hearing aid and qaulity of life

7/29/2019 hearing aid and qaulity of life

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225 Hearing Aids and Quality

of LifeC. E. Johnson . J. L. Danhauer

1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3872

2 Sensorineural Hearing Loss, Health-Related Quality of Life,

and Hearing Aids . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3875

3 Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3883

Summary Points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3884

# Springer Science+Business Media LLC 2010 (USA)


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Abstract: Hearing loss affects one in three people over 65 years of age, and it is the third most

prevalent chronic healthcare condition in this population, second only to arthritis and

hypertension. > Sensorineural hearing loss (SNHL) is an insidious disease with profound

negative consequences on the health-related quality of life (HRQOL) of its victims and theirfamilies if left unmanaged. The only treatment for most forms of SNHL is the use of hearing

aids fit as part of a comprehensive auditory rehabilitation program. The purpose of this

chapter is to discuss the evidence for the HRQOL benefits of hearing aids in persons with

SNHL as documented in a recent systematic review. The researchers on the systematic review

team established a priori criteria for study inclusion and an exhaustive list of search strings

that were submitted to several databases to retrieve relevant evidence. Results of qualitative

and quantitative analyses for data collected using generic and disease-specific outcome

measures which showed that hearing aids improve users HRQOL are summarized here.

List of Abbreviations: ADPI-VAS, Auditory Disability Preference Index-Visual Analog Scale;APHAB, Abbreviated Profile of Hearing Aid Benefit; BAHA, Bone-Anchored Hearing Aids;

CENTRAL, Cochrane Central Register of Controlled Trials; CINAHL, Cumulative Index to

Nursing and Allied Health; COMDISDOME, Communication Sciences and Disorders Dome;

COSI, Client-Oriented Scale of Improvement; dB HL, Decibel hearing level; EBMR, Evidence-

Based Medical Reviews; EQ-5D, EuroQOL; EQ-VAS, EuroQOL Visual Analog Scale; GDS,

Geriatric Depression Scale; HHIA, Hearing Handicap Inventory for Adults; HHIE, Hearing

Handicap Inventory for the Elderly; HRQOL, Health-related quality of life; MOS SF-36,

Medical Outcomes Study Short Form 36; QDS, Quantified Denver Scale of Communication

Function; RCT, Randomized, controlled trials; SELF, Self-Evaluation of Life; SNHL, Sensori-neural Hearing Loss; SPMSQ, Short Portable Mental Status Questionnaire; WHO, World

Health Organization; WHO-DAS II, Word Health Organization-Disability Assessment Sched-

ule; WHO-ICF, World Health Organization International Classification of Functioning

1 Introduction

Sensorineural hearing loss (SNHL), if left untreated, is a potentially devastating condition that

negatively affects millions of individuals and their families worldwide. Few medical or surgicaltreatments are available for SNHL. However, advancements in hearing aid technology have

the potential to provide important positive health-related quality of life (HRQOL) benefits for

its users.

The World Health Organizations (WHO) International Classification of Functioning,

Disability, and Health (WHO-ICF; WHO, 2004) is used for describing health and health-

related states. Health is defined in WHOs Constitution as a state of complete physical, mental,

and social well-being and not merely the absence of disease or infirmity. The ICF can be used

for many purposes in different healthcare disciplines that describe multiple health-related

domains including:

Changes in persons body function and structure

What persons can do in a standard environment (level of capacity)

What persons can do in their day-to-day environments (level of performance)

These domains are classified from body, individual, and societal perspectives through the

use of two lists of: (i) body functions and structures, and (ii) activity and participation.

3872 225 Hearing Aids and Quality of Life


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Functioning refers to all body functions, activities, and participation, while disability is an

umbrella term for impairments, activity limitations, and participation restriction. The ICF

includes environmental factors that interact with all components of the model.

Hearing is a bodily function in which the auditory system uses a variety of body structures(e.g., the outer ear pinna and external auditory canal; the middle ear cavity and ossicular chain

consisting of three tiny bones: the malleus, incus, and stapes; the inner ear with its basilar

membrane and sensory hair cells; and the auditory-vestibular cranial nerve and its pathways to

auditory reception and processing areas in the cortex) that through an elaborate process

converts acoustic sound waves into mechanical and electro-chemical pulses that are transmit-

ted to the brain resulting in the function of audition. Humans use hearing in the execution of

important activities such as understanding speech, listening to music, and using telephones.

Hearing is critical for participation or involvement in life situations (e.g., socializing with

friends, attending concerts, and talking with family on telephones).Under disability, impairment refers to damage to bodily structures (e.g., the destruction of

sensory hair cells in the organ of Corti of the inner ear that results in SNHL). Hearing

impairment often results in activity limitations that affect the ability to hear conversational

speech, appreciate music, or communicate on the telephone among other auditory functions.

Moreover, these activity limitations frequently result in participation restrictions or the

inability to partake in life situations with others. Adults with SNHL may limit their participa-

tion with others (e.g., by refusing invitations to dinner at restaurants, partaking in bingo

tournaments, or attending homeowners association meetings).>Table 225-1 shows methods by which hearing impairment and its subsequent activity

limitations and participation restrictions are typically measured. >Otoscopic examination

involves visually inspecting the ear canals and tympanic membranes using an otoscope.

. Table 225-1Examples of Measurements Typically Used to Assess Hearing Impairments, Activity Limitations,

and Participation Restrictions

Hearing

Impairments Activity Limitations Participation Restrictions

Otoscopic

Examinations

Client-Oriented Scale of Improvement

(COSI)

Hearing Handicap Inventory for the

Elderly (HHIE)

Immittance

testing

Abbreviated Profile of Hearing Aid

Benefit (APHAB)

Hearing Handicap Inventory for

Adults (HHIA)

Otoacoustic

emissions

Pure-tone

audiometry

Speech

audiometry

This table shows different tests that are routinely used to measure hearing impairment. It also lists examples of

self-assessment, paper-and-pencil tools that patients can complete before, during, or after treatments with

amplification to measure their performance, satisfaction, and HRQOL benefits. Some of these measures assess

activity limitations while others focus on participation restrictions; both are often used to measure treatment

outcomes

Hearing Aids and Quality of Life 225 3873


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The > immittance batteryincludes tympanometry and measurement of acoustic reflexes using

middle-ear analyzers to assess middle-ear function.>Pure-tone audiometry is used to determine

the type, degree, and configuration of hearing loss. The type of hearing loss may be conductive,

sensorineural, mixed, > retrocochlear, or central hearing losses. >Conductive hearing lossesinvolve the external and/or middle ear and result in an attenuation of sounds as they are

transmitted to the inner ear. Most conductive hearing losses can be treated medically or surgically

and usually do not require the use of hearing aids unless the loss is chronic. Alternatively, SNHLs

result from a destruction of sensory hair cells in the inner ear culminating in permanent loss of

hearing sensitivity. Because there are few medical/surgical solutions for SNHL,>hearing aids are

the primary treatment. >Mixed hearing losses have both conductive and sensorineural compo-

nents. Again, the conductive aspect may be managed medically/surgically, but the sensorineural

component must rely on amplification. Retrocochlear and central losses involving the auditory

nerve, pathways, and cortex may sometimes be treated medically/surgically and often do notbenefit from the use of hearing aids.

Degree of hearing loss is determined by assessing individuals audiometric thresholds

(>Audiologic Evaluations) or the softest decibel levels in dB Hearing Level (dB HL) that

they can detect at certain frequencies. Degree of hearing loss can range from slight to

profound. Configuration of hearing loss refers to the shape (e.g., flat, rising, or sloping) of

the audiometric thresholds when plotted and contiguously connected on an > audiogram

(i.e., a graphic description of hearing). Hearing losses can be unilateral or bilateral affecting

one or both ears, respectively. The symmetry between the audiograms for each ear is also often

used to describe hearing loss.

This chapter focuses on SNHL in adults, which occurs in about one of every three persons

over 65 years of age. The HRQOL of persons with SNHL and their families can be negatively

impacted by this type of hearing loss and its consequences. The effects of hearing impairment

can also be measured according to patients activity limitations and participation restrictions.

Activity limitations resulting from hearing impairment are measured through self-assessment

questionnaires, such as those listed in >Table 225-1. The ClientOriented Scale of Improvement

(COSI: Dillon et al., 1997) allows patients to list and prioritize difficult listening conditions to

target for intervention. Similarly, the Abbreviated Profile of Hearing Aid Benefit (APHAB: Cox

and Alexander, 1995) targets activity limitations resulting from hearing impairment. The

APHAB has 24 items and assesses difficulties experienced in listening situations across fourdomains: ease of communication, background noise, reverberation, and aversiveness. Patients

read phrases (e.g., have trouble understanding others when an air conditioner is on) and

then rate their degree of communication difficulty on a scale from always (99%), almost

always (87%), generally (75%), half-the-time (50%), occasionally (25%), seldom (12%), to

never (1%). Participation restrictions resulting from hearing impairment are often measured

using the Hearing Handicap Inventory for the Elderly (HHIE: Ventry and Weinstein, 1983) or

the Hearing Handicap Inventory for Adults (HHIA: Newman et al., 1990). The HHIE has

25 items across two domains which measure the social and emotional impact of hearing loss.

Patients answer questions (e.g., Does a hearing problem cause you difficulty when attending aparty?) to which they respond yes, no, or sometimes. The HHIA is almost identical to the

HHIE, except for two items, and is normed for use with adults under 64 years of age who are

still working.

Self-assessment scales vary in quality and can be evaluated by criteria listed in>Table 225-2(Hyde, 2000). A discussion of psychometric standards for self-assessment scales

is beyond the scope of this chapter, but readers are referred to Hyde (2000) for further



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explanation. Although most of these instruments are used to assess pre- and post-interven-

tion, some measure post-treatment only. Abrams et al. (2005) stated that activity limitations

and participation restrictions resulting from hearing impairment ultimately lead to reductions

in HRQOL, which has not traditionally been considered in audiologic rehabilitation. Recent

studies have used two different approaches for measuring HRQOL in persons with various

health conditions. One uses generic, single indicators of overall health status, health profiles,

and utility measures; the other employs disease-specific tools that assess a particular disease

(Guyatt et al., 1993). Both approaches have been used to measure the impacts of and

treatments for SNHL. Several studies have used the Medical Outcomes Study Short Form 36

(MOS-36: Ware and Sherbourne, 1992), a generic outcome measure, to assess the impact of

hearing impairment on HRQOL (e.g., Chia et al., 2007), and/or the HHIE and the HHIA,

disease-specific instruments to evaluate the effects of and treatments for hearing impairment

in adults.

2 Sensorineural Hearing Loss, Health-Related Quality of Life,and Hearing Aids

Bilateral hearing impairment is the third most common chronic healthcare condition, secondonly to arthritis and hypertension. Persons with hearing loss frequently experience social

isolation, depression, anxiety, and loneliness; lessened self-efficacy and mastery; and stress in

relationships when family, friends, and co-workers experience frustration, impatience, anger,

pity, or guilt while interacting with them (Campbell et al., 1999; Keller et al., 1999; Kramer

et al., 2002). Evidence also demonstrates that the mental, emotional, and social consequences

of untreated hearing loss in adults can have negative impacts on individuals overall HRQOL

(Dalton et al., 2003; Keller et al., 1999; Pugh, 2004; Strawbridge et al., 2000).

In most cases, SNHL is permanent, but can be treated effectively through the use of

hearing aids as part of a comprehensive auditory rehabilitation program.>Audiologists oftendiagnose hearing loss and participate in the non-medical management of hearing problems in

part by the evaluation, recommendation, fitting, and verification of amplification devices

including all types of hearing aids.

Over the past few years, hearing aid technology has undergone significant development

in styles, circuitries, and suitability for patients with various types of hearing losses.

Hearing aid styles include body, eyeglass, behind-the-ear, in-the-ear, in-the-canal,

. Table 225-2Characteristics of High-Quality Self-Assessment Tools (Hyde, 2000)

Characteristics

Stated clarity of purpose

Specified population

Defined by a conceptual framework

Developed through a logical process of design, pilot testing, validation, and norming

Stated reliability and validity

Available norms

This table lists qualities that good patient self-assessment tools should possess



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completely-in-the-canal, and open-canal fittings, and most circuitry now uses digital signal

processing. Although bone-conduction hearing aids and > bone-anchored hearing aids

(BAHAs) are effective mainly for persons with conductive hearing losses, by far the most

prevalent use of hearing aids is for amplifying air-conducted signals for patients having SNHL.The primary acoustic benefit of air-conduction hearing aids is to increase the audibility of

soft sounds and conversational speech. Indeed the audiology literature is replete with studies

demonstrating the acoustic benefits of hearing aids for persons with hearing loss. However,

until recently, relatively little attention was focused on how amplification may contribute to

patients HRQOL. With that in mind, in 2004, the American Academy of Audiology assembled

a task force to investigate the HRQOL benefits of hearing aids for adults with SNHL (Chisolm

et al., 2007). That team conducted a systematic review by submitting relevant search strings to

databases including the Cochrane Central Register of Controlled Trials (CENTRAL), Cumu-

lative Index to Nursing and Allied Health (CINAHL), Cochrane Reviews, CommunicationSciences and Disorders Dome (ComDisDome), Evidence-Based Medical Reviews (EBMR),

and PubMed to identify studies that involved persons at least 18 years of age who had SNHL,

assessed HRQOL with outcome measures, and were at least at the Level III of evidence using a

rubric modified specifically for the study (as summarized in >Table 225-3). The search and

retrieval process identified hundreds of titles which were narrowed down to 171 abstracts, then

75 articles, and ultimately to the inclusion of 16 articles.

>Table 225-4 summarizes the characteristics of the included studies and shows that only

two of them used randomized controlled trials. Although four of the studies were quasi-

experimental, some of them were determined to be non-experimental, pre-post comparison

designs according to the criteria used in this systematic review. Study participants included

both males and females, mostly over 65 years of age, who were both new and experienced

. Table 225-3

Levels of Evidence Used by Chisolm et al. (2007) for Rating Studies as Adapted from the ScottishIntercollegiate Guideline Network (SIGN) System

1. High-quality meta-analyses, systematic reviews of randomized, controlled trials (RCTs), or RCTs

with a very low risk of bias

1. Well-conducted meta-analyses, systematic reviews of RCTs, or RCTs with a low risk of bias

1. Meta-analyses, systematic reviews of RCTs, or RCTs with a high risk of bias

2. High-quality systematic reviews of case-control or cohort studies

2. High-quality case-control or cohort studies with a very low risk of confounding, bias, or chance,

and a high probability that the relationship is causal2. Well-conducted case-control or cohort studies with a low risk of confounding, bias, or chance,

and a moderate probability that the relationship is causal

2. Case-control or cohort studies with a high risk of confounding, bias, or chance, and a significant

risk that the relationship is not causal

3. Non-analytic studies (e.g., case reports, case series)

4. Expert opinion

This table summarizes the ranking from most to least rigorous hierarchy of study designs used in the Chisolm et al.

(2007) systematic review of the HRQOL benefits of hearing aids in adults



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. Table 225-4Characteristics of Included Studies for the Systematic Review of the Health-Related Quality of

Life Benefits for Hearing Aids

Study characteristic Description

Study design Randomized, controlled clinical trial

Mulrow et al. (1990)

Yueh et al. (2001)

Quasi-experimental

Abrams et al. (1992)

Chmiel and Jerger (1996)

Jerger et al. (1996)

Newman et al. (1993)

Primeau (1997)

Non-experimental

Dillon et al. (1997)

Humes et al. (2001)

Joore et al. (2003)

Joore et al. (2002)

Malinoff and Weinstein (1989)

Mulrow et al. (1992)

Newman and Weinstein (1988)

Stark and Hickson (2004)

Taylor (1993)

Participant characteristics Gender

Male and female

Age

All over 18 years

Mostly over 60 years

Hearing aid experience

New users

Experienced users

Independent living arrangements

Hearing aid delivery systems Veterans Affairs National Hearing Aid Program

National health programs

Medical insurance programs

Private pay



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hearing aid users that lived independently and participated in a variety of hearing aid delivery

systems.

The included studies employed nine different outcome measures. Five were generic:

the EuroQOL-5D (EuroQOL, 1990), the Geriatric Depression Scale (GDS: Yesavage et al.,

19821983), the MOS-SF-36 (Ware and Sherbourne, 1992), the Self-Evaluation of Life

(SELF: Linn and Linn, 1984), and the Short Portable Mental Status Questionnaire (SPMSQ:

Pfeiffer, 1975). Four were disease-specific: the Auditory Disability Preference IndexVisual

Analog Index (ADPI-VAI: Joore et al., 2002), the HHIA (Newman et al., 1990), the HHIE

(Ventry and Weinstein, 1982), and the Quantified Denver Scale of Communication Function

(QDS: Tuley et al., 1990). The 16 included studies were also assessed for quality according to

their use of: level of evidence, experimental and control groups, equivalence of groups at

baseline, power analysis to determine adequate sample size, a description of participantinclusion and exclusion criteria, well-described hearing aid fitting and verification procedures,

appropriate statistical analyses, and accounting for dropouts of participants.

Both qualitative and quantitative analyses were completed to determine the HRQOL

benefits derived from the use of amplification. Qualitative inspection of differences between

pre- and post-treatment results on generic instruments showed that the use of hearing aids

decreased anxiety and depression (Joore et al., 2002, 2003; Mulrow et al., 1990), and increased

mental functioning (Mulrow et al., 1990, 1992), and social functioning (Joore et al., 2003).

Some of these results were contradictory to those of Stark and Hickson (2004) who found a

decrease in social functioning and vitality post-hearing aid treatment. Pre- and post-hearingaid treatment for disease-specific outcome measures demonstrated strong reductions in

negative social and emotional impacts of SNHL (Abrams et al., 1992; Chmiel and Jerger,

1996; Dillon et al., 1997; Humes et al., 2001; Jerger et al., 1996; Malinoff and Weinstein, 1989;

Mulrow et al., 1990, 1992; Newman et al., 1993; Newman and Weinstein, 1988; Primeau, 1997;

Stark and Hickson, 2004; Taylor, 1993; Yueh et al., 2001) in addition to reductions in

participation restriction (Mulrow et al., 1990, 1992).

. Table 225-4 (continued)

Study characteristic Description

Outcome measures Generic

EuroQOL-5-D

Geriatric Depression Scale

Medical Outcomes Study Short Form-36

Self-Evaluation of Life Function

Short Portable Mental Health Status Questionnaire

Disease-Specific

Auditory Disability Preference Index-Visual Analog Scale

Hearing Handicap Inventory for Adults

Hearing Handicap Inventory for the Elderly

Quantified Denver Scale of Communication Function

This table lists characteristics of studies that were ultimately included in the systematic review of the HRQOL

benefits of hearing aids (Chisolm et al., 2007). These studies were analyzed according to their designs, population

of subjects, how the hearing aids were fit, and types of outcome measures used. The outcome measures were

either generic or disease-specific tools



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The quantitative comparisons included a meta-analysis, a mathematical synthesis of

findings across multiple investigations that permit calculations of effect size, a metric used

for determining the magnitude of a result measured within and across studies (Robey and

Schultz, 1993). A random effects meta-analysis synthesized the results of included studies that

. Table 225-5Unadjusted Effect Sizes (do) and Effect Sizes Adjusted for the Test-Retest Reliabilities of the

Outcome Measure (d) as a Function of HRQOL Domain, Design (and Levels of Evidence in

Parentheses), and Outcome Measure for the 15 Studies Used in the Meta-analysis (Reprinted

with permission from A Systematic Review of the Health-Related Quality of Life and Hearing

Aids: Final Report of the American Academy of Audiology Task Force on the Health-Related

Quality of Life Benefits of Amplification in Adults by T.H. Chisolm, et al. J Am Acad Audiol

18: 151183. Copyright 2007 by American Academy of Audiology. All rights reserved.)

Domain Design Outcome measure Study do

d

Generic Between

(12)

SELF Mulrow et al. (1990) 0.11 0.12

GDS 0.25 0.27

SPMSQ 0.42 0.47

Within (3) EQ-5D: Anxiety/depression Joore et al. (2002) 0.28 0.33

EQ-5D: Mobility 0.07 0.07

EQ-5D: Self-Care

0.05

0.06EQ-5D: Pain and Complaints 0.02 0.03

EQ-5D: Daily Activities 0.05 0.06

EQ-5D: Visual Analog Scale 0.09 0.10

EQ-5D: Daily Activities Joore et al. (2003) 0.26 0.31

EQ-5D: Self-Care 0.02 0.03

EQ-5D: Pain and Complaints 0.04 0.04

EQ-5D: Visual Analog Scale 0.06 0.06

EQ-5D: Mobility 0.06 0.07

EQ-5D: Anxiety/depression 0.18 0.21

MOS SF-36: Social Function 0.23 0.28

SPMSQ Mulrow et al. (1999) 0.10 0.11

GDS 0.15 0.16

MOS SF-36: General Health Stark and Hickson (2004) 0.13 0.15

MOS SF-36: Vitality 0.11 0.12

MOS SF-36: Physical function 0.06 0.06

MOS SF-36: Bodily Pain 0.05 0.05

MOS SF-36: Mental health 0.02 0.02

MOS SF-36: Role-Function

Physical

0.03 0.03

MOS SF-36: Role-Function

Emotional

0.09 0.10

MOS SF-36: Social function 0.09 0.11



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used similar experimental designs and types of outcome measures. >Table 225-5 shows the

hierarchical arrangement of included studies based on outcome measures (i.e., generic versus

disease-specific) and experimental designs (i.e., between- and within-subject comparisons)

along with the specific outcome measure, unadjusted effect sizes (do), and adjusted effect sizesbased on the test-retest reliability of the outcome measure (d). The d-values are plotted in>Figure 225-1, which shows that they varied considerably across experimental designs and

outcome measures. Larger effect sizes were obtained for disease-specific outcome measures

than for generic instruments.

Based on study sample size, the meta-analysis weighted and averaged the individual d

values to determine overall effect sizes based on possible combinations of experimental designs

and type of outcome measures which are plotted in > Figure 225-2along with their respective

confidence intervals. The task force used Cohens (1988) criteria for between-subjects analyses

(i.e., d = 0.2, 0.5, and 0.8 for small, medium, and large effects, respectively). Within-subjectscriteria were calculated using an equation provided by Barcikowski and Robey (1985) where

d = 0.48, 1.21, and 1.95 for small, medium, and large effects, respectively. Although the results

of the meta-analysis on generic outcome measures used in within-subjects designs (d = 0.02

with 95% confidence intervals of0.04 and 0.07) indicated that the effect of hearing aid

treatment was not significant, similar generic data from between-subjects designs (d = 0.28

with 95% confidence intervals of 0.09 and 0.48) indicated that hearing aid treatment resulted

. Table 225-5 (continued)

Domain Design Outcome measure Study do

d

Disease-

Specific

Between

(12)

HHIE Abrams et al. (1992) 0.93 0.95

QDS Mulrow et al. (1990) 1.90 2.22

Within (3) HHIE Chmiel and Jerger

(1996)

0.45 0.46

HHIE Dillon et al. (1997) 1.35 1.38

HHIE Humes et al. (2001) 0.76 0.77

HHIE Jerger et al. (1996) 0.25 0.26

ADP-VAS Joore et al. (2002) 1.38 1.52

ADP-VAS Joore et al. (2003) 1.35 1.49

HHIE Malinoff and Weinstein(1989)

1.68 1.72

QDS Mulrow et al. (1992) 0.44 0.52

HHIE Mulrow et al. (1992) 0.85 0.87

HHIE Newman and Weinstein

(1988)

1.65 1.68

HHIE Newman et al. (1993) 1.06 1.09

HHIE Primeau (1997) 1.29 1.32

HHIE Stark and Hickson (2004) 1.17 1.20

HHIE Taylor (1993) 1.06 1.08

This table summarizes results of a meta-analysis used to combine the findings of similar studies to increase their

overall power and the strength with which conclusions could be made (d0 and d) about the HRQOL benefits of

hearing aids in adults in the Chisolm et al. (2007) study. Results are shown for generic and disease-specific

outcome measures



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in a small positive effect on HRQOL. Alternatively, effect sizes using data from disease-specific

measures yielded medium-to-large effects regarding the HRQOL benefits of hearing aids.

For example, effect sizes for disease-specific measures for within-subjects designs was 1.01

with 95% confidence intervals of 0.76 and 1.26, and was 2.07 with 95% confidence intervals of

0.51 and 3.63 for between-subjects designs.

The relatively small effects for generic tools compared to the disease-specific outcome

measures was possibly due to the fact that the former may not be particularly sensitive to the

effects of hearing loss on HRQOL. However, in a randomized clinical trial, McArdle et al. (2005)used a multi-dimensional tool, the World Health Organization-Disability Assessment Schedule

(WHO-DAS II: World Health Organization, 1999), to measure the effects of hearing aid use on

the generic HRQOL of adults with SNHL. The WHO-DAS II has two domains, communica-

tion and participation, that are particularly sensitive to the effects of hearing loss on HRQOL.

Using the composite score, McArdle et al. (2005) found a small effect size of 0.2 for the

effectiveness of hearing aid intervention on generic HRQOL. Therefore, the benefits of hearing

. Figure 225-1Estimated Mean Effect Sizes and Confidence Intervals by Research Design, Level of Evidence, and

Type of Outcome Measure (Reprinted with permission from A Systematic Review of the

Health-Related Quality of Life and Hearing Aids: Final Report of the American Academy ofAudiology Task Force on the Health-Related Quality of Life Benefits of Amplification in Adults by

T.H. Chisolm, et al. J Am Acad Audiol 18: 151183. Copyright 2007 by American Academy of

Audiology. All rights reserved.). This figure shows that generic measures led to fewer and less

strong conclusions about the HRQOL benefits of hearing aids in adults than did the

disease-specific measures in the systematic review by Chisolm et al. (2007), particularly for

between-subjects designs. The disease-specific measures showed that hearing aids had at least a

medium effect on HRQOL



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aids may be underestimated by some generic outcome measures which are not responsive to

aspects of HRQOL that focus on communication and relationships with others.

It is important to note that conclusions drawn from any systematic reviews are limited due

to the time sensitive nature of their findings. Therefore, systematic reviews must be updated

frequently to reflect the latest evidence on particular interventions. The findings from the

Chisolm et al. (2007) and the McArdle et al. (2005) studies provided data available through

2005. A few other studies have provided additional evidence about the HRQOL benefits of

amplification. For example, using the screening version of the HHIE and the EuroQOL-Visual

Analog Scale, Vuorialho et al. (2006) found that hearing aid use significantly improved theHRQOL of elderly adults. Similar to earlier studies, they found that the EQ-5D, a generic

outcome measure, was not sensitive to changes in the HRQOL of patients with hearing loss as

a result of hearing aid use. This is further evidence that generic outcome measures are less

sensitive to these effects than are disease-specific tools.

Future research in this area should use randomized, controlled clinical trials in

addition to other methodology common in high quality studies (e.g., power analysis to

. Figure 225-2Estimated Mean Effect Sizes and Confidence Intervals by Research Design, Level of Evidence, and

Type of Outcome Measure. (Reprinted with permission from A Systematic Review of the

Health-Related Quality of Life and Hearing Aids: Final Report of the American Academy ofAudiology Task Force on the Health-Related Quality of Life Benefits of Amplification in Adults by

T.H. Chisolm, et al. J Am Acad Audiol 18: 151183. Copyright 2007 by American Academy of

Audiology. All rights reserved.). This figure again shows that disease-specific outcome measures

produced stronger conclusions abut the HRQOL benefits of hearing aids for adults in the Chisolm

et al. (2007) systematic review



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determine appropriate sample sizes for statistical significance, participant inclusion/exclusion

criteria, use of control groups that are equivalent at baseline, and accounting for dropouts).

Moreover, systematic reviews dealing with the HRQOL benefits derived from other types

of amplification, particularly those requiring surgery like BAHAs or cochlear implants,

in comparison to more traditional types of hearing aids would be useful in clinical decision-

making, providing that findings are viewed in perspective. For example, Johnson et al. ( 2006)found limited HRQOL benefits from BAHAs in elderly patients when compared to other

forms of hearing aids or no amplification at all. However, their failure to find strong HRQOL

evidence for BAHAs with the elderly does not mean that positive outcomes are not realized

for patients of other ages. Rather, methodological limitations of studies, particularly the

heterogeneity of participant groups, and the paucity of sensitive generic outcome measures

may explain the seemingly limited evidence regarding the HRQOL benefits of BAHAs

seen in that study.

3 Conclusions

Evidence-based practice blends patient preferences, scientific evidence, and clinical expertise

for clinical decision-making (American Speech-Language-Hearing Association, 2004).

A positive outcome from systematic reviews is to generate clinical recommendations regarding

specific treatments in comparison to alternative interventions. Customarily, grades of A, B,

. Table 225-6Key Features of Hearing Aids

1. Hearing impairment is the third most common chronic healthcare condition in persons aged

65 years and older

2. Unmanaged hearing loss can lead to a reduction of health-related quality of life (HRQOL)

3. The primary treatment for acquired sensorineural hearing loss is the use of hearing aids

4. In the United States, adult patients require a medical clearance through a physician or must

sign a medical waiver prior to seeking hearing aids

5. Only one in 10 afflicted with hearing loss seek help; most patients wait several years after

diagnosis to try hearing aids

6. The alternative treatment for hearing aid is usually no treatment at all

7. Reasons for not seeking help include denial of hearing loss, cost, and social stigma

8. Hearing aids are funded through a variety of sources including insurance, national healthcare

programs, and out-of-pocket expenditure

9. The major goal of hearing aids is to make soft sounds and conversational speech audible

10. The selection, evaluation, and fitting of hearing aids is best done as part of a comprehensive

program of auditory rehabilitation

11. Hearing aids usually have a free trial period

12. The average life of a hearing aid is about 35 years

13. Hearing aids can provide important HRQOL benefits for users and their families

This table lists key facts about hearing aids including the effects of unmanaged hearing loss, obstacles to its

treatments, and information about hearing aid fitting in general



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C, or D are assigned to guide clinical decision-making (Cox, 2005). Based on the best

evidence available, the American Academy of Audiology Task Force assigned a grade of B to

the recommendation that amplification improves the HRQOL of patients and their families

who must consider hearing aid treatment against the alternative of not getting hearing aids orno treatment for their SNHLs. As Chisolm et al. (2007, pp. 169) stated, Sensorineural hearing

loss is an insidious, potentially devastating chronic health condition if left unmanaged.

Moreover, because hearing aids are a non-invasive, low risk treatment with a guaranteed

trial period prior to purchase, the benefits for improved HRQOL far outweigh the risks of

amplification for adults with SNHL. >Table 225-6 provides some key points about SNHL

and hearing aids.

Summary Points

SNHL affects one in three people who are 65 years of age and older.

The mental, emotional, and social consequences of untreated hearing loss in adults can

have negative impacts on overall HRQOL of individuals and their families.

HRQOL benefits from hearing aids can be assessed using generic or disease-specific

outcome measures.

Generally, generic measures are less sensitive to the effects of and treatments for SNHL and

show fewer benefits than disease-specific tools.

Hearing aid use improves the HRQOL of adults with SNHL.

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