Research Needs in Accessible and Affordable Hearing Health Care for Adults With Mild to Moderate Hearing Loss
The National Institute on Deafness and Other Communication Disorders/National Institutes of Health (NIDCD/NIH), since its creation in 1988, has encouraged and supported research related to all aspects of audiology, including prevention, diagnosis, treatment, and the development of better devices and prostheses, including hearing aids and cochlear implants. However, very little research has addressed the hearing health care (HHC) system, including accessibility and affordability.
Several statistics confirm the importance of the HHC system. Hearing loss (HL) is the third most prevalent chronic health condition facing seniors (Collins, 1997). Approximately 17% of American adults report some degree of hearing loss (HL; NIDCD, n.d.-a), and HL is the third most prevalent chronic health condition facing seniors (Collins, 1997). Yet fewer than 20% of those with HL who require intervention and treatment seek help (NIDCD, n.d.-b). Further, most hearing aid users live with HL for over 10 years and their impairments progress to moderate-to-severe levels before a hearing aid is sought (Davis, Smith, Ferguson, Stephens, & Gianopoulos, 2007). These statistics clearly indicate a need for an increased utilization of HHC services for many individuals with HL.
In August 2009 NIDCD sponsored a research working group titled Accessible and Affordable Hearing Health Care for Adults with Mild to Moderate Hearing Loss. The purpose of the working group was to develop a research agenda to increase accessibility and affordability of HHC, including accessible and low cost hearing aids, for adults with mild to moderate HL. The group sought research recommendations designed to lead to outcomes increasing accessibility and affordability of HHC, and ultimately to an increase in the number of hearing-impaired adults receiving quality HHC in the United States. Ensuring quality was paramount in all considerations and deliberations.
The working group specifically focused on adults with mild to moderate HL, a group least likely to have a hearing screening/assessment or to use hearing aids (due to one of many reasons, including perceived benefit, cost, stigma, value, etc.). However, many of these individuals can benefit from amplification, as research demonstrates that psychosocial health declines with increasing HL (Nachtegaal et al., 2009). Many individuals with mild to moderate HL will progress to severe HL, requiring complex professional services in later years.
Hearing Health Care Access
For the research working group's purposes, HHC included hearing assessment along with access to hearing aids and nonmedical treatment. The term access included hearing screening/assessment as well as acquiring an appropriate device and services for the individual's HL and communication needs. The United States lacks readily accessible low-cost hearing screening programs, in contrast to many other nations. Currently, HHC access can be confusing to the consumer. There are multiple entry points, including family practitioners, audiologists, hearing aid specialists, otolaryngologists, and direct web access, as well as magazine, newspaper and television ads. In addition, access to low cost aids exists only on the web or through newspaper or magazine ads, making it difficult for consumers to determine the merit or efficacy of the various options. It is also important to note that the availability of a product on the web does not ensure that it is "accessible," because many older individuals (the group with the highest prevalence of HL) and individuals of lower income have particularly low levels of Internet use. Hearing aids are necessary health care devices; thus, there is a compelling need for better alternatives for access.
What are the barriers for patients' accessing HHC? Is it availability of services, cost, location, health care insurance coverage, and/or the referral network? Are there unique needs and concerns across a patient's life span and among different cultures or special populations that have an impact on access (e.g., perceived need, personal attitudes, stigma, socioeconomic status)? Which hearing screening method (face-to-face, telephone, Internet, language-free, emerging technologies, questionnaire, audiometric, speech-in-noise) has the best sensitivity and specificity and results in the highest rate of follow-up of individuals seeking interventions and for what populations? We need research seeking to answer these questions.
Hearing Health Care Affordability
The definition of affordable remains undetermined. There are likely different price points for different segments of the population, and only limited scientific data are available on the specific effect of cost on hearing aid penetration/adoption rates. Yet, cost is considered to be one of the primary reasons for non-adoption of hearing aids. A high percentage of individuals require two aids, and while the life span of a hearing aid depends on many factors, in general, hearing aids have an average life of 4–6 years. Batteries add additional costs. A hearing aid wearer, over the wearer's lifetime, may spend tens of thousands of dollars acquiring and maintaining hearing aids. Given these factors, hearing aids can be among the most expensive items purchased by many Americans with HL, after their home or car.
Most programs provide hearing aids only for the most severely hearing-impaired adults; adults with mild to moderate HL may be ignored. Many individuals who cannot afford hearing aids rely on Lions Clubs, hearing aid loaner banks, and various other philanthropic organizations. This is an unacceptable public health solution for a necessary health care device.
It is appropriate to question the assumption that the best HHC is synonymous with the most advanced technology, especially for adults with mild to moderate HL. This assumption makes HHC even less accessible for those who can least afford it. What is the minimal hearing aid technology that will achieve success? What is the difference in outcomes among very low cost/one-size-fits-all, low cost/try-and-select, individually programmed, and full-feature/high-cost devices for varying patient populations and for individual patients? What are the effectiveness and patient satisfaction levels of low cost (entry level) hearing aids and full-feature hearing aids? We need research seeking to answer these questions.
External Factors Influencing Accessibility and Affordability
Beyond the public health urgency, four external factors influenced the need and timing of the research working group: changes in both the demographics and socioeconomics of the United States, emerging technologies, and evolving service delivery paradigms.
There is a strong relationship between age and reported HL. America is aging, and by 2026, 30% of the U.S. population will be over 55 and 18% will be over 65. A concomitant increase in hearing aid candidates is expected. Many will have an initial hearing loss of a mild to moderate level and will be active in the workforce.
What is the relationship between degree of hearing loss (and its associated audiometric configuration) and attitudes toward hearing health care, including hearing aids? What are the characteristics of patients who would benefit from hearing aid use? What are the patient-centered variables (e.g., age, degree of HL, socioeconomic status) that contribute to the penetration rate of hearing aids? We need research seeking to answer these questions.
Addressing health disparities in underserved populations remains a public health imperative; NIDCD/NIH research and emergent solutions should address the needs of all Americans. Individuals who live in rural America are more likely to be older, have low incomes, be in fair or poor health, and have chronic conditions. Inner city individuals are also underserved. Many Americans have limited disposable income. Socioeconomic disparities in health care likely also exist in HHC due to the high cost of hearing aids and limited access to these devices. Acquiring appropriate HHC may be especially challenging for the working poor.
What is the make up, and what is the size of, the unserved and underserved populations for HHC? Can currently available lower cost hearing aids be used to increase access and reduce overall cost for those with limited incomes? Do special populations, such as those with comorbid diseases/conditions, intellectual disabilities, cultural or language differences, or advanced age have unique HHC requirements? Research is needed to answer these questions.
Audiological assessment and hearing aid fitting/management processes are increasingly moving toward automation. Automated hearing tests (telephone/computer/web-based), including speech-in-noise testing, are now a viable possibility. Microphones and other hearing aid components cost less than $100, with prices decreasing due to technological and manufacturing advances. Hearing aid fitting is automated, with programs and algorithms routinely run on PCs. Open canal fittings offer less burdensome fitting possibilities. Technological advances make it likely that audiometry, real-ear measurements, hearing aid programming, and fitting can be packaged and performed on one chip, quickly and conveniently for the patient.
Can we develop a quality self-testing, self-fitting hearing aid, considering technology and patient characteristics, selection, fitting, and aftercare? What are the technology-centered factors (cost, appearance, and performance) that determine the penetration and utilization rate of hearing aids and how do these vary among various age, cultural, and socioeconomic groups? What technology-centered variables predict success with amplification? We need research to answer these questions.
Changing Service Delivery Paradigms
Hearing aids now are available over the web and from store fronts, adding to the traditional entry points offered by audiology, hearing aid specialist, and otolaryngology offices. Direct-to-patient hearing aid sales and referral/consolidators are also available. Internet and telemedicine opportunities now exist for remote audiometric testing and, importantly, for hearing aid fitting and management. The unbundling of costs for HHC services is being actively discussed, providing the consumer with information separating the cost of services from the cost of the device. Professional workforce demographics are also changing. There is a shortage of primary care physicians. Professional organizations are discussing the training and certification of audiology assistants and technicians in an effort to maximize productivity of the most highly trained individuals. Convenient care clinics, providing access to basic care for the most common acute conditions, are now a part of the health care access landscape and provide an example of new routes of access and service delivery paradigms (Mehrotra et al., 2009).
What are the opportunities to use new health care delivery models and methodologies, including the Internet and other forms of telehealth, for HHC? How can current delivery systems (including the system and the provider) be utilized or modified to increase accessibility and affordability of HHC? What are the knowledge, skills, and abilities of hearing health care professionals (audiologists and audiology assistants) and other persons providing HHC (nurses, nurse practitioners, trained volunteers, caregivers, students, physician assistants)? What are the training requirements for HHC service delivery in nontraditional settings (i.e., convenient care clinics, pharmacies)? Research is needed to answer these questions.
Professional Issues Influencing Accessibility and Affordability
Many interrelated issues, tensions, and conflicts across provider groups have contributed to the current HHC situation. The willingness of manufacturers to produce lower cost hearing aids and the willingness of audiologists to sell lower cost aids in the traditional distribution system is debated within and among the professions. Direct access for patients has long been a tension among professional groups (otolaryngologists and audiologists), as have the differing educational qualifications and credentialing standards of those who dispense hearing aids. Professional organizations have not uniformly supported full reimbursement of hearing aids in Medicare. The value and burden of current federal regulations to the patient/consumer requiring a medical evaluation is also is under debate. Many medical clearances and evaluations are not full otologic evaluations. Many patients sign a medical waiver, essentially circumventing the medical evaluation, but exact numbers are unknown.
What is the appropriate medical evaluation to rule out contraindications for using a hearing aid? Do the existing FDA requirements for medical evaluation and clearance prior to hearing aid procurement provide significant protection to patients or create a significant barrier to access? What percentage of hearing aid recipients opts for the medical waiver, and of these, what percentage is subsequently diagnosed with medically treatable hearing loss? What is the prevalence of medically/surgically treatable causes of hearing loss in adults with mild to moderate HL and in the subpopulation of those adults seeking hearing aids? Research is needed to answer these questions.
What Is the Future?
Problems surrounding access and affordability can be solved, and audiologists should and must play a crucial role in solving these problems. The solution requires research, which NIDCD is eager to support (see funding opportunities below), and requires the willing engagement of audiologists at both the individual level and the collective level (professional society). It also requires the willing engagement of all organizations that have a role in HHC, including industry, patient advocacy organizations, and government. The ultimate goal—an increase in the number of adults with hearing impairments who are receiving quality HHC in the United States—is a public health mandate we can all support. Let's work together to achieve this goal.
Amy M. Donahue, PhD
Judy R. Dubno, PhD
Medical University of South Carolina
Lucille B. Beck, PhD
Department of Veterans Affairs
Drs. Donahue, Dubno, and Beck served as co-chairs of the NIDCD Research Working Group on Accessible and Affordable Hearing Health Care for Adults with Mild to Moderate Hearing Loss.
Report of the NIDCD Research Working Group on Accessible and Affordable Hearing Health Care for Adults with Mild to Moderate Hearing Loss, August 25–27, 2009 [includes agenda, participant list, and research recommendations] National Institute on Deafness and Other Communication Disorders. (2009). Report of the NIDCD Working Group on Accessible and Affordable Hearing Health Care for Adults with Mild to Moderate Hearing Loss. Bethesda, MD: Author.
Guest Editorial on the Research Working Group [Free]
Donahue, A., Dubno, J. R., & Beck, L. (2010). Guest editorial: Accessible and affordable hearing health care for adults with mild to moderate hearing loss. Ear & Hearing, 31, 2–6.
NIDCD Funding Initiatives
Watch the NIH Guide (it comes out every Friday) for funding opportunity announcements (FOAs). Each FOA identifies a specific type of funding mechanism and names NIDCD staff contacts. We encourage your interest.
Collins, J. G. (1997). Prevalence of selected chronic conditions: United States 1990–1992. National Center for Health Statistics. Vital Health Statistics, 10, 194.
Davis, A., Smith, P., Ferguson, M., Stephens, D., & Gianopoulos, I. (2007). Acceptability, benefit and costs of early screening for hearing disability: A study of potential screening tests and models. Health Technology Assessment, 11(42), 1–294.
Mehrotra, A., Liu, H., Adams, J. L., Wang, M. C., Lave, J. R., Thygeson, N. M., ... McGlynn, E. A. (2009). Comparing costs and quality of care at retail clinics with that of other medical settings for 3 common illnesses. Annals of Internal Medicine, 151, 321–328.
Nachtegaal, J., Smit, J., Smits, C., Bezemer, P., van Beek, J., Festen, J., & Kramer, S. (2009). The association between hearing status and psychosocial health before the age of 70 years: Results from an Internet-based national survey on hearing. Ear & Hearing, 30, 302–312.
National Institute on Deafness and Other Communication Disorders. (n.d.-a). Quick statistics. Retrieved from www.nidcd.nih.gov/health/statistics/quick.htm.
National Institute on Deafness and Other Communication Disorders. (n.d.-b). Use of hearing aids in 2001. Retrieved from www.nidcd.nih.gov/health/statistics/hearingaids.
About the Authors
Amy M. Donahue, PhD, presently serves as deputy director, division of scientific programs, at the National Institute on Deafness and Other Communication Disorders (NIDCD). She is responsible for program planning, coordination, and conduct of grant research in hearing and balance/vestibular sciences. She has been at NIDCD since 1991 and has been responsible for the creation of numerous scientific initiatives in hearing and balance sciences as well as for creating new grant and funding programs for NIDCD. Many of her activities have been instrumental in increasing NIDCD support for clinical research and patient-oriented research activities.
Judy R. Dubno, PhD, is a professor and conducts auditory research in the department of otolaryngology–head and neck surgery at the Medical University of South Carolina in Charleston. Her research focuses on human auditory system function, with an emphasis on the processing of auditory information and how this ability changes in adverse listening conditions, with age, with hearing loss, and with hearing aids. She is vice president of the Acoustical Society of America, a past president of the Association for Research in Otolaryngology, and a past member of the National Advisory Council of NIDCD. Dr. Dubno is the recipient of the 2011 AAA Jerger Career Award for Research in Audiology.
Lucille B. Beck, PhD, is chief consultant for rehabilitation services and director of the audiology and speech pathology program in the Office of Patient Care Services, Veterans Health Administration for the Department of Veterans Affairs (VA). She is also chief of audiology and speech pathology service at the Washington, DC, VA Medical Center. As chief consultant for rehabilitation services, her responsibilities include oversight and direction for audiology and speech pathology service, blind rehabilitation service, physical medicine and rehabilitation service and polytrauma, and recreation therapy service. Dr. Beck has authored numerous publications on amplification, outcomes, patient satisfaction, and professional issues in audiology and rehabilitation for the nation's veterans. She is a recognized subject matter expert in hearing technology.