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Interview with Chien-Wen W. Tseng, MD, USPSTF member and coauthor of USPSTF Recommendation: Screening for Hearing Loss in Older Adults
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>> From the JAMA Network, this is conversations with Dr Bauchner, interviews featuring researchers and thinkers in healthcare about their publications in the latest issue of JAMA.
>> Howard Bauchner: Hello, and welcome to conversations with Dr Bauchner. Once again, it is Howard Bauchner, Editor in Chief of JAMA. And I'm here with Chien-Wen Tseng. Chien-Wen is a physician, is a professor, and is the Associate Research Director in the Department of Family Medicine and Community Health at the University of Hawaii John A Burns School of Medicine. Welcome, Chien-Wen.
>> Chien-Wen Tseng, MD: Thanks, Howard. It's a pleasure to be here.
>> Howard Bauchner: So we're going to be discussing the U.S Preventative Services Task Force recommendation statement entitled "Screening for Hearing Loss in Older Adults," but Chien-Wen before we start I ask this each time. What's it like to be a member of the Task Force?
>> Chien-Wen Tseng, MD: You know, Howard, this is actually starting my fifth year, and I've been asked this question several times, but I still use the same one which is it is an honor and it's amazing. It's an incredible group of people to work with and the work we're doing is so important for people.
>> Howard Bauchner: What do you think you've learned by being on the Task Force for five years?
>> Chien-Wen Tseng, MD: One is humbleness because there's always a lot to learn. It's really understanding sort of the importance of preventative healthcare. I mean I know we understand that as primary care physicians, but when you're diving deep and you're looking at all of this data and all these facts, and then you come back and you see it translated into ways that really impact care for people, I mean the ones you come away with is, you know, what we do is really important.
>> Howard Bauchner: Well, people have heard me say it on almost every Task Force podcast. They know how much I love the Task Force. And clearly it is so impactful on population health in the United States. So let's start with the recommendation statement around screening for hearing loss. What is the summary of the recommendation?
>> Chien-Wen Tseng, MD: Sure. So this is -- the particular topic is on age related hearing loss. And this is an I statement meaning that the U.S Preventative Services Task Force looked at the evidence and concluded that the evidence is actually insufficient to assess the balance of benefits and harms of screening for hearing loss in older adults.
>> Howard Bauchner: Now we'll go through the statement. I think people will be disappointed by the I statement, but I think there's very, very good evidence for it. But before we get to the evidence, can you talk about the magnitude of the problem?
>> Chien-Wen Tseng, MD: Sure. I mean I think everybody understands that hearing loss is extremely important. It's very common. As many as, you know, over 40% of people aged 70 years and older self-report hearing loss. And we actually do diagnostic hearing tests. It can be as many as 2/3 of people in the age group 70 and over. So the problem that we're working on is actually age related hearing loss which is the most common type of hearing loss that we have which is basically I believe each year degrades over time. And it's just related to age. Now there may be other factors, but in this case age really is the most common. It's an important public health burden because it has tremendous impact on I believe the function or quality of life especially at times when we can't communicate properly because of problems with hearing. It can lead to social distancing, depression, cognitive decline, as well as other health issues. So really being able to address it and to say, "Hey, you know what? If we screen for hearing loss in people who aren't reporting any signs or symptoms or have concerns about hearing loss, we know we can catch it early. Does this really make a difference, though, when we do this screening? Does it make a difference on people's health?“
>> Howard Bauchner: So let's walk through some of the different categories that are within the recommendation statement because I always find the recommendation statements it's not just the recommendation, it's they also contain a great deal of important and practical information for clinicians. When the Task Force is talking about hearing loss, what definition of hearing loss are they using?
>> Chien-Wen Tseng, MD: So there's no one single definition of hearing loss. We do detect hearing loss by formal audiometry. So although there's no one single definition of hearing loss, general guidelines would say if for the frequencies that are most important to speech, which is between 500 to 4,000 hertz, somebody would have mild hearing loss if they had the inability to hear those frequencies at 25 decibels or lower. It has to be at least 25 decibels or louder. If they can't hear lower, then it's mild hearing loss. If somebody needs at least 40 decibels or louder, then that's considered moderate hearing loss. And to sort of put it all in context, you know, when somebody whispers in conversation, that's about a 20 decibel loudness. When somebody talks in a normal conversation, that's about 30. And then when crying babies and other louder sounds are, you know, starting around 60 and above decibels.
>> Howard Bauchner: Thanks for giving those examples because it's always funny when someone says 25 decibels. Who would actually know what that was? So I really like that notion of whispering, talking, and then a crying baby.
>> Chien-Wen Tseng, MD: Yeah. We’ve had the experience of crying babies. Most of us have. And so, you know, when I say whispering is at 20 decibels, you can understand that if you are starting to require 25 decibels or louder, you may not be able to hear somebody whisper. But if normal communication is 30 decibels loud, you can still hear conversations. So that might be considered some moderate hearing loss. If you are having trouble hearing and need 40 decibels or louder, then you're actually experiencing with, you know, actual just conversation. Difficulties hearing conversation just at 30 decibels or louder.
>> Howard Bauchner: Now there's screening tests short of formal testing. What are some of the screening tests that the Task Force examined?
>> Chien-Wen Tseng, MD: There's different ways of actually trying to figure out who might have this measurable hearing loss that we can do in screening and primary care. It can be something as simple as asking the questions, "Do you have problems with your hearing?" Or it can be a questionnaire that asks a series of problems about whether somebody's having problems with hearing or function because of problems with hearing. The other way to do it is actually to do some type of physical test. And again that can be pretty simple such as whispering as a test, rubbing fingers as a test, or doing something that is a -- it's not the full diagnostic audiometry, but it's sort of a smaller less detailed one that just tests hearing at certain frequencies. So this might be, for instance, an otoscope that emits a sound that you just do some preliminary testing. If that is positive, then somebody goes on to the full audiogram.
>> Howard Bauchner: So the screening tests where you talk about whispering or some of the other approaches, after the screening test would be positive then it could go on to the mechanical testing of hearing. Would that be a kind of current practice?
>> Chien-Wen Tseng, MD: Yes. I think most people would say primary care doctors do the screening. Then we do it either by a small physical test like whispering or finger rubbing or we will do it with a question either asking do you have problems with hearing or a series of questions [inaudible] hearing and functions because of the problems with hearing. That then goes on to a hearing specialist or a diagnostic test. So this is usually an audiologist who will put you in a sound proof booth and do a more sophisticated test looking at ability to hear at certain frequencies and the loudness it takes for somebody to hear it.
>> Howard Bauchner: Do we have a sense of what actually goes on at the national level, a sense of current practice in the United States?
>> Chien-Wen Tseng, MD: I think it's hard to really understand. There's not a lot of huge data about how often primary care doctors are doing the initial screening tests or how often we're necessarily sending people for audiograms. What we do know is that for physicians we know that there are some barriers in the sense of not having the knowledge we need and definitely lack of time. And we know from the patient side there's definitely issues of potential same thing awareness, lack of time, and even lack of resources to get those tests. So we know it's an important problem to try to think about and address.
>> Howard Bauchner: Let's go on to the supporting evidence because that really is the basis for the I statement. And the supporting evidence is broken out into different categories, so let's talk about the accuracy of screening tests and risk assessment. If you could just briefly summarize sort of the weight of the evidence with respect to accuracy of screening tests and risk assessment.
>> Chien-Wen Tseng, MD: Sure. First we have to really think about what do we really mean by accuracy. And by accuracy what we say is if we screen somebody one way or the other, when we send them on to a formal audiogram, do they actually have detectable hearing loss by some of the standards we talked about? So we know it is -- there's enough accuracy in some of the tests that we talked about before where we can actually identify people who have measurable hearing loss. I think this is what we'll get to later which is the difficulty that we have is that somebody who has detectable hearing loss by a diagnostic measurement may or may not always have problems with their hearing in terms of function or even perceive that they have a hearing loss. And the flip is also true which is some people who feel like they have hearing loss or a problem with hearing loss, when they're sent on to audiograms they actually have normal hearing. And that's really -- you know, it's not a problem that we can actually measure. Having said all that, some of the tests that we do it's been shown that we actually have sufficient accuracy to, one, detect people who go on to have measured hearing loss.
>> Howard Bauchner: Benefits of early detection and treatment, that is often the key to screening case findings. What do we know about the actual benefits of early detection and treatment?
>> Chien-Wen Tseng, MD: I think this is the really tough part. You asked a key question. We have to know that there is a benefit. So when the Task Force reviewed the evidence the way we looked at benefit was to say, "We know from evidence we can actually improve hearing." You know, somebody gets a hearing assisted device. You can improve hearing. But the benefits and health outcomes we're looking for is improvement in quality of function or a decrease in morbidity. So that, for instance, could be a decreased risk of -- whether there's any change in rates of cognitive decline, depression, or any other things like hospitalization, falls, or even death. Those are the outcomes that are most important to us. Now of the evidence that's out there, one of the ways we look at evidence is has anybody done an actual screening study. So there has been one that's been done. It's known formally as the say what study. And this was a study that took over 2,000 veterans and it put them in to three intervention arms, meaning that they got screened. Three out of the four groups got screened. And one group had a control arm that didn't get active screening. But the three intervention arms that got screened, they were screened in one of three ways. One is they were asked a questionnaire that measured whether they had problems in hearing or problems with function because of hearing. If they tested positive for that, they were actually referred to an audiologist. The second was actually an otoscope that emitted sounds where they could test for hearing. And if there was an abnormality there, they got referred on as well. The third was they did both those tests, and if either test was positive they sent people on. And in this case people could choose whether they went on to an audiologist or not. When they saw the audiologist, they could choose whether or not they wanted the intervention of a hearing assistive -- a hearing aid or not. While it's true that the intervention group did have higher rates of hearing aid use, the overall rates of hearing aid use even in the intervention group was extremely low. So this was between around 4% to a little over 7% even when people got their hearing intervention of screening. And even in this case hearing aids were completely free as well. So that really makes it difficult for us to understand, well, what is the benefit if we do all the screening, but people actually don't go on to actually use hearing aid use? The other is their measurement was really looking at rates of hearing aid use, and what we're looking for is is there really a difference in quality of life or health outcomes. So we don't have the answers based on that from a direct study.
>> Howard Bauchner: It seems like the Task Force often makes recommendations around future research efforts. It would seem like this is where the research effort really is needed. It does appear as though there are a number of screening tests. They are reasonably accurate. But the key is this benefits question. It seems that's where their data are lacking.
>> Chien-Wen Tseng, MD: Yeah. You just summed it up. It's just we know we can detect hearing loss. We have the screening tools to do that. We know that when people have it, you can give them assistive hearing devices that will improve their measured level of hearing. What we need to see is in people who don't have symptoms or are having problems, when we do that and we do the screening and we detect it, do they go on to use any sort of an intervention? And then does it ultimately have a benefit improving health outcomes? And that's really what the data's lacking. It's a huge research gap.
>> Howard Bauchner: Harms of screening?
>> Chien-Wen Tseng, MD: So we actually believe that the harms of screening are fairly small. The screening process of asking a question or doing a small simple physical test is not invasive and there's really very little harms to it. Having said that, there still has to be a benefit for us to do the screening in the sense that it does take time and commitment and effort especially if some of these screenings are positive and we go on to refer people to formal audiograms. People have to go and get them and get the tests. If there's not a health benefit to that in terms of function, it takes resources from people to go ahead and do that. So we really want to make sure that there's a benefit to help if we do so.
>> Howard Bauchner: Now I think some people will be disappointed with the I statement because everyone knows that hearing loss particularly as you get older is more common and can be difficult. I think many people have experienced it. Interestingly enough, my father went deaf when he was in the military, and he learned to read lips. But it was very difficult going out to dinner with him or if there were multiple conversations around the dinner table. So I think people will be disappointed with the I statement, but it does seem that's where the data lead. What are the recommendations of the other groups?
>> Chien-Wen Tseng, MD: Well I think, you know, there are several other groups that have come out with recommendations on this, and they recognize this importance of hearing loss. There are groups that actually agree in the sense that they don't find that there's enough of a benefit to recommend screening in general for everybody. There are also other groups that recommend hearing screening. So for instance American Geriatrics Society will say screen adults aged 65 years and older annually for hearing loss. And there are other groups that actually recommend to screen earlier or more frequently. What this means is that we actually -- we believe that this is an important problem. We're all in agreement with that. And because this is an I statement, there's insufficient evidence, sometimes it can come down to clinical judgment or expert opinion. So we can't say what the other groups do in terms of how they get to their recommendations. What we can say is when we look at the evidence piece of it right now this is an I statement with insufficient evidence. I think it's very important to understand that because of the evidence that's an I statement, but this is not a recommendation for or against screening. So we definitely don't want people to say oh we are recommending against screening. What we're saying is there's a tremendous gap in the research on how to do this in the right way to see if there is a benefit or not. And that's why it's an I statement.
>> Howard Bauchner: So Chien-Wen I want to reemphasize that, what you just said, because I think sometimes people confuse the I statement with the Task Force recommending not to do screening. And that's not at all what the I statement implies. It means simply that there's insufficient evidence. Could you comment on that again?
>> Chien-Wen Tseng, MD: Sure. What we're looking for here is really if we screen and we detect people before they feel like they have a problem with hearing loss or they're aware of hearing loss, were there any sort of intervention that could be done after that so that we can actually improve health outcomes? And the I statement is really just saying there's insufficient evidence right now, and we really need more of this evidence. And so that's our role as a Task Force is to say -- to call the importance of this research gap, and how we need to address it.
>> Howard Bauchner: So Chien-Wen you're a physician. You see patients. So you have the I statement, but you're seeing patients. How do you integrate the I statement with the patient who's in front of you?
>> Chien-Wen Tseng, MD: Well I think the message for clinicians and myself as a family medicine doc, this is how we approach it, and that is one we want to get the message out to people that hearing loss is common and that it's important and we should not forget about it. So if anybody comes to us with a concern, we should definitely be aware of it and want to address it directly. And any patient who has concerns should definitely ask their provider to help them with the options of how to address this because it does affect quality of life. Two is definitely remember that it's not a recommendation against -- I apologize. Can you guys hear my dog?
>> Howard Bauchner: Yep, but that's okay. It's funny. I like hearing dogs. And that means my hearing's okay. So keep going.
>> Chien-Wen Tseng, MD: The dog test. We add another screening.
>> Howard Bauchner: It's the dog test.
>> Chien-Wen Tseng, MD: Okay. And the second thing I would say is that for clinicians we really want to make sure too that they understand this is not a recommendation against screening. It just means that we have to use our clinical judgment. And third. If somebody comes in with symptoms, so for instance they might say, "Oh, I have depression," or "I'm really feeling isolated" or they say "My mom or dad has cognitive decline." Since they're having trouble, that might be an appropriate time. It's okay to ask. You know, and to think about sharing as one of the potential causes. So again it's not a recommendation against screening. We simply don't know whether or not there's a benefit to doing it on everybody who doesn't have reports of hearing problems.
>> Howard Bauchner: This is Howard Bauchner, editor in chief of JAMA, and I've been here with Chien-Wen Tseng who is a professor and the associate research director in the Department of Family Medicine and Community Health at the University of Hawaii John A Burns School of Medicine. Chien-Wen is a member of the U.S preventative services Task Force, and we've been discussing the U.S Preventative Services Task Force recommendation statement entitled Screening for Hearing Loss in Older Adults. Again to all of you I say thank you for listening. For more of our podcast, please visit us at jamanetworkaudio.com. You can listen and subscribe on your favorite podcast app. Chien-Wen, thanks so much for joining me today.
>> Chien-Wen Tseng, MD: Thank you, Howard. It’s always a pleasure.
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