Hearing loss, alone or in combination with impairment of other sensory modalities, can have an impact on patient safety.
In our September 12, 2017 Patient Safety Tip of the Week “Can You Hear Me Now?” we stressed that even minor degrees of hearing loss may impair communication between healthcare professionals and patients. Cudmore and colleagues (Cudmore 2017) found that, of 100 adults age 60 and older, 57 reported having some degree of hearing loss and 43 of the 100 reported mishearing a physician or nurse in a primary care or hospital setting. They identified several themes (in order of frequency): general mishearing, consultation content, physician-patient or nurse-patient communication breakdown, hospital setting, use of language, selective deafness. Some patients especially noted problems with similar sounding words. Others complained that the physician or nurse did not look at them while talking (we’ll bet some of these patients were lip reading) and others complained the healthcare professional spoke too fast or in too low a volume.
The accompanying editorial (Weinreich 2017) notes patients with hearing loss are missing instructions, missing diagnoses, and missing medication information. Weinreich notes that, in addition to physicians speaking too quickly or quietly, background noise may cause patients to miss messages. She notes we need to know when our patients have hearing loss and change how we communicate with hearing loss patients. She notes we need to:
Never assume that what is heard is actually understood. That emphasizes the concepts of “hear back” and “teach back” which we have stressed in our columns on health literacy and numeracy. (“Hear back” is obviously also critical in communication between healthcare professionals).
In all healthcare settings you need to assess whether your patients have hearing impairment (some of us won’t admit it!). Use some of the techniques noted above in the Cudmore and Weinreich articles. And, perhaps most importantly, use hear back and teach back to make sure your patients truly understand what you are trying to communicate to them.
So, one way hearing loss presents a threat to patient safety is through impairment of communication. But there are other ways that hearing loss is a patient safety issue. Hearing loss and impairment of other sensory modalities are risk factors for delirium. In our numerous columns on delirium, you’ve heard us note the importance of ensuring that hospitalized patients have their hearing aids and eye glasses brought in from home as part of delirium prevention or management programs.
And our February 2018 What's New in the Patient Safety World column “Global Sensory Impairment and Patient Safety” discussed the “multiple sensory deficit syndrome” as a major cause of impaired ambulation and falls. Many older patients have impairments of sensory function (such as vision, hearing, vestibular function, and proprioception) that individually are not severe enough to produce disability but collectively have an additive or synergistic effect that does result in disability. It also discussed a related concept, “global sensory impairment” (GSI), and its impact on overall health. Correia and colleagues assessed the 5 classical primary sensations (vision, hearing, touch, taste, and smell) in community-dwelling U.S. adults aged 57 to 85 (Correia 2016). They found that two-thirds of subjects had two or more sensory deficits, 27% had just one, and 6% had none. Seventy-four percent had impairment in taste, 70% in touch, 22% in smell, 20% in corrected vision, and 18% in corrected hearing. Older adults, men, African Americans, and Hispanics had greater multisensory impairment. Global Sensory Impairment (GSI) is also a predictor of morbidity and mortality in older adults (Pinto 2017).
In the past couple months, there have been several studies demonstrating the impact of hearing loss on health care utilization and costs.
Lin and colleagues (Lin 2018) did a cross-sectional analysis of responses of a nationally representative sample of 232.2 million individuals 18 years or older who participated in the National Health Interview Survey from 2007 to 2015 and responded to the questions related to the hearing and injury modules. 50.1% considered their hearing to be less than excellent. Accidental injuries occurred in 2.8% of survey respondents. In comparison with normal-hearing adults, the odds of accidental injury were higher in those with a little trouble hearing (4.1%; OR, 1.6), moderate trouble hearing (4.2%; OR, 1.7), and a lot of trouble hearing (4.8%; OR, 1.9). Work- and leisure-related injuries were more prevalent among those with self-perceived hearing difficulty.
Another recent study analyzed healthcare costs of insured older Americans found more than 20% higher total healthcare payments over 18 months for a group of insured individuals with hearing loss regardless of insurance type or hearing services use (Simpson 2018).
So, is there any evidence to suggest that correction of hearing has a positive impact on these healthcare utilization and cost issues? Mahmoudi and colleagues (Mahmoudi 2018) used the nationally representative 2013-2014 Medical Expenditure Panel Survey data to evaluate the use of hearing aids among 1336 adults aged 65 years or older with hearing loss. Use of hearing aids was associated with reduced probability of any ED visits and any hospitalizations and in reducing the number of nights in the hospital.
Of course, when we hear about accidental injuries in hearing-impaired individuals, we first of all attribute them to failure to hear things like honking horns or warning shouts. But hearing loss may have more subtle contributions to accidental injuries. While we usually think about vision, vestibular function, cerebellar function, and proprioception as being the primary modalities that keep us from falling, hearing also plays a role. You may not realize it but, when you are walking on a snow-covered walkway, a subtle change in auditory feedback from your footsteps might alert you that you have reached a dangerous patch of ice. Or you might miss the warning “creak” in a faulty stairway step or ladder rung.
So when you are evaluating your patients, whether during an annual risk factor assessment session or a health maintenance visit or an acute illness visit, pay careful attention to whether they may have hearing impairment. That is key to help prevent any miscommunication that could have adverse effects, but also to identify a potentially modifiable risk factor. Traditional Medicare does not currently cover the cost of hearing aids, though some Medicare Advantage plans may cover some costs or provide discounts for hearing aids. But you should at least point out the above studies to such patients so they understand the importance of hearing correction to the overall health status.
In an editorial accompanying the Mahmoudi study, Wallhagen (Wallhagen 2018) points out that hearing assessment can be simple and not time consuming. You can use a combination of a simple question and a brief objective test like a finger rub or whisper test, or a brief questionnaire like the Hearing Handicap Inventory for the Elderly. She points out that this takes minimal time and can be scheduled at regular intervals, much like the foot examination for a patient with diabetes.
Cudmore V, Henn P, O’Tuathaigh CMP, et al. Age-Related Hearing Loss and Communication Breakdown in the Clinical Setting. JAMA Otolaryngol Head Neck Surg 2017; Published online August 24, 2017
Weinreich HM. Hearing Loss and Patient-Physician CommunicationThe Role of an Otolaryngologist. JAMA Otolaryngol Head Neck Surg 2017; Published online August 24, 2017
Correia C, Lopez KJ, Wroblewski KE et al. Global sensory impairment in older adults in the United States. J Am Geriatr Soc 2016; 64: 306-313
Pinto JM, Wroblewski KE, Huisingh-Scheetz M, et al. Global Sensory Impairment Predicts Morbidity and Mortality in Older U.S. Adults. J Am Geriatr Soc 2017; 65: 2587-2595
Lin HW, Mahboubi H, Bhattacharyya N. Self-reported Hearing Difficulty and Risk of Accidental Injury in US Adults, 2007 to 2015. JAMA Otolaryngol Head Neck Surg 2018; Published online March 22, 2018
Simpson AN, Simpson KN, Dubno JR. Healthcare Costs for Insured Older U.S. Adults with Hearing Loss. Journal of the American Geriatrics Society 2018; First published: 24 May 2018
Mahmoudi E, Zazove P, Meade M, et al. Association Between Hearing Aid Use and Health Care Use and Cost Among Older Adults With Hearing Loss. JAMA Otolaryngol Head Neck Surg 2018; Published online April 26, 2018
Wallhagen MI. Hearing Aid Use and Health Care Costs Among Older Adults. JAMA Otolaryngol Head Neck Surg 2018; Published online April 26, 2018