hearing and the health care system: a call to action...prevalence of hearing loss in the 3 united...

1

Hearing and the Health Care System: A Call to ActionNicholas S. Reed, AuD

8/17/2020

2Conflicts of Interest and Acknowledgements

Conflicts of Interest:Funded by Johns Hopkins Via NIH (NIA, NIDCD), Cochlear Inc Gift,

Eleanor Schwartz Foundation GiftNon-financial member of Scientific Advisory Board (Shoebox, Inc; Good

Machine Studio)Consultant to Helen of Troy

Acknowledgements:Frank R. Lin, MD, PhDJennifer A Deal, PhDAmber Willink, PhDAdele Goman, PhDJoshua Betz, MS

3Prevalence of Hearing Loss in the United States, 2001-2008

8/17/2020 Lin et al., Arch Int Med. 2011

4Hearing Loss & Hearing Aid Use Prevalence in the U.S. 1999-2006

8/17/2020 Chien & Lin, Arch Int Med. 2012

5

Conceptual Framework

8/17/2020 Reed AJHQ (under review)

Hearing Loss

Delirium

Confusion

CommunicationBreakdown

Satisfaction

Health Care Utilization

(hospitalizations, 30-day

readmission)Agitation/Frustration

Poor Treatment

Understanding

Sensory Deprivation

Exposure Immediate outcomes

Mediators Long-term Outcomes

Isolation

Length of Stay

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Patient-Provider Communication

8/17/2020 Berwick., Health Affairs, 2002; IOM Quality Chasm Report 2001

IOM 2001: Patient-provider communication is a cornerstone ofpatient-centered care

“…care that is respectful of and responsive to individualpatient preferences, needs, and value…”

Patient-provider communication is related to health careoutcomes Time to diagnosis Treatment understanding Long term post-hospitalization outcomes

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Hearing Loss and Patient-Provider Communication

8/17/2020Cudmore et al., JAMA-Otolaryngology 2017; Cohen et al. (2017) JAGS

100 adults (>60 years) semi-structured interviews following medicalappointments Hearing loss led to reports of missed consultation content and

unable to understand unfamiliar language

Very few studies consider hearing loss in patient-providercommunication Only 23.9% of patient-provider communication papers involving

older adults included any mention of hearing loss Only 6% included hearing loss in analyses

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8/17/2020 Shukla et al. 2018 AJHQ

Systematic review of association of hearing loss onpatient-provider communication among inpatients

13/13 studies found hearing loss associated withpoorer perceived patient-provider communication

Emergent themes: Provider perspective that hearing loss contributed to poor

relationships and longer treatment When addressed, patients report perceived better

communication

Hearing Loss and Patient-Provider Communication

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Hearing Loss

Delirium

Confusion


Satisfaction




Poor Treatment

Understanding

Sensory Deprivation



Isolation

Length of Stay

10

Hypothesis

8/17/2020

Hearing loss is associated with increased health careutilization and cost

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Data Source & Analytic Sample

8/17/2020 Reed et al. 2019 JAMA-Otolaryngology

OptumLabs® Data Warehouse 125 million de-identified data claims from across US Private and Medicare Advantage Physician, hospital, prescription claims information (EMR) Socioeconomic and satisfaction measures Medicare and private insurance surveys

Analytic Sample Jan 1, 2000 to Dec 31, 2014 2-, 5-, 10- year cohorts

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Outcome Variables

8/17/2020

1. Medical Costs Total

Health plan paid Out of Pocket Isolated to hearing loss

2. Number inpatient hospitalizations3. Total days hospitalized4. Number of readmissions with 30-days of discharge5. Number Emergency Department Visits6. Number of days with at least one outpatient visit

Reed et al. 2019 JAMA-Otolaryngology

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Hearing Loss and Health Care Outcomes


Methodologic question:

How to measure hearing loss in a claims data set?

• Careful approach• Several limitations

• Appropriate coding from physicians?• Capture hearing aids (not covered by insurance)• Undocumented hearing loss

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Exposure

8/17/2020

Evidence of Age-Related Hearing Loss from ICD codes ≥ 50 years No hearing loss ICD code two years prior to index date Included

ICD codes for hearing loss and/or sensorineural hearing loss Excluded

ICD hearing codes such as sudden, hyperacusis, neural, conductive,central, etc.

Persons with same year code related to ear disease such asotorrhea, otalgia

Hearing aid usage evidence from ICD codes


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Methods

8/17/2020

Propensity matched (1:1) to those with evident hearing loss to those without anyevidence of hearing loss (at any point)

Matching variables Insurance type Demographics (Age, Sex, Education, Income) Census geographic region Education level Charlson co-morbidty index Number of office visits, inpatient stays, ED visits Dementia, depression, stroke, cancer (breast, prostate, renal cell, colorectal) Baseline medical costs

Regression analyses (linear – cost, poisson – 30-day readmissions)


16Difference in Unadjusted Mean Costs, Hearing Loss vs. No Hearing Loss

8/17/2020

Hearing lossassociatedwith a 46.5%increase inhealthcarecosts over a10-yearperiod


17Unadjusted Difference in 30-day Readmissions, Hearing Loss vs. No Hearing Loss

8/17/2020

Hearing lossassociatedwith a 44%increase inrisk of 30-dayreadmissionsover 10-years


18Hearing Loss and Health Care Utilization:Public Consumption


19Hearing Loss and Health Care Utilization:Public Consumption


20

Summary

8/17/2020

Older adults with hearing loss experience higher health care costs andutilization patterns compared with adults without hearing loss

Limitations: Claims data presents inherent limitations Designed for billing Exposure capture Limited hearing aid data

Reed et al. 2019 JAMA-Otolaryngology; Simpson et al. 2016 JAMA-Otolaryngology

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Cost and Utilization

8/17/2020 Mahmoudi et al. (2018) JAMA-OTO

Do Hearing Aids Effect the Relationship? In theory, hearing aids could improve

communication Issues in measurement?

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• People with hearing loss who use hearing aids are different to those with hearing loss who do not use hearing aids• Income• Education• Health seeking behaviors• Perception of hearing loss

• Difficult to capture hearing aid use in claims analyses

Hearing Aid Users

8/17/2020

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Example study:

Willink A, Reed NS, Lin FR. Cost-Benefit Analysis of Hearing Care Services: What Is It Worth to Medicare? Journal of the American Geriatrics Society. 2019.

Data set:

Medicare Current Beneficiary Survey 2013

Hearing Care Services and Health Care Costs

8/17/2020Your footer text comes here

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Question: How does hearing care service utilization affect health care utilization?

Objective: to determine how using hearing care services among those with hearing aids impacts the total cost of care and by service type compared to those who do not use hearing care services.


8/17/2020Your footer text comes here

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Methods: propensity score matching using a one-to-one, nearest neighbor matching approach without replacement to create comparable groups.

Matched on: age, gender, race, education, income, # of chronic conditions, # of activities of daily living, presence of helper, self-reported trouble hearing


8/17/2020

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• Older adults with hearing aids using hearing care services had total Medicare spending $2,513 less than those who did not use hearing care services

• Post-acute care greatest difference

8/17/2020Willink A, Reed NS, Lin FR. Cost-Benefit Analysis of Hearing Care Services: What Is It Worth to Medicare? Journal of the American Geriatrics Society. 2019.

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Hearing Loss

Delirium

Confusion


Satisfaction




Poor Treatment

Understanding

Sensory Deprivation



Isolation

Length of Stay

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Hypothesis

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Hearing loss is associated with reduced satisfaction withhealth care

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Data Source

8/17/2020

Medicare Current Beneficiaries Survey 2015

Nationally representative sample of 12311 US MedicareBeneficiaries

Interview conducted survey

Reed et al. (under review)

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Outcome

8/17/2020

Satisfaction with Care

“Please tell me how satisfied you have been with the following:The overall quality of the health care [you have] received [overthe past year/since (reference date)].”

[very satisfied, satisfied, dissatisfied, very dissatisfied] Recoded to binary


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Exposure

8/17/2020

Self Report Functional Hearing Trouble “Which statement best describes your hearing [with a

hearing aid]?” No Trouble A Little Trouble A Lot of Trouble


32Unadjusted proportion dissatisfied with care by degree of hearing loss

8/17/2020

Functional Hearing Status

Variable TotalNo

TroubleA Little Trouble

A Lot of Trouble

Unweighted Sample 11,447 5915 4667 865Weighted Sample 48,599,593 26,061,904 19,324,911 3,212,778Dissatisfied with care 3.94% 3.10% 4.64% 6.52%


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8/17/2020

Variable Odds Ratio(95% CI) SE P

Functional Hearing Loss

No trouble REFA little trouble 1.468(1.060 – 2.029) 0.240 0.021A lot of trouble 1.737(1.150 – 2.623) 0.361 0.009

Adjusted for Usual place of care, age, sex, race, education, income, general health, functional limitations


Adjusted odds ratios of dissatisfaction with care by degree of hearing loss

34Pilot: Objective Hearing Measures - Satisfaction

8/17/2020

Hypothesis : Objectively measured hearing is associated with reducedsatisfaction with quality of care

Reed et al., 2019 JAGS

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Methods

8/17/2020

Data Source:

Atherosclerosis Risk in Communities Study Visit 5 (2013) Hearing Loss pilot (Washington County) 256 participants aged 67-89 years (all white)

Outcome:

“Overall, how satisfied are you with the quality of care you received fromyour healthcare providers over the past 12 months?” less than optimally satisfied (somewhat satisfied, somewhat

dissatisfied, or very dissatisfied) vs optimally satisfied (very satisfied)


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Methods

8/17/2020

Exposure:

Pure-tone audiometry 4-frequency pure-tone average (i.e., speech range) Continuous Categorical (normal, mild, moderate or greater)

Analysis:

Logistic regression Adjusted for age, sex, cognition (global score), comorbidities count

(diabetes, hypertension, myocardial infarction, asthma, cancer, stroke,and hospital stay)


37The probability of being less than optimally satisfied by hearing loss (HL) for 70-, 75-, and 80-year-old individuals.

8/17/2020

75-year-old participant: every 10 dB increase in hearing loss, theodds of being less satisfied increased 0.94 (95% CI:0.74-1.20).

85-year-old: for every 10 dB increase in hearing loss, the odds ofbeing less satisfied increased 1.33 (95% CI:0.96-1. 83)


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MCBS – Delay of Care

8/17/2020 Shukla et al. 2018 AJHQ; IOM 2001; Cohen et al. (2017) JAGS

Help-Seeking

OR of Knowingly Delaying Care [Reference = no HL] A Little Trouble Hearing: 1.61 [1.33-1.95] A Lot of Trouble Hearing: 2.01 [1.44-2.80]

Reason for delay for ‘A lot of trouble’ group Trouble getting to Dr: 2.3% Insurance acceptance: 0% Schedule conflict: 6.5% Thought Dr couldn’t do much: 19.82% Didn’t think it was serious: 27.38%

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MCBS – Delay of Care


Help-Seeking

Why would hearing loss be related to help-seeking behavior? Previous experiences with health care are reflected and

considered in future actions Consider an example of a person with hearing loss

repeatedly having a poor experience due tocommunication breakdown from hearing loss This individual may be less likely to seek care in the

future

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MCBS - Accompaniment


Accompaniment

OR of Accompaniment [Reference = no sensory impairment] Hearing Loss (HL) Alone: 1.04 [0.84-1.29] Vision Loss (VL) Alone: 2.14 [1.61-2.85] Dual Sensory (DSI): 2.70 [1.55-4.72]

Reason for accompaniment HL v. VL Persons with HL report communication issues at higher

proportions Take notes: HL (55.4%)v. VL (38.2%) Explain instructions: HL (47.7%)v. VL (36.8%) Transportation: HL (60.5%)v. VL (80.5%)

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8/17/2020 Reed et al. (under review)

Help-Seeking Behavior by Hearing Status


Unadjusted Model Adjusted with Socio-demographics

Adjusted with Socio-demographics & Health Determinants

Odds Ratio(95% CI) SE P Odds Ratio

(95% CI) SE P Odds Ratio(95% CI) SE P

Patient will do anything to avoid seeing the doctorNo trouble REF REF REF

A little trouble 0.91 (0.84 – 0.99) 0.04 0.03 1.05 (0.96 – 1.14) 0.05 0.29 1.01 (0.92 – 1.10) 0.05 0.86

A lot of trouble 1.49 (1.28 – 1.73) 0.11 <0.01 1.54 (1.32 – 1.80) 0.12 <0.01 1.41 (1.20 – 1.65) 0.12 <0.01

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A little trouble 0.91 (0.84 – 0.99) 0.04 0.03 1.05 (0.96 – 1.14) 0.05 0.29 1.01 (0.92 – 1.10) 0.05 0.86

A lot of trouble 1.49 (1.28 – 1.73) 0.11 <0.01 1.54 (1.32 – 1.80) 0.12 <0.01 1.41 (1.20 – 1.65) 0.12 <0.01

Patient will see the doctor as soon as he/she feels badNo trouble REF REF REF

A little trouble 0.81 (0.75 – 0.87) 0.03 <0.01 0.87 (0.80 – 0.94) 0.03 <0.01 0.85 (0.77 – 0.94) 0.043 <0.01

A lot of trouble 0.76 (0.66 – 0.89) 0.06 <0.01 0.76 (0.65 – 0.89) 0.06 <0.01 0.68 (0.56 – 0.84) 0.071 <0.01

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A little trouble 0.91 (0.84 – 0.99) 0.04 0.03 1.05 (0.96 – 1.14) 0.05 0.29 1.01 (0.92 – 1.10) 0.05 0.86

A lot of trouble 1.49 (1.28 – 1.73) 0.11 <0.01 1.54 (1.32 – 1.80) 0.12 <0.01 1.41 (1.20 – 1.65) 0.12 <0.01


A little trouble 0.81 (0.75 – 0.87) 0.03 <0.01 0.87 (0.80 – 0.94) 0.03 <0.01 0.85 (0.77 – 0.94) 0.043 <0.01

A lot of trouble 0.76 (0.66 – 0.89) 0.06 <0.01 0.76 (0.65 – 0.89) 0.06 <0.01 0.68 (0.56 – 0.84) 0.071 <0.01

Patient worries about health more than others their ageNo trouble REF REF REF

A little trouble 0.84 (0.77 – 0.91) 0.04 <0.01 1.25 (0.96 – 1.14) 0.06 <0.01 0.98 (0.88 – 1.10) 0.05 0.78

A lot of trouble 1.09 (0.92 – 1.28) 0.09 0.33 1.54 (1.32 – 1.80) 0.15 <0.01 0.90 (0.74 – 1.10) 0.09 0.31

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A little trouble 0.91 (0.84 – 0.99) 0.04 0.03 1.05 (0.96 – 1.14) 0.05 0.29 1.01 (0.92 – 1.10) 0.05 0.86

A lot of trouble 1.49 (1.28 – 1.73) 0.11 <0.01 1.54 (1.32 – 1.80) 0.12 <0.01 1.41 (1.20 – 1.65) 0.12 <0.01


A little trouble 0.81 (0.75 – 0.87) 0.03 <0.01 0.87 (0.80 – 0.94) 0.03 <0.01 0.85 (0.77 – 0.94) 0.043 <0.01

A lot of trouble 0.76 (0.66 – 0.89) 0.06 <0.01 0.76 (0.65 – 0.89) 0.06 <0.01 0.68 (0.56 – 0.84) 0.071 <0.01

Patient worries about health more than others their ageNo trouble REF REF REF

A little trouble 0.84 (0.77 – 0.91) 0.04 <0.01 1.25 (0.96 – 1.14) 0.06 <0.01 0.98 (0.88 – 1.10) 0.05 0.78

A lot of trouble 1.09 (0.92 – 1.28) 0.09 0.33 1.54 (1.32 – 1.80) 0.15 <0.01 0.90 (0.74 – 1.10) 0.09 0.31

Patient keeps it to him/herself when he/she is sickNo trouble REF REF REF

A little trouble 1.07 (0.99 – 1.16) 0.04 0.07 1.16 (1.07 – 1.25) 0.05 <0.01 1.11 (1.03 – 1.20) 0.05 <0.01

A lot of trouble 1.30 (1.13 – 1.51) 0.10 <0.01 1.33 (1.15 – 1.54) 0.10 <0.01 1.22 (1.04 – 1.42) 0.10 0.01

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Perceptions of Care

8/17/2020

In the MCBS 2016 dataset, persons with hearing loss were:

More likely to Agree with: “Doctor often seems to be in a hurry” “The doctor often does not explain medical problems to you” “The doctor acts as though s/he is doing you a favor by talking to you”

More likely to Disagree with: “The doctor answers all your questions” “The doctor tells you all you want to know about condition/treatment” “The doctor has a complete understanding of the things wrong with you”


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Summary

8/17/2020

Hearing loss is associated with higher odds of being less than optimallysatisfied and/or dissatisfied with health care among older adults

Limitations: Cross-sectional MCBS Self-report hearing loss Limited hearing aid data

ARIC Small sample size homogenous population


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Hearing Loss

Delirium

Confusion


Satisfaction




Poor Treatment

Understanding

Sensory Deprivation



Isolation

Length of Stay

48

Hearing Loss and Delirium

8/17/2020

Incidence rates of delirium among older adults with hearing loss (36-61.7%)higher compared to those without hearing loss (12-38.2%)

Mediation: Sensory-Deprivation Isolation Removal of Hearing Aids Treated as inventory

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Translating Research Into Action

8/17/2020

50Hearing Loss Screening and Intervention in Hospital Setting

8/17/2020

No universal program to identify and intervene on hearing loss in adults inthe hospital system

Many calls for adult hearing screening but most have ignored basicprinciples of implementation science

Reed et al., (in-prep)

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Implementation Science: Translating evidence into sustainable practice

Current state of hearing screenings for adults:

Run by foreign units (audiology) Single person screening all

Generally from outside Purpose is generally for referral for formal hearing care

Indirect implications Use specialized equipment

Training, time Label patient (puts responsibility on patient) Lack training programs Lack of “buy-in”

Hearing Loss Screening and Intervention in Hospital Setting

Reed et al. (in prep); Pronovost et al. JAMA 2017

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Implementation Science

8/17/2020 Pronovost et al. JAMA 2017

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Implementation Science

8/17/2020 Wick et al. J AM COLL SURG 2015

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Engaging Health Care to Address Communication Environments

ENHANCE

8/17/2020

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ENHANCE - Workflow

8/17/2020

No Hearing Loss

Mild Hearing Loss

Admission:Screen for

hearing loss using self-

report as part of common procedures

≥Moderate Hearing Loss

No InterventionCommunicatio

n Signage

Signage + Amplifier


56Staff Training Component

Wallhagen and Reed, J Gero Nurs 2018

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Identification Signage


58

Amplification Products


59Sustainable Hearing Screening and Intervention Solution

8/17/2020

Imbedded within current workflow Universal training end education sessions

Improve fidelity and “buy-in” Purpose is to improve patient-provider communication

Direct implications for staff Onus of communication placed on staff/providers Self-report hearing loss

Minimizes training, time


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ENHANCE

8/17/2020

From Jan –Mar 2018: Feasibility Trial

Med A and Med B (general medicine) at Bayview Hospital (CommunityHospital)


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Engaging Key Figures

8/17/2020

1 meeting with Armstrong Institute 2 meetings with ADA compliance office 3 meetings with Aesthetics Committee 3 meetings with Bayview Med A+B administration 5 meetings with Med A +B clinical nurse specialists, charge nurses

Champion: Clinical nurse specialist 6 lunch and learn events with staff (3 each Med A and B)


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Educating Staff

8/17/2020

6 lunch and learn prior to kick off Materials were printed and distributed to all staff and providers 8 lunch and learn during program (~15-20 minutes)

4 in 2nd week 4 in 4th week

16 check-in huddles (~1-2 minutes) 4 in 1st week 4 in 3rd week 4 in 6th week 4 in 8th week

Amounts to 8 formal education opportunities per shift over period


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Evaluating ENHANCE

8/17/2020

502 screenings captured (77.9% of all admitted per charge nurse numberreports)

41 indicated form not completed (15 unresponsive patient, 14 refusals, 12time constraints)

543/644 for 84.3% capture rate


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Process Evaluation

8/17/2020

Screened No HL(n=264)

Mild HL(n=157)

≥ Moderate HL (n=81)

Overall(n=502)

Device Distributed 0/264 (0%) 7/157 (04.4%)

75/81 (91.4%)

82/502 (16.3%)

Discharge Completed 121/264 (45.8%)

114/157 (72.6%)

71/81 (87.6%)

306 (60.9%)


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Previous communication troubles?

8/17/2020


Mild HL(n=157)


Overall(n=502)

Never 23 (19.0%) 17 (14.9%) 3 (04.2%) 43 (14.1%)Sometimes 71 (58.6%) 42 (36.8%) 11 (15.5%) 124 (40.5%)

Most of the time 21(17.3%) 46 (40.4%) 41 (57.7%) 108 (35.3%)Always 6 (04.9%) 9 (07.9%) 16 (22.5%) 31 (10.1%)


66Was hearing an issue previously in communication?

8/17/2020


Mild HL(n=157)


Overall(n=502)

No 116 (95.8%)

82(71.9%)

19(26.8%)

217 (70.9%)

Yes5 (04.1%)

32(28.1%)

52(73.2%)

89 (29.7%)


67Improved communication during current stay?

8/17/2020


Mild HL(n=157)


Overall(n=502)

No difference 21 (17.4%) 3 (02.6%) 4 (05.6%) 28 (09.2%)Slight Improvement 36 (29.8%) 21 (18.4%) 9 (12.7%) 66 (21.6%)

Improved A little 46 (38.0%) 58 (50.9%) 17 (23.9%) 121 (39.5%)Improved A lot 18 (14.9%) 32 (28.1%) 41 (57.7%) 91 (23.7%)


68Satisfied with communication during current stay?

8/17/2020


Mild HL(n=157)


Overall(n=502)

Not Satisfied 11 (9.09%) 5 (04.4%) 1 (01.4%) 17 (5.6%)

Somewhat Satisfied 12 (9.92%) 13 (11.4%) 4 (05.6%) 29 (9.5%)

Mostly Satisfied 18 (14.9%) 15 (13.2%) 7 (09.9%) 40 (13.1%)

Completely Satisfied 80 (66.1%) 81 (71.1%) 59 (83.1%) 220 (71.9%)


69See communication program used in other healthcare settings?

8/17/2020


Mild HL(n=157)


Overall(n=502)

No 21 (17.4%) 6 (05.3%) 1 (01.4%) 28 (09.2%)Yes 92 (76.0%) 103 (90.4%) 67 (94.4%) 262 (85.6%)

Yes, with changes 8 (06.6%) 5 (04.4%) 3 (04.2%) 16 (5.2%)


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Provider Perspective

8/17/2020

Survey:

Strongly Agree, Agree, Neutral, Disagree, Strong Disagree with the followingstatements:

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8/17/2020

Strongly Agree

Agree Neutral Disagree Strongly Disagree

Negatively Disrupted Workflow 0 0 3 8 7Took Too Long 0 1 13 4 0

Made it easier to communicate with patients 10 8 0 0 0During program, found I was repeating myself less often 6 6 9 2 1

During the program I found that patients were less confused when discussing care 3 10 5 0 0

I found the program saved me time by making communication easier 7 9 2 0 0

I found myself using best-practice communication more often regardless of whether patients had hearing loss 3 11 3 1 0


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8/17/2020

Strongly Agree

Agree Neutral Disagree Strongly Disagree

Felt Patients appreciated the program 6 11 1 0 0I felt like I needed more training to implement the

program 0 2 2 13 1

I would like to see this program implemented throughout the system 8 7 3 0 0

The hearing screening and intervention program has value in the medical setting 8 8 9 1 0


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8/17/2020

“Best intervention ever! I normally have a loud voice andsome people still can't hear me, but once they put theheadphones on, then they can hear. It's nice not loosingyour voice :)”

“Such a wonderful program for patients. This has come inhandy and patients truly benefit from this. This has mademy job much easier! Thank you!”

74

Summary

8/17/2020

ENHANCE was well received in an inpatient setting and may improvecommunication perceptions among inpatients

Limitations: Unknown if program functions without third party influence Lack of process evaluation More trials are required

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Hearing in Health Care

8/17/2020

Universal Adult Hearing Screening: Move towards acceptance Educating the rest of the medical community Future for objective measures

Professionals in the context of OTC (in the United States): Raise awareness Potential for knowledge disbursement

HCAHPS (the Hospital Consumer Assessment of Healthcare Providersand Systems): Medicare reimbursement in the American Health Care System Hospital Incentive

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Thanks!

8/17/2020

hearing and the health care system: a call to action...prevalence of hearing loss in the 3 united...

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