Hearing matters: An audiology and geriatrics collaboration to improve hearing care service utilization among older Veterans

Abstract: Hearing impairment is highly prevalent among older Americans, with estimates of 80% of US adults over the age of 85 having significant hearing loss that impairs communication. Hearing loss is associated with increased mortality, a higher risk of cognitive decline, depressive symptoms, and worse quality of life in older adults; it is estimated to be the largest potentially modifiable risk factor for dementia. Although hearing loss is prevalent among older veterans, it is underdiagnosed and undertreated. Hearing aids have been shown to significantly improve the adverse effects associated with hearing loss. The Veterans Affairs (VA) healthcare system provides universal access to audiology care but many veterans may not be accessing the benefits. We report lessons learned from a quality improvement initiative to increase the access of hearing care services by veterans in a Geriatrics Consult clinic. An audiology team reviewed geriatrics schedules weekly to identify and electronically communicate to Geriatrics providers the audiology needs of veterans with upcoming appointments. Geriatrics providers could then discuss hearing care needs during the visit and place appropriate referrals including audiology and/or ear cleaning if indicated. We reviewed 50 charts randomly selected via convenience samples from 2017 to 2018 to determine the impact of the audiology and geriatrics partnership on veterans' access to appropriate audiology care. Local ethics review deemed the study to be a quality improvement initiative and so it was exempted from further review. At the time of chart review, of the 50 veterans reviewed, 49 were male (98%), the average age was 80.96 years, 39 had a diagnosis of dementia on their problem list (78%), 25 had a diagnosis of hearing impairment (50%), and 30 died during the 3-year follow-up period (60%) (Table 1). The audiology review of the 50 charts sampled revealed that prior to their Geriatrics appointment, 18 patients had never had audiology testing (36%), and 14 patients had hearing aids older than 2 years and were due for updates (28%) (Figure 1). Of the 50 patients reviewed, 10 (20%) did not attend their Geriatrics appointment. Of the 40 who presented to Geriatrics, eight received referrals to audiology (20%) and three received referrals for ear cleaning (8%). Of the eight veterans referred for audiology, two did not go to their appointments (25%), one did not qualify for hearing aids (13%), one declined hearing aids (13%), and four received new hearing aid prescriptions (50%). Of the veterans referred for ear cleaning, one did not go to their appointment (33%). An audiology-geriatrics quality improvement collaboration revealed that hearing loss was highly prevalent among a sample of veterans in a Geriatrics Consult clinic, and the partnership led to the provision of new hearing aids or ear cleaning in five veterans of the 50 charts reviewed (10%). However, audiology referrals were not consistently placed when indicated by audiology review, in some cases because patients declined. There was also a 20% or greater no-show rate to geriatrics and audiology appointments. This review highlights possible barriers to receiving audiology care among older veterans and suggests that even if care is free and accessible, a dedicated review to identify high-risk patients may be insufficient to ensure care is received. High rates of dementia among the clinic population (78%) may contribute to high no-show rates, as well as the need to address multimorbidity taking precedence over hearing impairment. Telehealth, which has been shown to significantly decrease no-show rates for this population, may provide one solution. This study is one of the first to examine methods of improving utilization of hearing care services. Limitations of the study included limited generalizability given it was a single-site study with a largely male population. Given hearing impairment's impact on the age-friendly domains of memory, mood, mobility, and more, and as hearing aids have recently been approved to be available over the counter, the need to characterize and address the barriers to hearing care in future studies is all the more urgent.

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