Is there an echo in here? There’s still not enough evidence to assess the balance of benefits and harms of screening for hearing loss in asymptomatic older adults, according to the U.S. Preventive Services Task Force (USPSTF), who repeated a nearly decade-old recommendation.
“Because of a lack of evidence, the USPSTF concludes that the benefits and harms of screening for hearing loss in asymptomatic older adults are uncertain and that the balance of benefits and harms cannot be determined. More research is needed [because direct] evidence of the effect of screening for hearing loss on clinical outcomes is limited,” wrote Alex H. Krist, MD, MPH, of Virginia Commonwealth University in Virginia, and co-authors. “This recommendation is consistent with the 2012 USPSTF statement.”
The “I” grade recommendation is for people ages ≥50 who have not noticed any issues with their hearing, they explained in JAMA, and does not hold for “adults with conductive hearing loss, congenital hearing loss, sudden hearing loss, or hearing loss caused by recent noise exposure, or those reporting signs and symptoms of hearing loss.”
As for further research, areas that need exploration are the effects of hearing loss on quality of life and other health outcomes in asymptomatic adults; the potential for overtreatment from a false-positive test result; and “Screening tools that identify not just adults with hearing loss by audiometry definition criteria, but adults with unrecognized hearing loss that would benefit (the most) from amplification,” according to Krist and co-authors.
In an accompanying JAMA editorial, Jay F. Piccirillo, MD, of Washington University School of Medicine in St. Louis, and Bevan Yueh, MD, MPH, of University of Minnesota in Minneapolis, reiterated the dearth of evidence to support screening for hearing, with a single randomized clinical trial — SAI-WHAT — in the more than 2,000 U.S. veterans. SAI-WHAT found that screening for hearing loss led to more hearing aid use and that the results primarily applied to “older populations [ages ≥50] with few cost barriers to hearing aids.” Yueh was a SAI-WHAT investigator.
While the USPSTF may not be all in on the benefits of hearing loss screening in this population, Piccirillo and Yeuh advised that “primary care physicians [should] adopt a more nuanced approach, grounded in clinical judgement… screening with either a single question (’Do you have difficulty with your hearing?’) or a tone-emitting device to be more effective if they follow up with an assessment of bother (’How bothered are you by your hearing loss?’) and motivation for seeking treatment.”
Ultimately, the “Potential harms of screening for hearing loss are likely minimal, as both screening and confirmatory tests are noninvasive,” noted Jill Jin, MD, MPH, of Northwestern Medicine in Chicago, in a JAMA Patient Page. She added that hearing aids are a “low-risk” treatment, but possible harms may include anxiety and stigma, or hearing aid-associated ear infections and wax build-up, although the evidence report for the recommendation found “no studies reported on harms of screening or interventions.”
In an accompanying JAMA Otolaryngology-Head & Neck Surgery editorial,” Nicholas S. Reed, AuD, and Esther S. Oh, MD, PhD, both of Johns Hopkins Bloomberg School of Public Health in Baltimore, acknowledged that “Audiologists, otolaryngologists, geriatricians, and other stakeholders may feel disappointed in the USPSTF conclusion.”
They agreed with Piccirillo and Yeuh regarding the “large holes in the evidence around the care pathway and benefits of addressing hearing loss,” but highlighted that the technology to assess hearing loss has outpaced the research.
For instance, [r]ecent advances in tablet- and smartphone-based portable audiometer systems and hearing testing apps… provide quality means to assess hearing outside of the traditional sound booth… The work on the importance of addressing hearing loss beyond the traditional audiology clinic should be celebrated, and it lays the foundation for new implementation science work to improve sustainability,” they stressed.
Reed and Oh also warned fellow hearing specialists against “hand-wringing” over the recommendation. Instead, “we should see an opportunity to build on nascent efforts in answering these big-picture questions and engage in rigorous scientific investigation across disciplines of audiology, otolaryngology, geriatrics, implementation science, and public health,” they wrote.
For the evidence report, Cynthia Feltner, MD, MPH, of the University of North Carolina at Chapel Hill, and co-authors, looked at 41 studies (n=26,386 patients), less than half of which were new since 2012.
They noted in JAMA that in SAI-WHAT, “there was no significant difference in the proportion of participants experiencing a minimum clinically important difference in hearing-related function at 1 year (36%-40% in the screened groups versus 36% in the nonscreened group).”
As for other tests that evaluated testing efficacy, they reported the following:
- Single-question screening for mild hearing loss (>20-25 dB): 66% pooled sensitivity of 66% (95% CI 58%-73%); 76% pooled specificity (95% CI 68%-83%).
- Single-question screening for moderate hearing loss (>35-40 dB) 80% pooled sensitivity (95% CI 68%-88%); 74% pooled specificity (95% CI, 59%-85%).
- Hearing Handicap Inventory for the Elderly-Screening for moderate hearing loss (>40 dB)” 68% pooled sensitivity (95% CI 52%-81%); 78% pooled specificity (95% CI 67%-86%).
Limitations of the evidence report included the fact that the review was “limited to study designs that included a control group and those that reported on health outcomes. Intermediate outcomes, including increased rates of audiology referrals associated with screening, may not indicate that people identified by routine screening have better long-term health outcomes than those who are identified and referred for treatment in the context of routine primary care,” Feltner and co-authors wrote.
The recommendation has the backing of the American Academy of Family Physicians, while the American Speech-Language-Hearing Association calls for adults to undergo screening by an audiologist once every decade, and then every three years after age 50, or more often in people with known exposures or risk factors linked with hearing loss.
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The current evidence is insufficient to assess the balance of benefits and harms of screening for hearing loss in older adults, according to the U.S. Preventive Services Task Force (USPSTF).
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The recommendation is the same as the one the task force made in 2012,and applies to asymptomatic adults ages ≥50; it is not for those with conductive hearing loss, congenital hearing loss, sudden hearing loss, or other hearing loss issues.
Shalmali Pal, Contributing Writer, BreakingMED™
The USPSTF is funded by the Agency for Healthcare Research and Quality (AHRQ). The evidence report was funded by AHRQ. USPSTF members reported travel reimbursement and an honorarium for participating in USPSTF meetings. One member reported relationships with Healthwise.
Reed reported support from, and/or relationships with, the National Institute on Aging, SHOEBOX, and Good Machine Studio.
Jin reported serving as JAMA associate editor.
Piccirillo, Yueh, and Oh, as well as Feltner and co-authors, reported no relationships relevant to the contents of this paper to disclose.
Cat ID: 494
Topic ID: 398,494,282,494,730,192,255,151,60,925
