Rehabilitation Service Needs and Preferences among Veterans with Tinnitus: A Qualitative Study

Tinnitus is prevalent among military Veterans, yet there is a gap between the demand and the provision of services for tinnitus rehabilitation services within the Veterans Health Administration (VHA). We sought to understand tinnitus rehabilitation service needs and preferences among Veterans with bothersome tinnitus who use Veterans Affairs (VA) services. We conducted semistructured telephone interviews in 2019 with Veterans diagnosed with tinnitus, who reported it as bothersome. Veterans were purposively sampled to represent national VA users, with and without comorbid traumatic brain injury (TBI), and who were or were not interested in tinnitus rehabilitation services. Qualitative data were analyzed using a modified grounded theory approach. Among 40 Veterans interviewed (32 men, 8 women; 50% with TBI), 72.5% endorsed being somewhat/very likely to be interested in tinnitus rehabilitation services while 27.5% were very/somewhat unlikely. Themes related to Veterans' interest in tinnitus rehabilitation services included barriers and facilitators to participation and preferences for receiving tinnitus services (e.g., individual vs. group-based; in-person vs. remote access). Our findings highlight factors that influence Veterans' reported need and preferences for, and readiness to engage in, rehabilitation services for tinnitus. Personalized or otherwise adaptable approaches to program delivery may help ensure maximal uptake among Veterans.

Hearing Loss Prevalence, Years Lived With Disability, and Hearing Aid Use in the United States From 1990 to 2019: Findings From the Global Burden of Disease Study

OBJECTIVES

This article describes key data sources and methods used to estimate hearing loss in the United States, in the Global Burden of Disease study. Then, trends in hearing loss are described for 2019, including temporal trends from 1990 to 2019, changing prevalence over age, severity patterns, and utilization of hearing aids.

DESIGN

We utilized population-representative surveys from the United States to estimate hearing loss prevalence for the Global Burden of Disease study. A key input data source in modeled estimates are the National Health and Nutrition Examination Surveys (NHANES), years 1988 to 2010. We ran hierarchical severity-specific models to estimate hearing loss prevalence. We then scaled severity-specific models to sum to total hearing impairment prevalence, adjusted estimates for hearing aid coverage, and split estimates by etiology and tinnitus status. We computed years lived with disability (YLDs), which quantifies the amount of health loss associated with a condition depending on severity and creates a common metric to compare the burden of disparate diseases. This was done by multiplying the prevalence of severity-specific hearing loss by corresponding disability weights, with additional weighting for tinnitus comorbidity.

RESULTS

An estimated 72.88 million (95% uncertainty interval (UI) 68.53 to 77.30) people in the United States had hearing loss in 2019, accounting for 22.2% (20.9 to 23.6) of the total population. Hearing loss was responsible for 2.24 million (1.56 to 3.11) YLDs (3.6% (2.8 to 4.7) of total US YLDs). Age-standardized prevalence was higher in males (17.7% [16.7 to 18.8]) compared with females (11.9%, [11.2 to 12.5]). While most cases of hearing loss were mild (64.3%, 95% UI 61.0 to 67.6), disability was concentrated in cases that were moderate or more severe. The all-age prevalence of hearing loss in the United States was 28.1% (25.7 to 30.8) higher in 2019 than in 1990, despite stable age-standardized prevalence. An estimated 9.7% (8.6 to 11.0) of individuals with mild to profound hearing loss utilized a hearing aid, while 32.5% (31.9 to 33.2) of individuals with hearing loss experienced tinnitus. Occupational noise exposure was responsible for 11.2% (10.2 to 12.4) of hearing loss YLDs.

CONCLUSIONS

Results indicate large burden of hearing loss in the United States, with an estimated 1 in 5 people experiencing this condition. While many cases of hearing loss in the United States were mild, growing prevalence, low usage of hearing aids, and aging populations indicate the rising impact of this condition in future years and the increasing importance of domestic access to hearing healthcare services. Large-scale audiometric surveys such as NHANES are needed to regularly assess hearing loss burden and access to healthcare, improving our understanding of who is impacted by hearing loss and what groups are most amenable to intervention.

First Experiences with Over-the-Counter Hearing Aids for Mild-to-Moderate Hearing Loss: A Case Report

This patient case report describes a first experience in late 2022 and early 2023 with over-the-counter (OTC) hearing aids for a 71-year-old male with self-perceived, age-related hearing loss. The patient reported no "red flag" medical conditions that would preclude him from safely using an OTC hearing aid device. After also meeting inclusionary criteria required to be printed on the device label, the patient was offered FDA registered OTC hearing aids. The first device pair was returned due to malfunction. The second device pair was an in-the-canal style, black in color, and powered by disposable batteries. He required help setting up the device from his spouse, an audiologist, and a pharmacist. Improved scores on the Self-Assessment of Communication and Significant Other Assessment of Communication were noted from the patient and his spouse. The patient continued to use the second device pair for 6 months after first use with no additional help. Our experience supports the pharmacist's role in identifying appropriate candidates for OTC hearing aids, helping patients select a device, and supporting device setup and self-fitting processes at community pharmacies. Further experiences are needed to demonstrate how pharmacists can support OTC hearing aid purchases at community pharmacies.

Machine Learning in Diagnosing Middle Ear Disorders Using Tympanic Membrane Images: A Meta-Analysis

OBJECTIVE

To systematically evaluate the development of Machine Learning (ML) models and compare their diagnostic accuracy for the classification of Middle Ear Disorders (MED) using Tympanic Membrane (TM) images.

METHODS

PubMed, EMBASE, CINAHL, and CENTRAL were searched up until November 30, 2021. Studies on the development of ML approaches for diagnosing MED using TM images were selected according to the inclusion criteria. PRISMA guidelines were followed with study design, analysis method, and outcomes extracted. Sensitivity, specificity, and area under the curve (AUC) were used to summarize the performance metrics of the meta-analysis. Risk of Bias was assessed using the Quality Assessment of Diagnostic Accuracy Studies-2 tool in combination with the Prediction Model Risk of Bias Assessment Tool.

RESULTS

Sixteen studies were included, encompassing 20254 TM images (7025 normal TM and 13229 MED). The sample size ranged from 45 to 6066 per study. The accuracy of the 25 included ML approaches ranged from 76.00% to 98.26%. Eleven studies (68.8%) were rated as having a low risk of bias, with the reference standard as the major domain of high risk of bias (37.5%). Sensitivity and specificity were 93% (95% CI, 90%-95%) and 85% (95% CI, 82%-88%), respectively. The AUC of total TM images was 94% (95% CI, 91%-96%). The greater AUC was found using otoendoscopic images than otoscopic images.

CONCLUSIONS

ML approaches perform robustly in distinguishing between normal ears and MED, however, it is proposed that a standardized TM image acquisition and annotation protocol should be developed.

LEVEL OF EVIDENCE

NA Laryngoscope, 133:732-741, 2023.

Activity Tracking Using Ear-Level Accelerometers

Introduction: By means of adding more sensor technology, modern hearing aids (HAs) strive to become better, more personalized, and self-adaptive devices that can handle environmental changes and cope with the day-to-day fitness of the users. The latest HA technology available in the market already combines sound analysis with motion activity classification based on accelerometers to adjust settings. While there is a lot of research in activity tracking using accelerometers in sports applications and consumer electronics, there is not yet much in hearing research.

Objective: This study investigates the feasibility of activity tracking with ear-level accelerometers and how it compares to waist-mounted accelerometers, which is a more common measurement location.

Method: The activity classification methods in this study are based on supervised learning. The experimental set up consisted of 21 subjects, equipped with two XSens MTw Awinda at ear-level and one at waist-level, performing nine different activities.

Results: The highest accuracy on our experimental data as obtained with the combination of Bagging and Classification tree techniques. The total accuracy over all activities and users was 84% (ear-level), 90% (waist-level), and 91% (ear-level + waist-level). Most prominently, the classes, namely, standing, jogging, laying (on one side), laying (face-down), and walking all have an accuracy of above 90%. Furthermore, estimated ear-level step-detection accuracy was 95% in walking and 90% in jogging.

Conclusion: It is demonstrated that several activities can be classified, using ear-level accelerometers, with an accuracy that is on par with waist-level. It is indicated that step-detection accuracy is comparable to a high-performance wrist device. These findings are encouraging for the development of activity applications in hearing healthcare.

Decentralising paediatric hearing services through district healthcare screening in Western Cape province, South Africa

Background

Childhood hearing loss is a global epidemic most prevalent in low- and middle-income countries where hearing healthcare services are often inaccessible. Referrals for primary care services to central hospitals add to growing lists and delays the time-sensitive treatment of childhood hearing loss.

Aim

To compare a centralised tertiary model of hearing healthcare with a decentralised model through district hearing screening for children in the Western Cape province, South Africa.

Setting

A central paediatric tertiary hospital in Cape Town and a district hospital in the South Peninsula region.

Methods

A pragmatic quasi-experimental study design was used with a 7-month control period at a tertiary hospital (June 2019 to December 2019). Decentralising was measured by attendance rates, travelling distance, number of referrals to the tertiary hospital and hearing outcomes. There were 315 children in the tertiary group and 158 in the district group. Data were collected from patient records and an electronic database at the tertiary hospital.

Results

Attendance rate at the district hospital was significantly higher (p < 0.001). Travel distance to the district hospital was significantly shorter (p < 0.001). Number of referrals to the tertiary hospital decreased significantly during the intervention period (p < 0.001). Most children in both the tertiary and district groups (78.7% and 80.4%, respectively) passed initial hearing screening bilaterally.

Conclusion

Hearing screening should be conducted at the appropriate level of care to increase access, reduce patient travelling distances and associated costs and reduce the burden on tertiary-level hospitals.

Health Literacy and Hearing Healthcare Use

OBJECTIVE

To assess whether health literacy is associated with: 1) degree of hearing loss at initial presentation for audiogram and 2) hearing aid adoption for hearing aid candidates.

METHODS

We identified 1376 patients who underwent audiometric testing and completed a brief health literacy questionnaire at our institution. The association between health literacy and degree of hearing loss at initial presentation was examined using linear regression, adjusted for age, gender, marital status, education level, race, language, employment status, and insurance coverage. The association between health literacy and hearing aid adoption was examined in the subset of patients identified as hearing aid candidates using logistic regression, adjusted for demographic factors and insurance coverage.

RESULTS

Patients with inadequate health literacy were more likely to present with more severe hearing loss (adjusted mean pure-tone average [PTA] difference, 5.38 dB, 95% confidence interval [CI] 2.75 to 8.01). For hearing aid candidates (n = 472 [41.6%]), health literacy was not associated with hearing aid adoption rate (odds ratio [OR] 0.85, 95% CI 0.40 to 1.76). Hearing aid coverage through Medicaid (OR 2.22, 95% CI 1.13 to 4.37), and moderate (OR 2.70, 95% CI 1.58 to 4.69) or moderate-severe (OR 2.23, 95% CI 1.19 to 4.16) hearing loss were associated with hearing aid adoption.

CONCLUSIONS

In our population, patients with low health literacy are more likely to present with higher degrees of hearing loss, but no less likely to obtain hearing aids compared with patients with adequate health literacy. Hearing loss severity and hearing aid coverage by insurance appear to be the main drivers of hearing aid adoption.

LEVEL OF EVIDENCE

3 Laryngoscope, 131:E1688-E1694, 2021.

Self-Perceived Hearing Status Creates an Unrealized Barrier to Hearing Healthcare Utilization

OBJECTIVE

To examine sociodemographic and audiometric factors associated with hearing aid (HA) uptake in adults with hearing loss (HL), and to investigate the role of self-perceived hearing status on pursuit of hearing treatment. The relationship between self-perceived hearing status and HA adoption has not been reported in a nationally representative sample of United States (US) adults.

STUDY DESIGN

Cross-sectional analysis of nationwide household health survey.

METHODS

Audiometric and questionnaire data from the 2005 to 2012 National Health and Nutrition Examination Survey cycles were used to examine trends in untreated HL and HA adoption in US adults. Adjusted odds ratios for HA adoption were calculated for individuals with measured HL.

RESULTS

Of 5230 respondents, 26.1% had measurable HL, of which only 16.0% correctly self-identified their hearing status, and only 17.7% used an HA. Age, higher education, severe hearing impairments, and recent hearing evaluations, were positively associated with HA adoption.

CONCLUSION

Hearing loss is a global public health concern placing significant economic burden on both the individual and society. Self-reported hearing status is not a reliable indicator for HL, and measured HL is not correlated with increased rates of treatment. Recent hearing evaluation is positively associated with increased rates of treatment. Routine hearing assessment will help to better identify those with HL and improve access to hearing treatment.

LEVEL OF EVIDENCE

III Laryngoscope, 131:E289-E295, 2021.

Perceptions of adults with hearing impairment regarding the promotion of trust in hearing healthcare service delivery

OBJECTIVE

This paper describes how trust is promoted in adults with hearing impairment within the context of hearing healthcare (HHC) service delivery.

DESIGN

Data were analysed from a previously published descriptive qualitative study that explored perspectives of adults with hearing impairment on hearing help-seeking and rehabilitation.

STUDY SAMPLE

Interview transcripts from 29 adults from four countries with different levels of hearing impairment and different experience with the HHC system were analysed thematically.

RESULTS

Patients enter into the HHC system with service expectations resulting in a preconceived level of trust that can vary from low to high. Relational competence, technical competence, commercialized approach, and clinical environment (relevant to both the clinician and the clinic) influence a patient's resulting level of trust.

CONCLUSIONS

Trust is evolving rather than static in HHC: Both clinicians and clinics can promote trust. The characteristics of HHC that engender trust are: practicing good communication, supporting shared decision making, displaying technical competence, offering comprehensive hearing rehabilitation, promoting self-management, avoiding a focus on hearing-aid sales, and offering a professional clinic setting.

Technology for hearing loss--as We Know it, and as We Dream it

PURPOSE

Worldwide demand for accessible hearing health technology continues to increase while the numbers of hearing healthcare specialists are grossly inadequate to meet this demand. Proliferation of innovative technology and the advent of greater access to global connectivity are providing an opportunity to identify and harness new resources that may change current audiological service delivery methods to maximize access, efficiency and impact.

METHODS

By searching through the most current literature and engaging in discussions with industry experts, it is possible to identify avenues that could increase services to those who have hearing loss with innovative healthcare technology. This article aims to review the current state as well as future trends of hearing health technology by addressing: Technology as We Know it; and Technology as We Dream it.

RESULTS

Some of the newer technologies we have recently witnessed include: micro processors; personalized computing devices (e.g. smartphones); web-based applications; an expanding clinical repertoire with integrated test equipment; and globalization of telecommunications that opens the door to telehealth; and self-fitting of hearing aids. Yet, innovation continues scaffolding on recent successes with innovations for hearing healthcare expected to increase into the future.

CONCLUSION

As technology and connectivity continue to evolve so should the practice of audiology adapt to the global needs by capitalizing on these advances to optimize service delivery access and sustainability.

IMPLICATIONS FOR REHABILITATION

Capital investment in equipment will be dramatically reduced with smaller, lighter, less costly and more portable equipment. Individuals who live in remote regions with little or no hearing healthcare access can undergo valid assessments by a professional via telehealth. Web-based applications allow clinicians to expand their repertoire and reach of services.