Primary care approach to hearing loss: the hidden disability.
We report the results of a survey designed to investigate audiologic referral patterns of primary care physicians and, more specifically, their referral of patients for hearing aids Hearing Aids Definition
A hearing aid is a device that can amplify sound waves in order to help a deaf or hard-of-hearing person hear sounds more clearly. and cochlear implants Cochlear Implants Definition
A cochlear implant is a surgical treatment for hearing loss that works like an artificial human cochlea in the inner ear, helping to send sound from the ear to the brain. . Three hundred internal medicine and family medicine physicians were identified from a referral basin of a tertiary care center tertiary care center Hospital care A hospital or medical center for Pts often referred from secondary care centers, which provides subspecialty expertise
Tertiary care center
Surgery and chosen randomly to be faxed questionnaires concerning their views about patients with hearing loss, hearing loss screening and referral practices, and availability of local resources. Of the 260 physicians who received a questionnaire, 85 (32.7%) responded. Of their communities (60% of which had populations of fewer than 50,000). 82.4% had an otolaryngologist and 40% had access to an academic center. Although 97.6% of the responding physicians indicated that hearing loss affected patients' quality off life, only 60% assessed patients for hearing loss. "Lack of time" and "more pressing issues" were the most common reasons given for not evaluating patients for hearing loss. Although 76 physicians (89.4%) said they were aware of cochlear implants, only 22 (25.9%) had referred patients for implant evaluation. Lack of referral most commonly resulted from uncertainties about "where to refer" and "which patients were potential candidates." The results of this survey suggest that a large percentage of primary care physicians do not routinely test for hearing impairment hearing impairment
A reduction or defect in the ability to perceive sound. in adults.
As the population ages, more people have chronic health problems. Approximately 12.4% of the population is 65 years or older, and the segment older than 85 years has increased the most. (1) Hearing loss is the third most common chronic condition in older adults, affecting between 25 and 40% of adults over the age of 65. (2-4) Decreased hearing has many implications for older adults. Hearing loss has been associated with physical and psychosocial psychosocial /psy·cho·so·cial/ (si?ko-so´shul) pertaining to or involving both psychic and social aspects.
Involving aspects of both social and psychological behavior. dysfunction, depression, and decreased well-being. (5-7) However, auditory auditory /au·di·to·ry/ (aw´di-tor?e)
1. aural or otic; pertaining to the ear.
2. pertaining to hearing.
adj. rehabilitation rehabilitation: see physical therapy. , with hearing aids and cochlear implants, can ameliorate a·mel·io·rate
tr. & intr.v. a·me·lio·rat·ed, a·me·lio·rat·ing, a·me·lio·rates
To make or become better; improve. See Synonyms at improve.
[Alteration of meliorate. the adverse effects of hearing impairment and increase patients' physical, social, and psychological function. (8-10)
Primary care physicians (PCPs) have a unique opportunity to identify patients with hearing loss and direct them to appropriate treatment. They treat many chronic conditions, direct each patient's health maintenance, and are usually the first physicians to learn of a new problem. Because hearing impairment may be underdiagnosed, recent work has emphasized the importance of screening and has described practical approaches for evaluating hearing loss. (11-12) By screening for hearing impairment, PePs can uncover unrecognized cases and facilitate intervention. However, evaluating multiple chronic health problems and staying current with the ongoing improvements in hearing aids and the rapidly increasing field of cochlear cochlear
pertaining to or emanating from the cochlea.
the coiled portion of the membranous labyrinth located inside the cochlea; contains endolymph.
see Table 14. implantation implantation /im·plan·ta·tion/ (im?plan-ta´shun)
1. attachment of the blastocyst to the epithelial lining of the uterus, its penetration through the epithelium, and, in humans, its embedding in the stratum compactum of the can be a difficult task. This study provides insights about the current state of hearing-loss screening among PCPs.
Materials and methods
After obtaining Institutional Review Board approval, a questionnaire was sent to PePs practicing in a tertiary care tertiary care Managed care The most specialized health care, administered to Pts with complex diseases who may require high-risk pharmacologic regimens, surgical procedures, or high-cost high-tech resources; TC is provided in 'tertiary care centers', often referral basin. Physicians were identified by community visits, lists from local hospitals, continuing medical education continuing medical education See CME. programs, telephone books, and local medical societies. This list of physicians is updated at least yearly and includes 1,581 physicians practicing internal medicine and family medicine in 43 Kentucky and Tennessee counties Tennessee County was a subdivision of the territory of North Carolina that later became the state of Tennessee.
Tennessee County was organized in 1788 from a portion of Davidson County. .
A random sample of 300 physicians was selected, and each physician was faxed a questionnaire. If no response was received in 1 month, a second questionnaire was faxed; and if still no response was received, a third questionnaire was sent. Forty physicians who did not have a working fax machine were excluded, leaving 260 physicians.
Questions concerned the physician's practice setting, medical specialty medical specialty Any specialty that provides non-interventional Pt management, ie with drugs, or with minimum intervention–eg, balloon catheterization Examples Internal medicine–allergy and immunology, cardiology, gastroenterology, hematology/oncology, , attitudes regarding hearing loss, method of evaluating patients for hearing loss, and referral of patients for hearing aids and cochlear implants. When a respondent did not answer a question, the response was noted as "no response." Questions were of the yes/no variety or allowed the respondent to choose one of the provided answers or write in a response. Data are presented in numeric numeric
see ten-key pad. form and as a percentage. SigmaStat 2.03 (SPSS A statistical package from SPSS, Inc., Chicago (www.spss.com) that runs on PCs, most mainframes and minis and is used extensively in marketing research. It provides over 50 statistical processes, including regression analysis, correlation and analysis of variance. , Inc.; Chicago) software was used to perform chi-square or Fisher Exact Test analysis for categorical data categorical data
data relating to category such as qualitative data, e.g. dog, cat, female. It may be nominal when a name is used, e.g. location, breed, or ordinal when a range of categories is used, e.g. calf, yearling, cow. .
Of the 260 questionnaires sent, 85 responses were received, producing a response rate of 32.7%. More than half of all respondents were from towns of fewer than 50,000 people, and one-fourth practiced in towns of more than 500,000 people. Of the respondents' communities, 82.4% had an otolaryngologist, 67.1% had an audiologist Audiologist
A person with a degree and/or certification in the areas of identification and measurement of hearing impairments and rehabilitation of those with hearing problems. , 40.0% had an academic center, and 12.9% had none of the above.
Among the respondents, 34 (40.0%) reported that they do not routinely evaluate their patients for hearing loss. Among internal medicine physicians, 56.1% screen for hearing loss, compared with 70.6% of family medicine physicians (p = 0.3, chi-square test chi-square test: see statistics. ). Lack of time and the presence of more important issues were the most common reasons given for not evaluating hearing loss (table 1). Of the respondents, 17.6% reported that they assess hearing loss only when a patient recognizes a hearing problem; 11.8% examine possible hearing loss at yearly physicals; and 7.8% start investigating potential hearing impairment at age 40, 5.9% at age 50, and 5.9% at age 65. Responses indicated that various methods are used by PCPs when investigating patients' hearing (table 2). A patient's reporting a change in hearing was the most common reason given for referral to an audiologist or an otolaryngologist (table 3).
Of PCPs practicing in towns with an academic center, 50% assessed patients for hearing loss, compared with 66.7% of PCPs practicing in towns without an academic center (p = 0.1, chi-square test). Similarly, with respect to evaluating hearing loss, no statistically significant associations were seen between respondents' having an audiologist or an otolaryngologist available in the community (62.2%) and their having neither an audiologist nor an otolaryngologist available (45.5%; p = 0.3, Fisher Exact Test), or between PCPs practicing in towns of more than 500,000 people (74.5%) and those practicing in towns of fewer than 500,000 people (73.5%; p = 0.9, chi-square test).
All but two respondents thought that hearing loss affected their patients' quality of life. Among respondents, 70 (82.4%) thought patients with hearing aids were more likely to be socially active, 44 (51.8%) thought patients were satisfied with their hearing aids, and 8 (9.4%) thought patients were marginally satisfied. Although two-thirds of the physicians responded that they send patients back to the audiologist if the patients are unhappy with their aids, 12.9% do not.
Seventy-six respondents (89.4%) stated that they know about cochlear implants, and 22 (25.9%) refer deaf patients for evaluation. Eight of those who refer elderly adults stated that they have no age limit at which they stop referring. Of the 9 physicians who were unaware of cochlear implants, 5 had an audiologist, an otolaryngologist, and an academic center in their community. One of the 9 had none of the above. Of the 73 respondents who do not refer patients for cochlear implant cochlear implant
An electronic device that stimulates auditory nerve fibers in the inner ear in individuals with severe or profound bilateral hearing loss, allowing them to recognize some sounds, especially speech sounds. evaluation, not knowing which patients are appropriate candidates or where to refer them were the most common reasons preventing referral (table 4). Among physicians with academic centers in their communities, 35.3% referred deaf patients to an otolaryngologist, compared with 19.6% of those without academic centers in their communities (p = 0.2, chi-square test). Of respondents with local audiologists and otolaryngologists, 27.8% referred deaf patients for evaluation, compared with 15.4% of those without an audiologist or otolaryngologist (p = 0.7, Fisher Exact Test).
As the population ages, the prevalence of hearing loss and its adverse effects on quality of life and communication will escalate es·ca·late
v. es·ca·lat·ed, es·ca·lat·ing, es·ca·lates
To increase, enlarge, or intensify: escalated the hostilities in the Persian Gulf.
v.intr. . Because hearing loss poses a significant disease burden and effective screening methods and treatment options are available, routine screening should be performed. (11) Because PCPs are already involved in health promotion, they have the potential to identify elderly patients suffering from hearing impairment. This study was undertaken to uncover PCPs' attitudes regarding hearing loss and to identify the obstacles they face when referring impaired adults for treatment. Despite the resulting dysfunction hearing loss presents, various obstacles prevented a large portion of PCPs in our study from regularly evaluating their elderly patients for hearing loss.
Although the American Academy of Family Physicians American Academy of Family Physicians,
n.pr a national medical organization established in 1947 to promote the practice of family medicine. recommends screening for hearing loss at yearly physicals, (13) 40.0% of respondents reported that they do not screen for hearing loss. Similarly, Logan et al found that 80% of physicians surveyed did not routinely screen for hearing loss in elderly patients. (14) Bess et al found that when patients do complain, only half are referred for management. (15) Thus, many potential patients with hearing impairment do not receive the benefits of auditory rehabilitation. Respondents who had local audiologists, otolaryngologists, and academic centers were no more likely to evaluate their patients for hearing loss than those without these resources. Despite having the means for auditory rehabilitation within their communities, respondents were not taking full advantage of these resources by identifying patients with impaired hearing and referring them for interventions.
Various screening methods have been developed to assist PCPs in addressing hearing loss. Lichtenstein et al validated the use of a screening questionnaire and a portable audioscope--an otoscope otoscope /oto·scope/ (o´to-skop) an instrument for inspecting or auscultating the ear.
n. with a built-in audiometer au·di·om·e·ter
An electrical instrument for measuring the threshold of hearing for pure tones of normally audible frequencies generally varying from 200 to 8000 hertz and recorded in decibels. . (16) Not only can the ear be examined with this device, but an estimate of hearing thresholds also can quickly be obtained. The American Academy The American Academy in Berlin is a non-partisan academic institution in Berlin. It was founded in September 1994 by a group of prominent Americans and Germans, among them Richard Holbrooke, Henry Kissinger, Richard von Weizsäcker, Fritz Stern and Otto Graf Lambsdorff and opened in of Otolaryngology-Head and Neck Surgery also has developed a screening questionnaire. (17) The U.S. Preventive Services the duty performed by the armed police in guarding the coast against smuggling.
See also: Preventive Task Force and other professional organizations, geriatric geriatric /ger·i·at·ric/ (jer?e-at´rik)
1. pertaining to elderly persons or to the aging process.
2. pertaining to geriatrics.
1. experts, and available literature recommend screening elderly patients with a combination of questionnaires and audiometry. (11,18) Subsequently, patients who require further evaluation of potential hearing loss can be identified and directed to treatment.
Despite all these resources, only 40% of our respondents use some type of health-directed questionnaire and audiometric au·di·om·e·ter
An instrument for measuring hearing activity for pure tones of normally audible frequencies. Also called sonometer.
au assessment (table 2). Responses showed that certain barriers prevented PCPs from inquiring inquiring,
v to draw information from a client—whether by verbal questioning or physical examination—to assess the person's state of health. about hearing loss, although knowledge of the adverse impact of hearing impairment on patients' lives was evident among respondents and most acknowledged that hearing loss affects their patients' quality of life. Respondents expressed that the practical aspects of screening patients deterred them from assessing patients' hearing. Of the respondents who do not evaluate patients for hearing loss, almost 40.0% stated that time constraints In law, time constraints are placed on certain actions and filings in the interest of speedy justice, and additionally to prevent the evasion of the ends of justice by waiting until a matter is moot. and other health issues prevented them from screening patients (table 1). Additionally, despite the availability of effective screening tools, one-fourth of respondents were not sure which method to use. To increase the frequency of primary care screening, programs explaining how to use the audioscope and discussing how to quickly identify patients requiring referral with questionnaires are still needed.
Because many patients either do not discuss their hearing loss or do not accept it, active screening is essential. A study of 2,304 hearing-impaired adults aged 50 and older found that although patients not wearing hearing aids are more likely to experience depression, anxiety, paranoia paranoia (pr'ənoi`ə), in psychology, a term denoting persistent, unalterable, systematized, logically reasoned delusions, or false beliefs, usually of persecution or grandeur. , and emotional problems compared with hearing aid users, many patients do not use hearing aids. (19) Denial about needing hearing aids, believing aids would not help, and the cost and stigma stigma: see pistil.
mark of Cain
God’s mark on Cain, a sign of his shame for fratricide. [O. T.: Genesis 4:15]
scarlet letter of wearing hearing aids prevented patients from inquiring about them. (19) Wilson et al also found that 55% of men admitted to some hearing loss, but only 12% sought help. (20) Hence, some patients suffer unnecessarily with hearing impairment until they discuss the problem. Otolaryngologists must educate PCPs about the necessity of searching for hearing loss, counseling patients about its adverse consequences, and directing them to care.
Furthermore, teaching PCPs about treatable causes of hearing impairment can bring further benefit to patients. For example, routine physical examinations can uncover cerumen impaction Cerumen Impaction Definition
Cerumen impaction is a condition in which earwax has become tightly packed in the external ear canal to the point that the canal is blocked. . Sudden hearing loss, unilateral hearing loss Unilateral hearing loss (UHL) or single-sided deafness (SSD) is a type of hearing impairment where there is normal hearing in one ear and impaired hearing in the other ear. , tympanic membrane perforations tympanic membrane perforation Perforated, punctured, ruptured ear drum ENT A disruption of the tympanic membrane due to acoustic trauma, direct injury, barotrauma, introduction of Q-tips or small objects, or infection with fluid buildup in the middle ear. See Tympanoplasty. , and cholesteatoma may be recognized and referred to otolaryngologists for treatment. (11,12) Additionally, patients with hearing aids need to be reassessed. Poorly fitting hearing aids, dead batteries, and poor patient dexterity are correctable causes of poor outcomes with hearing aids. (12) However, among our respondents, 12.9% make no recommendations to patients who report problems with their hearing aids and do not refer them back to audiologists or otolaryngologists. Discussing the limitations and benefits of hearing aids and asking about their effectiveness may help to reduce the social stigma Social stigma is severe social disapproval of personal characteristics or beliefs that are against cultural norms. Social stigma often leads to marginalization.
Examples of existing or historic social stigmas can be physical or mental disabilities and disorders, as well as of wearing an aid, minimize potential frustration, and identify patients with suboptimal Suboptimal
A solution is called suboptimal if a part of the solution has been optimized without regards to the overall objective. improvement for reevaluation.
The need for increased education and outreach is most evident with respect to cochlear implantation. Almost 90% of our respondents were aware of cochlear implants, but only one-fourth referred their deaf patients for evaluation. More than half of respondents who were not aware of cochlear implants practiced in towns that had an academic center, as well as a local audiologist and otolaryngologist. PCPs need to know that options exist for deaf patients and others who do not benefit from conventional hearing aids. Otherwise, a segment of the hearing-impaired community may continue to suffer. Otolaryngologists need to actively teach PCPs about cochlear implants. Most respondents said they did not refer patients for cochlear implants because they did not know which patients were candidates or where to send patients (table 4). Surprisingly, fears about surgical risks and expenses were not common barriers to referral.
Through community lectures and educational programs, both patients and PCPs could be exposed to advances in hearing aids and cochlear implants, identification of likely candidates, and the resources available. However, 17.6% of our physicians did not have access to an otolaryngologist, and 32.9% did not have an audiologist in their community. Continued outreach from otolaryngologists and audiologists is essential to maximize the treatment of hearing loss. Furthermore, residents in primary care specialties could rotate through otolaryngology otolaryngology
Medical specialty dealing with the ear, nose, and throat (see larynx, pharynx). The connection of these structures became known in the late 19th century. to increase their comfort level in evaluating hearing impairment. Using a team approach, otolaryngolgists, audiologists, and PCPs must take the initiative in managing this widespread source of physical, social, and psychological dysfunction.
A few points regarding study design are relevant. First, certain questions might have been misinterpreted, and the answer choices provided might have influenced the responses given. Respondents might have been unwilling to admit that they did not evaluate hearing loss or that they were not aware of cochlear implants, underestimating these results. Because only one-fourth of respondents practiced in towns with more than 500,000 people, this study may not adequately represent PCPs in larger cities. Similarly, the results might have been different if more than 40.0% of respondents had academic centers in their communities.
Finally, our response rate (32.7%) reduces our ability to draw firm generalizations about PCPs' screening for hearing loss. Because data from nonresponders could not be collected, a sensitivity analysis comparing responders and nonresponders is not possible. Therefore, the extent to which responders were similar to nonresponders is not known. Attempts were made to examine a representative group within the primary care community. A random sample of PCPs was selected, and questionnaires were sent three times to maximize the response rate. Despite its limitations, this study provides insights about how PCPs address hearing loss among the elderly and the barriers that exist in referring patients for intervention.
The potential exists to improve the means of evaluating adults, especially elderly patients, for hearing loss. As the primary patient advocates, PCPs must play an essential role in identifying patients with hearing loss and referring them for intervention. However, otolaryngologists and audiologists need to advocate for hearing-impaired patients and educate PCPs about the continually improving technology designed for auditory rehabilitation. Furthermore, screening techniques, basic disease entities, and therapeutic options should be part of the curriculum for residents in family medicine. Exciting advances in the field of hearing aids and cochlear implants bring increased advantages for patients. Future efforts should focus on developing screening programs, determining their effectiveness, and studying patient benefit from continually improving hearing aids and cochlear implants.
Table 1. Barriers preventing respondents from evaluating hearing loss Reason for not evaluating hearing loss Number (% *) Not enough time 13 (38.2) More pressing issues 13 (38.2) Unsure of best method 9 (26.5) Evaluate only if patient reports problem 6 (17.6) No local otolaryngologist/audiologist 3 (8.8) Cost of testing equipment 1 (2.9) * Percentage calculated from the 34 respondents who do not evaluate hearing loss at all or do so only occasionally. Respondents could give multiple answers. Table 2. Methods used by respondents to evaluate hearing loss Method Number (% *) Health-directed questionnaires 20 (39.2) Audiogram in office 20 (39.2) Tuning forks 13 (25.5) Tympanometry 11 (21.6) Whisper test 3 (5.9) * Percentage calculated from the 51 respondents who do evaluate hearing loss. Respon-dents could give multiple answers. Table 3. Indications for audiologist/otolaryngologist referral among respondents Reason for referral Number (% *) Patient report of hearing loss 73 (85.9) Abnormal audiogram 25 (29.4) Abnormal health questionnaire 17 (20.0) Abnormal tympanometry 15 (17.6) Abnormal tuning fork test 13 (15.3) No response 1 (1.2) * Percentage calculated from all 85 respondents. Respondents could give multiple answers. Table 4. Barriers preventing respondents from referring elderly adults for cochlear implant evaluation Reason for not referring Number (% *) Unsure who is candidate 40 (54.8) Unsure where to refer 26 (35.6) Too expensive 8 (11.0) No deaf patients in practice 7 (9.6) Leave decision of candidacy to otolaryngologist 6 (8.2) No help 4 (5.5) Too risky 3 (4.1) No response 3 (4.1) * Percent calculated from 73 respondents who do not refer elderly adults for cochlear implants. Respondents could give multiple answers.
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tr.v. ran·dom·ized, ran·dom·iz·ing, ran·dom·iz·es
To make random in arrangement, especially in order to control the variables in an experiment. trial. Ann Intern intern /in·tern/ (in´tern) a medical graduate serving in a hospital preparatory to being licensed to practice medicine.
in·tern or in·terne
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1. A contemptible person.
2. An informer.
3. A hired strikebreaker.
intr.v. finked, fink·ing, finks
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(19.) National Council on the Aging. The Consequences of Untreated Hearing Loss in Older Persons. Washington D.C., 1999.
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From the Department of Otolaryngology, Vanderbilt University Medical Center The Vanderbilt University Medical Center (VUMC) is a collection of several hospitals and clinics associated with Vanderbilt University in Nashville, Tennessee. It comprises the following units:
Reprint reprint An individually bound copy of an article in a journal or science communication requests: Robert F. Labadie, MD, PhD, Vanderbilt University Medical Center, Department of Otolaryngology, S-2100 Medical Center North. Nashville, TN 37232-2559. Phone: (615) 343-6972: fax: (615) 343-7604; e-mail: email@example.com
Originally presented at the Southern Section Meeting of the Triological Society; January 9-11, 2003; Naples, Fla.