number of patients with hearing loss is expected to increase to 73.5 million by 2060.3 Hearing loss is associated with poor health outcomes, including cognitive deficits,4,5,6 reduced social engagement, impaired mental health,7,8 and decreased ability to perform activities of daily living.9 Of importance, studies10,11,12,13,14,15,16 have reported associations of hearing loss with negative health care utilization outcomes, including increased emergency department visits and hospitalizations, higher health care costs, and difficulty accessing health care. Given these associations, researchers and policy experts have shown increasing interest in identifying interventions that could ameliorate poor health care utilization outcomes among patients with hearing loss.
Hearing aids represent the first-line treatment for sensorineural hearing loss and have been shown in randomized clinical trials17,18,19 to reduce hearing disability. However, the association of hearing aid use with other factors, such as physical health, mental health, and cognition, remains controversial.20,21,22 Of note, the effect of hearing aid use on health care utilization has not been well studied. Two large studies8,23 assessed the association of hearing aid use with hospitalization among individuals with subjectively reported hearing loss and came to conflicting conclusions. To our knowledge, the association of hearing aid use with hospitalization has not been evaluated among patients with audiometrically confirmed hearing loss. Such an evaluation would have important implications for policy makers and physicians. Despite passage of the Over-the-Counter Hearing Aid Act of 2017, difficulty in accessing hearing aids and hearing health care persists, and only some individuals who could potentially benefit from hearing aid use have reported having or using a hearing aid.24,25,26,27,28
In this study, we aimed to evaluate the association of audiometrically measured hearing loss and self-reported hearing aid use with all-cause hospitalization in a large representative sample of adults aged 65 years or older in the US. We hypothesized that hearing loss would be associated with increased risk of hospitalization and that hearing aid use would be associated with decreased risk of hospitalization among patients with hearing loss.
Methods
Data
The National Health and Nutrition Examination Survey (NHANES) was approved by the institutional review board of the National Center for Health Statistics. This cross-sectional study was deemed exempt from review by the Stanford University School of Medicine institutional review board and did not require informed consent because it was conducted using publicly available, deidentified data. This study followed the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) reporting guideline. Data were extracted from NHANES, which contains demographic, health care utilization, and audiometric data for a representative sample of the noninstitutionalized civilian population in the US. Organized by the National Center for Health Statistics, NHANES is administered via computer-assisted personal interviewing completed by a team of physicians, medical technicians, and health interviewers. Data were pooled from the 4 most recent NHANES cycles with audiometric data for older adults (2005-2006, 2009-2010, 2011-2012, and 2015-2016) and were weighted according to guidelines provided in NHANES documentation.29 Given our interest in the older adult population, we limited analyses to individuals aged 65 years or older.
Hearing loss severity, determined by pure tone audiometry, and hearing aid use were the primary exposures of interest. In accordance with World Health Organization guidelines, pure tone average (PTA) was calculated as the average threshold in decibels at 500, 1000, 2000, and 4000 Hz. Hearing loss severity was determined by the unaided PTA in the better-hearing ear and categorized as normal hearing (PTA, <25 dB), mild hearing loss (PTA, ≥25 dB to <40 dB), moderate hearing loss (PTA≥40 dB to <60 dB), and severe to profound hearing loss (PTA≥60 dB).
For survey cycles starting in 2011, hearing aid use was queried by the following question: “In the past 12 months, how often have you worn a hearing aid?” Responses included “don’t know,” “never,” “seldom,” “about half the time,” and “usually.” Individuals wearing hearing aids at least seldomly were categorized as hearing aid users, and those responding as never wearing a hearing aid were categorized as non–hearing aid users. For survey cycles before 2011, hearing aid use was queried by the following question: “In the past 12 months, have you worn a hearing aid at least 5 hours a week?” Individuals responding “yes” were considered hearing aid users, and those responding “no” were considered non–hearing aid users. All other respondents were excluded from hearing aid analyses.
In terms of covariates, age and federal income poverty ratio were reported as continuous variables. In the 2005-2006 NHANES cycle, individuals aged 85 years or older were reported as 85 years of age. In all other NHANES cycles, individuals aged 80 years or older were reported as 80 years of age. NHANES reports any income poverty ratio of 5 or greater as 5. Race and ethnicity were recorded in NHANES as Hispanic (including Mexican American and other Hispanic), non-Hispanic Black, non-Hispanic White, or other race and ethnicity. Inclusion of race and ethnicity was considered important because they have been shown to be significantly associated with overall health outcomes and hearing health care use.14,30 Level of education was stratified as less than high school education, high school graduate or General Educational Development test or equivalent, or more than high school education. Marital status was recorded as married, widowed, divorced or separated, or never married or living with partner. The presence of the following reported comorbidities at any point in the respondent’s lifetime was also recorded: overweight, myocardial infarction, coronary heart disease, congestive heart failure, stroke, non–skin cancer, and diabetes. The main outcome of interest was self-reported hospitalization, assessed by the following question: “During the past 12 months, were you a patient in a hospital overnight? Do not include an overnight stay in the emergency room.” Respondents’ answers were “yes” or “no.”
Statistical Analysis
All analyses were performed using R, version 4.0.0 (R Project for Statistical Computing). Data were analyzed from February 23, 2021, to March 22, 2022. Descriptive statistics were applied to report characteristics of the study cohort by hearing status and hearing aid use. Mean (SD) values are reported for continuous variables, and the number and percentage of total respondents are reported for categorical variables. The χ2 test of independence and 1-way analysis of variance were used to compare categorical and continuous variables, respectively. All analyses incorporated survey weights supplied by the National Center for Health Statistics to account for sampling bias.
To assess the association between hearing loss severity and hospitalization, adjusted and unadjusted logistic regression models were used. For multivariable analysis, the following variables were entered a priori into the model: age, sex, race and ethnicity, level of education, marital status, income poverty ratio, overweight status, and history of myocardial infarction, coronary heart disease, congestive heart failure, stroke, non–skin cancer, and diabetes or high blood glucose level. Respondents with missing exposure, outcome, or covariate data were excluded.
Among individuals with hearing loss, the association between hearing aid use and hospitalization was analyzed using unadjusted and propensity score–matched logistic regression models. For the propensity score analysis, logistic regression was used to generate propensity scores by building a model estimating hearing aid use with the following variables: age, sex, race and ethnicity, level of education, marital status, income poverty ratio, hearing loss severity, overweight status, and history of myocardial infarction, coronary heart disease, congestive heart failure, stroke, non–skin cancer, and diabetes or high blood glucose level. A matching algorithm, consisting of 2:1 matching with 0.2-caliper distance and nearest neighbor matching without replacement, was used to create matched cohorts of hearing aid users and non–hearing aid users. The standardized mean difference was calculated for all included variables to assess for balance between the matched cohorts of hearing aid users and non–hearing aid users. The matched cohorts were then analyzed using unadjusted logistic regression.
Results
Participants
In the NHANES cycles included in the study, there were 14 479 respondents, of whom 2642 were aged 65 years or older. After removing individuals lacking exposure and covariate data, the cohort consisted of 2060 respondents; demographic and clinical data are shown in Table 1. The mean (SD) age was 73.9 (5.9) years; 1015 respondents (49.3%) were female, and 1045 (50.7%) were male. Most respondents were non-Hispanic White (1263 [61.3%]); 441 (21.4%) were Hispanic or other race and ethnicity (combined because sample sizes were small), and 356 (17.3%) were non-Hispanic Black. Most respondents reported more than a high school–level education (888 [43.1%]) and were married (1133 [55.0%]). In terms of hearing status, 875 respondents (42.5%) had normal hearing, 653 (31.7%) had mild hearing loss, 435 (21.1%) had moderate hearing loss, and 97 (4.7%) had severe hearing loss. Respondents with severe hearing loss were more likely to be older and male and to have a lower level of education. They were also more likely to report comorbid myocardial infarction and cancer.
Table 1. Demographics of Respondents by Normal Hearing and Hearing Loss Severity.
| Variable | Respondentsa | ||||
|---|---|---|---|---|---|
| Total | Normal hearing | Hearing loss | |||
| Mild | Moderate | Severe | |||
| Unweighted sample | 2060 | 875 (42.5) | 653 (31.7) | 435 (21.1) | 97 (4.7) |
| Age, mean (SD), y | 73.9 (5.9) | 71.1 (5.2) | 74.7 (5.4) | 77.1 (5.3) | 78.1 (4.9) |
| Sex | |||||
| Female | 1015 (49.3) | 501 (57.3) | 320 (49.0) | 162 (37.2) | 32 (33.0) |
| Male | 1045 (50.7) | 374 (42.7) | 333 (51.0) | 273 (62.8) | 65 (67.0) |
| Race and ethnicity | |||||
| Hispanic or otherb | 441 (21.4) | 226 (25.9) | 129 (19.7) | 71 (16.3) | 15 (15.4) |
| Non-Hispanic | |||||
| Black | 356 (17.3) | 219 (25.0) | 93 (14.2) | 37 (8.5) | 7 (7.2) |
| White | 1263 (61.3) | 430 (49.1) | 431 (66.0) | 327 (75.1) | 75 (77.3) |
| Educational level | |||||
| Less than high school | 687 (33.3) | 247 (28.2) | 228 (34.9) | 163 (37.5) | 49 (50.5) |
| High school graduate or GED | 485 (23.5) | 190 (21.7) | 176 (27.0) | 97 (22.3) | 22 (22.7) |
| More than high school | 888 (43.1) | 438 (50.1) | 249 (38.1) | 175 (40.2) | 26 (26.8) |
| Marriage status | |||||
| Married | 1133 (55.0) | 491 (56.1) | 363 (55.6) | 234 (53.8) | 45 (46.4) |
| Widowed | 562 (27.3) | 193 (22.1) | 185 (28.3) | 149 (34.3) | 35 (36.1) |
| Divorced or separated | 252 (12.2) | 126 (14.4) | 81 (12.4) | 36 (8.3) | 9 (9.3) |
| Never married or living with partner | 114 (5.5) | 65 (7.4) | 24 (3.7) | 16 (3.7) | 8 (8.2) |
| Income poverty ratio, mean (SD)c | 2.5 (1.5) | 2.6 (1.5) | 2.4 (1.5) | 2.4 (1.4) | 2.2 (1.3) |
| Comorbidities | |||||
| Overweight | 715 (34.7) | 313 (35.8) | 228 (34.9) | 147 (33.8) | 27 (27.8) |
| Congestive heart failure | 152 (7.4) | 43 (4.9) | 64 (9.8) | 34 (7.8) | 11 (11.3) |
| Coronary heart disease | 234 (11.4) | 87 (9.9) | 78 (11.9) | 56 (12.9) | 13 (13.4) |
| Myocardial infarction | 206 (10.0) | 58 (6.6) | 72 (11.0) | 59 (13.6) | 17 (17.5) |
| Stroke | 188 (9.1) | 60 (6.9) | 65 (610.0) | 50 (11.5) | 13 (13.4) |
| Non–skin cancer | 524 (25.4) | 196 (22.4) | 154 (23.6) | 138 (31.7) | 36 (37.1) |
| Diabetes | 442 (21.5) | 186 (21.3) | 151 (23.1) | 88 (20.2) | 17 (17.5) |
Abbreviation: GED, General Educational Development.
Data are presented as number (percentage) of respondents unless otherwise indicated.
Indicated as “other” race and ethnicity on the National Health and Nutrition Examination Survey. Hispanic and other race and ethnicity were combined because sample sizes were small.
Ratio is to the federal poverty level.
Association Between Hearing Loss Severity and Hospitalization
On unadjusted analysis, moderate hearing loss and severe hearing loss were significantly associated with hospitalization compared with normal hearing (moderate hearing loss: odds ratio [OR], 1.80 [95% CI, 1.28-2.55]; severe hearing loss: OR, 2.16 [95% CI, 1.40-3.31]) (Table 2). On multivariable analysis, moderate hearing loss and severe hearing loss were associated with hospitalization compared with normal hearing (moderate hearing loss: OR, 1.50 [95% CI, 1.01-2.24]; severe hearing loss: OR, 1.71 [95% CI, 1.03-2.84]). Mild hearing loss was not associated with hospitalization on either unadjusted or adjusted analysis.
Table 2. Association Between Hearing Status and Hospitalization.
| Variable | Odds ratio (95% CI) |
|---|---|
| Unadjusted model | |
| Hearing status | |
| Normal hearing | 1 [Reference] |
| Hearing loss | |
| Mild | 1.41 (0.99-2.00) |
| Moderate | 1.80 (1.28-2.55) |
| Severe | 2.16 (1.40-3.31) |
| Adjusted model | |
| Hearing status | |
| Normal hearing | 1 [Reference] |
| Hearing loss | |
| Mild | 1.24 (0.84-1.83) |
| Moderate | 1.50 (1.01-2.24) |
| Severe | 1.71 (1.03-2.84) |
| Age | 1.03 (1.00-1.06) |
| Sex | |
| Female | 1.14 (0.78-1.68) |
| Male | 1 [Reference] |
| Race and ethnicity | |
| Hispanic or othera | 1.32 (0.87-2.01) |
| Non-Hispanic | |
| Black | 1.08 (0.73-1.59) |
| White | 1 [Reference] |
| Educational level | |
| Less than high school | 1 [Reference] |
| High school graduate or GED | 1.08 (0.74-1.58) |
| More than high school | 0.98 (0.63-1.51) |
| Marriage status | |
| Married | 1 [Reference] |
| Widowed | 0.87 (0.58-1.30) |
| Divorced or separated | 1.84 (1.15-2.94) |
| Never married or living with partner | 1.07 (0.49-2.35) |
| Income poverty ratio | 0.99 (0.88-1.12) |
| Comorbidities | |
| Overweight | 1.21 (0.92-1.60) |
| Myocardial infarction | 1.45 (1.03-2.05) |
| Coronary heart disease | 1.68 (1.05-2.71) |
| Congestive heart failure | 1.54 (0.94-2.51) |
| Stroke | 1.99 (1.26-3.14) |
| Non–skin cancer | 1.33 (0.97-1.83) |
| Diabetes | 1.09 (0.80-1.49) |
Abbreviation: GED, General Educational Development.
Indicated as “other” race and ethnicity on the National Health and Nutrition Examination Survey. Hispanic and other race and ethnicity were combined because sample sizes were small.
Association of Hearing Aid Use With Hospitalization
After excluding patients with normal hearing and those with missing data on hearing aid use, the study cohort included 1185 respondents with hearing loss, of whom 200 (16.9%) reported current hearing aid use. Compared with the group of non–hearing aid users (n = 985), the group of hearing aid users had a higher mean (SD) age (77.0 [5.5] years vs 75.6 [5.5] years) and a higher percentage of male respondents (67.0% [134] vs 54.5% [537]) (Table 3). Compared with non–hearing aid users, a higher percentage of hearing aid users had moderate (60.0% [120] vs 32.0% [315]) or severe (31.0% [62] vs 3.6% [35]) hearing loss. Propensity score matching yielded well-balanced cohorts of hearing aid users and non–hearing aid users (Table 3).
Table 3. Demographics by Hearing Aid Use.
| Variable | Unmatcheda | SMD | Matcheda | SMD | ||
|---|---|---|---|---|---|---|
| Non–hearing aid users | Hearing aid users | Non–hearing aid users | Hearing aid users | |||
| Respondents, No.b | 985 | 200 | NA | 262 | 159 | NA |
| Age, mean (SD), y | 75.6 (5.5) | 77.0 (5.5) | 0.24 | 76.9 (5.2) | 77.2 (5.5) | 0.04 |
| Sex | ||||||
| Female | 448 (45.5) | 66 (33.0) | −0.26 | 97 (37.0) | 56 (35.2) | −0.007 |
| Male | 537 (54.5) | 134 (67.0) | 0.26 | 165 (63.0) | 103 (64.8) | 0.007 |
| Race and ethnicity | ||||||
| Hispanic or otherc | 194 (19.7) | 21 (10.5) | −0.27 | 30 (11.5) | 19 (11.9) | 0.03 |
| Non-Hispanic | ||||||
| Black | 124 (12.6) | 13 (6.5) | −0.25 | 19 (7.3) | 11 (6.9) | <0.001 |
| White | 667 (67.7) | 166 (83.0) | 0.44 | 213 (81.3) | 129 (81.1) | −0.05 |
| Educational level | ||||||
| Less than high school | 382 (38.8) | 58 (29.0) | −0.22 | 76 (29.0) | 47 (29.6) | 0.01 |
| High school graduate or GED | 252 (25.6) | 43 (21.5) | −0.10 | 64 (24.4) | 36 (22.6) | −0.008 |
| More than high school | 351 (35.6) | 99 (49.5) | 0.28 | 122 (46.6) | 76 (47.8) | 0.006 |
| Marriage status | ||||||
| Married | 529 (53.7) | 113 (56.5) | 0.05 | 154 (58.8) | 90 (56.6) | −0.06 |
| Widowed | 302 (30.7) | 67 (33.5) | 0.06 | 88 (33.6) | 53 (33.3) | −0.007 |
| Divorced or separated | 119 (12.1) | 7 (3.5) | −0.47 | 11 (4.2) | 6 (3.8) | <0.001 |
| Never married or living with partner | 35 (3.5) | 13 (6.5) | 0.11 | 9 (3.4) | 10 (6.3) | 0.09 |
| Income poverty ratio, mean (SD)d | 2.3 (1.4) | 2.8 (1.4) | 0.36 | 2.6 (1.5) | 2.8 (1.4) | 0.04 |
| Comorbidities | ||||||
| Overweight | 339 (34.4) | 63 (31.5) | −0.06 | 85 (32.4) | 49 (30.8) | −0.01 |
| Congestive heart failure | 87 (8.8) | 22 (11.0) | 0.07 | 27 (10.3) | 19 (11.9) | 0.02 |
| Coronary heart disease | 117 (11.9) | 30 (15.0) | 0.09 | 38 (14.5) | 26 (16.4) | 0.05 |
| Myocardial infarction | 116 (11.8) | 32 (16.0) | 0.12 | 40 (15.3) | 26 (16.4) | 0.02 |
| Stroke | 103 (10.5) | 25 (12.5) | 0.06 | 32 (12.2) | 20 (12.6) | 0.009 |
| Non–skin cancer | 257 (26.1) | 71 (35.5) | 0.20 | 79 (30.2) | 56 (35.2) | 0.07 |
| Diabetes | 225 (22.8) | 31 (15.5) | −0.21 | 49 (18.7) | 28 (17.6) | −0.009 |
| Hearing loss severity | ||||||
| Mild | 615 (64.5) | 18 (9.0) | −1.91 | 39 (14.9) | 18 (11.3) | −0.03 |
| Moderate | 315 (32.0) | 120 (60.0) | 0.57 | 192 (73.3) | 114 (71.7) | 0.02 |
| Severe | 35 (3.6) | 62 (31.0) | 0.59 | 31 (11.8) | 27 (17.0) | <0.001 |
Abbreviations: GED, General Educational Development; NA, not applicable; SMD, standardized mean difference.
Data are presented as number (percentage) of respondents unless otherwise indicated. Propensity score matching was performed with 2:1 nearest neighbor matching without replacement.
Individuals with hearing loss and available data on hearing aid use.
Indicated as “other” race and ethnicity on the National Health and Nutrition Examination Survey. Hispanic and other race and ethnicity were combined because sample sizes were small.
Ratio is to federal poverty level.
In the unmatched cohorts, hearing aid use was not associated with hospitalization (OR, 1.20; 95% CI, 0.73-1.97) (Table 4). This lack of association persisted when limiting to respondents with moderate or severe hearing loss (OR, 0.91; 95% CI, 0.53-1.57). In the matched cohorts, hearing aid use was not associated with hospitalization (OR, 1.17; 95% CI, 0.74-1.84), including in the subset of patients with moderate or severe hearing loss (OR, 1.17; 95% CI, 0.71-1.92).
Table 4. Association of Hearing Aid Use With Hospitalization Among Patients With Hearing Loss.
| Cohort | Odds ratio (95% CI) |
|---|---|
| Unmatched | |
| All | 1.20 (0.73-1.97) |
| Moderate or severe hearing loss only | 0.91 (0.53-1.57) |
| Matched | |
| All | 1.17 (0.74-1.84) |
| Moderate or severe hearing loss only | 1.17 (0.71-1.92) |
For survey years starting in 2011, individuals wearing hearing aids at least seldomly were categorized as hearing aid users. An analysis was repeated with hearing aid use defined as “about half the time” and “usually.” This categorization changed the group assignment for only 3 patients and did not change the results of the analysis.
Discussion
Our study demonstrated that moderate and severe hearing loss were associated with a higher risk of hospitalization in a representative sample of older US adults. However, hearing aid use was not associated with reduced hospitalization among individuals with hearing loss, even among those with moderate or severe hearing loss.
Our finding that hearing loss was associated with increased risk of hospitalization is consistent with previous studies that defined hearing loss audiometrically. Two cross-sectional studies10,31 used data from the 2005-2006 and 2009-2010 cycles of the NHANES database. Similar to our study, these studies found that increasing hearing loss severity, defined by pure tone hearing thresholds, was associated with increased risk of hospitalization. The second of these studies, by Huddle et al,31 found that only moderate or worse hearing loss was associated with hospitalization, similar to our study. Our study adds to the results of these previous studies by including 3 additional cycles of the NHANES data set. In a study that did not use NHANES data, the prospective Health, Aging and Body Composition study,32 which analyzed 2148 Medicare beneficiaries aged 70 to 79 years, found that mild and severe hearing loss was associated with higher hospitalization risk. Similar results were also reported when defining hearing loss using diagnostic codes in large claims databases.13 In contrast, studies11,12,15 that defined hearing loss through respondent self-report using data from large private and national databases, including the Medical Expenditure Panel Survey and Medicare Current Beneficiary Survey, showed no association of hearing loss with hospitalization. This discrepancy in findings may be because of the way hearing loss was defined. Subjectively reported hearing loss severity is known to correspond to a wide range of audiometric hearing thresholds with varying accuracy based on age, gender, race and ethnicity, and educational level.33 This variability is a major limitation of studies defining hearing loss severity subjectively, whereas consistent results among studies defining hearing loss severity by audiometric examination support the association of hearing loss and hospitalization.
The current study examined the association between hearing aid use and hospitalization among individuals with audiometrically confirmed hearing loss. Despite the association between increasing hearing loss severity and risk of hospitalization, our study did not find an association between hearing aid use and hospitalization among patients with hearing loss. The lack of association between hearing aid use and hospitalization persisted when limiting the analysis to patients with at least moderate hearing loss, who were initially found to have a higher risk of hospitalization. Two studies12,23 previously examined the association between hearing aid use and hospitalization among individuals with subjective hearing loss. Wells et al12 surveyed 20 110 individuals enrolled in a Medicare supplement plan and found that for patients with subjective mild hearing loss or severe hearing loss, hearing aid use was not associated with hospitalization. In contrast, Mahmoudi et al23 analyzed 1336 patients from the Medical Expenditure Panel Survey by using inverse propensity score weighting and found that hearing aid use was associated with lower likelihood of inpatient admissions among patients with subjective hearing loss. The differences in findings from the current study are likely because of differences in methods. Our study defined hearing loss severity based on audiometric examination, whereas the 2 previous studies relied on respondent self-report. Furthermore, we included hearing loss severity in our propensity score matching algorithm because hearing aid users were more likely to have severe hearing loss. Although the study by Mahmoudi et al23 used inverse propensity score weighting, it did not account for hearing loss severity in the analysis. A separate study32 of individuals with audiometric hearing loss found no association of hearing aid use with hospitalization but included only Black and White individuals from 3 US cities and did not report frequency of hearing aid use. The current study, which used a nationally representative sample of individuals with audiometric hearing loss and propensity score matching to address allocation bias, reached the same conclusion.
There are several potential reasons for the lack of association between hearing aid use and hospitalization in this study, including infrequent hearing aid use, lack of access to hearing care services, and the inability of hearing aids to address the cause for increased hospitalization among patients with hearing loss. Our study lacked detailed data regarding frequency of hearing aid use. For survey years starting in 2011, individuals wearing hearing aids at least seldomly were categorized as hearing aid users; we also observed similar results when hearing aid use was defined as at least about half the time. However, respondents may have reported higher frequency of hearing aid use than their actual use. For the survey years before 2011, respondents were asked if they used a hearing aid at least 5 hours per week. The threshold of 5 hours per week or about half the time may be insufficient to ameliorate the risk of hospitalization. For example, hearing loss has been associated with difficulty accessing care and communicating with physicians.15,34,35 Hearing aid use for 5 hours per week or half the time may not overcome these deficits, particularly if a hearing aid is not used in a health care setting. Objective data on hearing aid use, such as device data logging, are necessary for future studies to more accurately assess an association with hospitalization. Alternatively, respondents may regularly use a hearing aid but may lack access to routine hearing health care services to optimize hearing aid settings. One study25 showed that only one-third of Medicare beneficiaries using hearing aids reported using hearing care services over the past year; low income, lower educational status, and limitations in activities of daily living were associated with increased risk of not using hearing care services. In addition, hearing loss may be associated with increased hospitalization risk through a mechanism that is inadequately addressed by hearing aid use. For example, hearing loss is associated with increased cognitive decline, decreased social engagement, and poor mental health.4,5,6,7,8 However, the association of hearing aid use with these domains is controversial, with some studies8,17,21,22 showing an association with improved function and 1 study20 showing no association.
Strengths and Limitations
A main strength of this study is the large, representative sample of older US adults and individuals with hearing loss severity defined by audiometric examination. Use of regression and propensity score matching analyses adjusting for important demographic variables and comorbidities is another strength.
Our study also has several limitations. The study was primarily limited by its cross-sectional design. Although the findings indicated an association between hearing loss and hospitalization, we could not determine causation. Of importance, we lacked data to objectively assess frequency of hearing aid use and its timing relative to hospitalization. Respondents reported hospitalization and hearing aid use within the past 12 months but may have started using hearing aids after hospitalization. Respondents may also have overestimated or overreported their frequency of hearing aid use.36,37 Moreover, NHANES lacks data regarding cause for hospitalization; therefore, this study could not assess whether the association of hearing loss and hearing aid use with hospitalization differed by type or cause of hospitalization. In addition, although we used propensity score matching to minimize systemic differences between hearing aid users and non–hearing aid users, this cross-sectional study could not eliminate bias due to unmeasured confounding factors.
Conclusions
This cross-sectional study suggests that among US adults aged 65 years or older, moderate and severe hearing loss is associated with a higher risk of hospitalization. However, hearing aid use was not associated with less frequent hospitalization among individuals with hearing loss in our study. Although our study examined frequency of hearing aid use, our data set did not include granular data on frequency of use, and it is unclear whether there is a threshold effect for frequency of hearing aid use. Consequently, larger prospective studies including reliable measures of the frequency of hearing aid use are needed to adequately assess the effectiveness of hearing aid use with reducing hospitalizations among older adults with hearing loss.
References
- 1.Lin FR, Niparko JK, Ferrucci L. Hearing loss prevalence in the United States. Arch Intern Med. 2011;171(20):1851-1852. doi: 10.1001/archinternmed.2011.506 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2.Goman AM, Lin FR. Prevalence of hearing loss by severity in the United States. Am J Public Health. 2016;106(10):1820-1822. doi: 10.2105/AJPH.2016.303299 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 3.Goman AM, Reed NS, Lin FR. Addressing estimated hearing loss in adults in 2060. JAMA Otolaryngol Head Neck Surg. 2017;143(7):733-734. doi: 10.1001/jamaoto.2016.4642 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 4.Lin FR, Yaffe K, Xia J, et al. ; Health ABC Study Group . Hearing loss and cognitive decline in older adults. JAMA Intern Med. 2013;173(4):293-299. doi: 10.1001/jamainternmed.2013.1868 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 5.Lin FR, Metter EJ, O’Brien RJ, Resnick SM, Zonderman AB, Ferrucci L. Hearing loss and incident dementia. Arch Neurol. 2011;68(2):214-220. doi: 10.1001/archneurol.2010.362 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 6.Golub JS, Luchsinger JA, Manly JJ, Stern Y, Mayeux R, Schupf N. Observed hearing loss and incident dementia in a multiethnic cohort. J Am Geriatr Soc. 2017;65(8):1691-1697. doi: 10.1111/jgs.14848 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 7.Shukla A, Cudjoe TKM, Lin FR, Reed NS. Functional hearing loss and social engagement among Medicare beneficiaries. J Gerontol B Psychol Sci Soc Sci. 2021;76(1):195-200. doi: 10.1093/geronb/gbz094 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 8.Wells TS, Nickels LD, Rush SR, et al. Characteristics and health outcomes associated with hearing loss and hearing aid use among older adults. J Aging Health. 2020;32(7-8):724-734. doi: 10.1177/0898264319848866 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 9.Carniel CZ, Sousa JCF, Silva CDD, Fortunato-Queiroz CAU, Hyppolito MÂ, Santos PLD. Implications of using the hearing aids on quality of life of elderly. Codas. 2017;29(5):e20160241. [DOI] [PubMed] [Google Scholar]
- 10.Genther DJ, Frick KD, Chen D, Betz J, Lin FR. Association of hearing loss with hospitalization and burden of disease in older adults. JAMA. 2013;309(22):2322-2324. doi: 10.1001/jama.2013.5912 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 11.Foley DM, Frick KD, Lin FR. Association between hearing loss and healthcare expenditures in older adults. J Am Geriatr Soc. 2014;62(6):1188-1189. doi: 10.1111/jgs.12864 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 12.Wells TS, Wu L, Bhattarai GR, Nickels LD, Rush SR, Yeh CS. Self-reported hearing loss in older adults is associated with higher emergency department visits and medical costs. Inquiry. 2019;56:46958019896907. doi: 10.1177/0046958019896907 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 13.Reed NS, Altan A, Deal JA, et al. Trends in health care costs and utilization associated with untreated hearing loss over 10 years. JAMA Otolaryngol Head Neck Surg. 2019;145(1):27-34. doi: 10.1001/jamaoto.2018.2875 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 14.Bainbridge KE, Ramachandran V. Hearing aid use among older U.S. adults; the National Health and Nutrition Examination Survey, 2005-2006 and 2009-2010. Ear Hear. 2014;35(3):289-294. doi: 10.1097/01.aud.0000441036.40169.29 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 15.Thai A, Megwalu UC. Association of self-reported hearing loss severity and healthcare utilization outcomes among Medicare beneficiaries. Am J Otolaryngol. 2021;42(4):102943. doi: 10.1016/j.amjoto.2021.102943 [DOI] [PubMed] [Google Scholar]
- 16.Pandhi N, Schumacher JR, Barnett S, Smith MA. Hearing loss and older adults’ perceptions of access to care. J Community Health. 2011;36(5):748-755. doi: 10.1007/s10900-011-9369-3 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 17.Mulrow CD, Aguilar C, Endicott JE, et al. Quality-of-life changes and hearing impairment: a randomized trial. Ann Intern Med. 1990;113(3):188-194. doi: 10.7326/0003-4819-113-3-188 [DOI] [PubMed] [Google Scholar]
- 18.Tolson D, Swan I, Knussen C. Hearing disability: a source of distress for older people and carers. Br J Nurs. 2002;11(15):1021-1025. doi: 10.12968/bjon.2002.11.15.10529 [DOI] [PubMed] [Google Scholar]
- 19.Yueh B, Souza PE, McDowell JA, et al. Randomized trial of amplification strategies. Arch Otolaryngol Head Neck Surg. 2001;127(10):1197-1204. doi: 10.1001/archotol.127.10.1197 [DOI] [PubMed] [Google Scholar]
- 20.Dawes P, Cruickshanks KJ, Fischer ME, Klein BEK, Klein R, Nondahl DM. Hearing-aid use and long-term health outcomes: hearing handicap, mental health, social engagement, cognitive function, physical health, and mortality. Int J Audiol. 2015;54(11):838-844. doi: 10.3109/14992027.2015.1059503 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 21.Kochkin S, Rogin C. Quantifying the obvious: the impact of hearing instruments on quality of life. Hear Rev (Auckl). 2000;7(1):6-34. [Google Scholar]
- 22.Jerger J, Chmiel R, Florin E, Pirozzolo F, Wilson N. Comparison of conventional amplification and an assistive listening device in elderly persons. Ear Hear. 1996;17(6):490-504. doi: 10.1097/00003446-199612000-00005 [DOI] [PubMed] [Google Scholar]
- 23.Mahmoudi E, Zazove P, Meade M, McKee MM. Association between hearing aid use and health care use and cost among older adults with hearing loss. JAMA Otolaryngol Head Neck Surg. 2018;144(6):498-505. doi: 10.1001/jamaoto.2018.0273 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 24.US Food and Drug Administration . FDA issues landmark proposal to improve access to hearing aid technology for millions of Americans. October 19, 2021. Accessed April 11, 2022. https://www.fda.gov/news-events/press-announcements/fda-issues-landmark-proposal-improve-access-hearing-aid-technology-millions-americans
- 25.Willink A, Reed NS, Lin FR. Access to hearing care services among older Medicare beneficiaries using hearing aids. Health Aff (Millwood). 2019;38(1):124-131. doi: 10.1377/hlthaff.2018.05217 [DOI] [PubMed] [Google Scholar]
- 26.Popelka MM, Cruickshanks KJ, Wiley TL, Tweed TS, Klein BE, Klein R. Low prevalence of hearing aid use among older adults with hearing loss: the Epidemiology of Hearing Loss Study. J Am Geriatr Soc. 1998;46(9):1075-1078. doi: 10.1111/j.1532-5415.1998.tb06643.x [DOI] [PubMed] [Google Scholar]
- 27.Smeeth L, Fletcher AE, Ng ESW, et al. Reduced hearing, ownership, and use of hearing aids in elderly people in the UK—the MRC Trial of the Assessment and Management of Older People in the Community: a cross-sectional survey. Lancet. 2002;359(9316):1466-1470. doi: 10.1016/S0140-6736(02)08433-7 [DOI] [PubMed] [Google Scholar]
- 28.Smits C, Kramer SE, Houtgast T. Speech reception thresholds in noise and self-reported hearing disability in a general adult population. Ear Hear. 2006;27(5):538-549. doi: 10.1097/01.aud.0000233917.72551.cf [DOI] [PubMed] [Google Scholar]
- 29.US Centers for Disease Control and Prevention; National Center for Health Statistics . National Health and Nutrition Examination Survey: analytic guidelines, 2011-2014 and 2015-2016. December 14, 2018. Accessed March 28, 2022. https://wwwn.cdc.gov/nchs/data/nhanes/analyticguidelines/11-16-analytic-guidelines.pdf
- 30.Nieman CL, Marrone N, Szanton SL, Thorpe RJ Jr, Lin FR. Racial/ethnic and socioeconomic disparities in hearing health care among older Americans. J Aging Health. 2016;28(1):68-94. doi: 10.1177/0898264315585505 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 31.Huddle MG, Deal JA, Swenor B, Genther DJ, Lin FR. Association between dual sensory impairment, hospitalization, and burden of disease. J Am Geriatr Soc. 2016;64(8):1735-1737. doi: 10.1111/jgs.14210 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 32.Genther DJ, Betz J, Pratt S, et al. ; Health, Aging and Body Composition Study . Association between hearing impairment and risk of hospitalization in older adults. J Am Geriatr Soc. 2015;63(6):1146-1152. doi: 10.1111/jgs.13456 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 33.Kamil RJ, Genther DJ, Lin FR. Factors associated with the accuracy of subjective assessments of hearing impairment. Ear Hear. 2015;36(1):164-167. doi: 10.1097/AUD.0000000000000075 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 34.Mick P, Foley DM, Lin FR. Hearing loss is associated with poorer ratings of patient-physician communication and healthcare quality. J Am Geriatr Soc. 2014;62(11):2207-2209. doi: 10.1111/jgs.13113 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 35.Cudmore V, Henn P, O’Tuathaigh CMP, Smith S. Age-related hearing loss and communication breakdown in the clinical setting. JAMA Otolaryngol Head Neck Surg. 2017;143(10):1054-1055. doi: 10.1001/jamaoto.2017.1248 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 36.Gaffney P. Reported hearing aid use versus datalogging within a VA population. Hear Rev (Auckl). 2008;15(6):42-47. [Google Scholar]
- 37.Laplante-Lévesque A, Nielsen C, Jensen LD, Naylor G. Patterns of hearing aid usage predict hearing aid use amount (data logged and self-reported) and overreport. J Am Acad Audiol. 2014;25(2):187-198. doi: 10.3766/jaaa.25.2.7 [DOI] [PubMed] [Google Scholar]