NCBI Bookshelf. A service of the National Library of Medicine, National Institutes of Health.
National Guideline Centre (UK). Hearing loss in adults: assessment and management. London: National Institute for Health and Care Excellence (NICE); 2018 Jun. (NICE Guideline, No. 98.)
8.1. Introduction
Hearing loss is usually insidious in onset with slow progression over a number of years. Early symptoms can be subtle but can have a significant impact on the individual, affecting their social functioning, work and quality of life.
There appears to be considerable variation across the country in the time taken between a patient presenting with hearing loss and receiving treatment, with no national guidance or standards available. Data suggest that most people with hearing loss have lived with their symptoms for 10 years before being referred for the most appropriate intervention.28,38 There is uncertainty around whether receiving audiological care earlier would result in improved outcomes for patients as well as financial savings for the NHS. This chapter examines the clinical and cost effectiveness of early versus delayed management of hearing loss.
8.2. Review question: What is the clinical and cost effectiveness of early versus delayed management of hearing loss on patient outcomes?
The focus of this question was to investigate the effectiveness of managing patients with early or mild hearing loss rather than waiting until their hearing loss is more severe in later-presenting patients, which is a common scenario in clinical practice. Therefore, studies of patients with sudden sensorineural hearing loss were excluded. For full details see review protocol in appendix C.
Table 17
PICO characteristics of review question.
8.2.1. Clinical evidence
One study was included in the review;28 this is summarised in Table 18 below. Evidence from this study is summarised in the clinical evidence summary below (Table 19). No randomised trials were identified and the available data were from a case–control study design, which starts at low quality in the GRADE rating system. See also the study selection flow chart in appendix E, forest plots in appendix K, study evidence tables in appendix H, GRADE tables in appendix J and excluded studies list in appendix L.
Table 18
Summary of studies included in the review.
Table 19
Clinical evidence summary: early management group versus delayed management group 1.
This study was part of a Health Technology Assessment and addressed the question of early versus delayed management of hearing loss with hearing aids using a case–control study design. The aim was to evaluate the benefit of prescribing and fitting hearing aids in those found to be eligible after early adult screening for hearing loss among 50–65 year olds. This was compared with people who were fitted after standard referral to a hearing aid clinic, who are generally older and have a longer history of hearing loss. Two control groups were selected to reduce the chance that any identified advantage was due to unpredictable bias, assuming that any benefit of early management via a screening programme was consistently present in comparison with both control groups. Note that the duration of hearing loss and the hearing level at hearing aid fitting is not reported for the control groups.
Table 20
Clinical evidence summary: early management group versus delayed management group 2.
8.2.2. Economic evidence
8.2.2.1. Published literature
No relevant health economic studies were identified.
See also the health economic study selection flow chart in appendix F.
8.2.2.2. Original cost-effectiveness analysis – summary
An original health economic model was constructed in order to conduct cost–utility analysis for this question and the review question regarding hearing aid use versus no hearing aids (see section 15.2). These questions were agreed by the guideline committee to be the highest priorities for original economic analysis in this guideline due to the very large number of people using or potentially eligible for hearing aids, and the lack of existing health economic research in this area.
Full details of the analysis can be found in appendix N. It includes a comparison between a cohort of people given a hearing assessment and offered hearing aids, if eligible, immediately after first presenting with hearing difficulties (early treatment) and a cohort who were not assessed or offered hearing aids until 10 years after they first reported hearing difficulties (delayed treatment).
The base case probabilistic results, reflecting the costs and outcomes for men aged 65 at the start of the analysis over a lifetime horizon, are in Table 21.
Table 21
Results of early versus delayed use of hearing aids, base case.
Sensitivity analysis found these results to be robust to variations in all the parameters investigated in the analysis, including the age of the participants at the start of the analysis, their sex, the proportions not suitable for hearing aids or who decline to use hearing aids, rates at which participants stop using hearing aids, and the magnitude of improvement in quality of life caused by hearing aid use: the ICER was below £8,100 per QALY gained in every case.
The original health economic modelling is summarised in the health economic evidence profile below (Table 22).
Table 22
Health economic evidence profile: early management versus delayed management using hearing aids.
8.2.3. Evidence statements
Clinical
Early management group versus delayed management group 1
- There was a clinically important benefit of early management for SHHI, GHSI (general) and for GHABP use, benefit, and satisfaction (very low quality evidence, 1 study).
- There was no clinically important difference in ERS, GHSI (social support), GHABP residual disability and EuroQuol thermometer (very low quality evidence, 1 study).
Early management group versus delayed management group 2
- There was a clinically important benefit of early management for GSHI (general and social support), GHABP use, benefit and satisfaction (very low quality evidence, 1 study).
- There was no clinically important difference in GHABP residual disability and EuroQuol thermometer (very low quality evidence, 1 study).
Economic
- One original cost–utility analysis found that early provision of hearing aids was cost effective compared with delayed provision of hearing aids for managing hearing loss (ICER: £3,976 per QALY gained). This analysis was assessed as directly applicable with minor limitations.
8.2.4. Recommendations and link to evidence
| Recommendations |
|
| Relative values of different outcomes | The following critical outcomes were included in this review: hearing-specific health-related quality of life, health-related quality of life, listening ability and outcomes reported by carer or ‘communications partner’. The following important outcomes were also included: usage of hearing aids (including data logging and self-report), change in cognitive function, social functioning or employment, sound localisation as measured by laboratory tests and speech in noise detection as measured by laboratory tests. |
| Quality of the clinical evidence | One study assessing the benefits of early fitting of hearing aids was included and all outcomes were of very low quality due to the study design (case–control), the fact that not all of the potential confounders noted in advance by the guideline committee were controlled for and only those people still using their hearing aids at follow-up were included (<50% in the early management group). In addition, the definition of early versus delayed was based on the mode of referral or identification (proactive screening versus standard presentation through GP visits) with no data available about the time from onset to GP visit. Therefore, there was serious indirectness. No studies were available for other interventions, such as assistive listening devices, pharmacological or behavioural management. |
| Trade-off between clinical benefits and harms | Overall, the study showed evidence across a range of self-report questionnaires for a benefit of fitting hearing aids at an earlier age, compared with fitting at an older age. This was after controlling for age, hearing level, gender and socio-economic group using 2 control groups that differed on some important variables to minimise the chance of any findings being influenced by unidentified biases. Specifically, clinical benefits were found in comparison with both control groups related to:
The majority of the outcomes provided corroborative support for a benefit of early fitting of hearing aids. The EuroQol thermometer is part of a quality of life instrument (EQ-5D) thought to be insensitive to hearing loss and so the committee was not surprised that this outcome did not show a benefit of early fitting. It was also noted that it appears inconsistent for the residual disability subscale of the GHABP not to show a clinical difference when there is more hearing benefit and hearing aid satisfaction. However, there are a number of points that led the committee to believe that this apparent inconsistency does not discredit the other findings:
In summary, the evidence suggests a range of benefits for hearing ability, hearing aid use and quality of life, without any known harms. The committee noted that the clinical study identified focused on early screening for hearing loss and the committee discussed the risks and benefits of fitting a hearing aid for mild hearing loss when other management strategies such as listening tactics or communication training might be preferable to the person. The committee noted that current best practice is to offer active management, such as information and education, hearing aids, assistive listening devices or auditory training at presentation with hearing difficulties. However, there is variability across the country. The committee agreed that it is not good practice for a GP to delay referral for hearing difficulties until the problem is more severe. Not only could delay impact on everyday function at work and home but an older person is likely to have a greater number of additional health problems, less manual dexterity, and less brain plasticity and opportunity for perceptual learning. The committee agreed that all people with hearing difficulties presenting to a GP should, after exclusion of earwax or acute ear infections as the only cause, be referred to an audiology service for hearing assessment and advice in the first instance unless their need is for immediate or urgent medical care for hearing problems. The committee were aware of guidance from the BAA and BSHAA with regard to onward referral. They anticipated that should an individual require a subsequent referral for a medical opinion, the audiologist would follow this guidance and advise or refer accordingly. |
| Trade-off between net clinical effects and costs | No published health economic evaluations were identified for this question. Original health economic modelling was conducted for this question. It found that at a cost-effectiveness threshold of £20,000 per QALY gained, early treatment with hearing aids is highly cost effective compared with delayed treatment, with an ICER of £3,976 per QALY for lifetime treatment, or £4,591 per QALY for the first 10 years of treatment (based on men aged 65 at the start of the analysis). Sensitivity analysis found these results to be robust to all uncertainties investigated in the data used, including the age of the participants at the start of the analysis. The committee noted that assumptions and estimated data used in the model were chosen conservatively, that is, on balance they were likely to overestimate incremental costs and underestimate incremental effectiveness, favouring delayed treatment over early treatment. Notably, the model did not seek to include any advantages that the use of hearing aids might lead to in respect of improvements in any aspects of health other than hearing, or reduction in NHS costs as a result. The committee was hence satisfied that referring people who present with hearing difficulties for a hearing assessment at the earliest opportunity is cost effective, and so agreed that such people should be referred. The committee also noted that conducting a hearing assessment continued to be cost effective in the analysis even when the proportion of people without aidable hearing loss was increased very substantially. Given this, and the benefits of identifying people with hearing loss early, the committee agreed that proactively identifying people who appear to be showing signs of hearing loss and encouraging them to have a hearing assessment, even if they have not presented reporting hearing loss, would also be both clinically beneficial and cost effective. |
| Other considerations | The definition of ‘early intervention’ was discussed and it was suggested ‘early’ could be defined as ‘at the time of first presentation to the GP’ with an awareness of hearing problems. The committee highlighted the importance of education and training of health and social care professionals across all sectors in improving referral of people for hearing difficulties. It was felt that hearing loss is not always considered a priority in a GP’s appointment. While that may be as a consequence of short appointments and a lot to cover, it is acknowledged that there is a tendency to overlook sensory health in clinical practice. There was concern at reports of GPs being reluctant to refer. The committee also recognised that many people do not report hearing loss to their GP (or any other medical professional) until it has been present for a long time (around 10 years28). Given the advantages and cost effectiveness of managing hearing loss at an earlier stage, the committee agreed that in addition to referring people for assessment when they directly report hearing problems, GPs, other healthcare professionals and carers should actively consider the possibility of hearing problems in the course of routine consultations or care for other conditions. For example, if a patient appears to be having problems hearing the healthcare or social care professional when he or she is talking to them, they should specifically ask about hearing difficulties and recommend referral for audiological assessment. |
- Early versus delayed management of hearing loss - Hearing loss in adultsEarly versus delayed management of hearing loss - Hearing loss in adults
Your browsing activity is empty.
Activity recording is turned off.
See more...