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Objective: To determine normative values for the Inner Effectiveness of Auditory Rehabilitation (Inner EAR) scale, a validated instrument utilized to study the impact of hearing loss and potential treatments., Study Design: Observational outcomes study., Setting: Academic medical center and community care sites., Methods: We included patients who were at least 18 years of age and completed the Inner EAR scale, pure-tone audiometry, and word recognition score assessment. Based on audiometry results, patients were categorized as having: (1) normal bilateral hearing, (2) unilateral hearing loss, and (3) bilateral hearing loss. The distributions of Inner EAR scale scores were assessed within each category. Fisher's exact test was utilized to determine whether data-driven threshold values could discriminate among the 3 clinical groups., Results: Two hundred and twenty-two consecutive patients with hearing-related complaints met inclusion criteria. Mean Inner EAR scores for patients with bilateral hearing loss (29.2, interquartile range [IQR] 10-41.5), unilateral hearing loss (38.9, IQR 23-49), and normal hearing (46.6, IQR 31-62) were significantly different (analysis of variance F < 0.0001). An Inner EAR score threshold of 50 supported the ability to statistically significantly discriminate between bilateral hearing loss and normal hearing (p = .003), as well as between unilateral hearing loss and normal hearing (p = .015)., Conclusion: An Inner EAR score normative threshold value of 50 provides significant discriminatory ability between normal hearing and unilateral or bilateral hearing loss on audiometry. Normative values provide useful, frequently referenced data when assessing responses to treatment. Based on these data, this threshold may help distinguish patients with and without perceived functional impact from hearing loss., (© 2023 American Academy of Otolaryngology-Head and Neck Surgery Foundation.)

Objectives (1) To assess the 11-item Inner Effectiveness of Auditory Rehabilitation (Inner EAR) instrument with item response theory (IRT). (2) To determine whether the underlying latent ability could also be accurately represented by a subset of the items for use in high-volume clinical scenarios. (3) To determine whether the Inner EAR instrument correlates with pure tone thresholds and word recognition scores. Design IRT evaluation of prospective cohort data. Setting Tertiary care academic ambulatory otolaryngology clinic. Subjects and Methods Modern psychometric methods, including factor analysis and IRT, were used to assess unidimensionality and item properties. Regression methods were used to assess prediction of word recognition and pure tone audiometry scores. Results The Inner EAR scale is unidimensional, and items varied in their location and information. Information parameter estimates ranged from 1.63 to 4.52, with higher values indicating more useful items. The IRT model provided a basis for identifying 2 sets of items with relatively lower information parameters. Item information functions demonstrated which items added insubstantial value over and above other items and were removed in stages, creating a 8- and 3-item Inner EAR scale for more efficient assessment. The 8-item version accurately reflected the underlying construct. All versions correlated moderately with word recognition scores and pure tone averages. Conclusion The 11-, 8-, and 3-item versions of the Inner EAR scale have strong psychometric properties, and there is correlational validity evidence for the observed scores. Modern psychometric methods can help streamline care delivery by maximizing relevant information per item administered.

Objective To assess disease-specific (Inner EAR) and general (Patient-Reported Outcomes Measurement Information System [PROMIS]) health status in patients reporting hearing loss and whether there is enough correlation between scales such that the general instrument alone could suffice. Study Design Correlation analysis of prospective cohort data. Setting Tertiary care academic medical center. Methods Adults presenting with a chief complaint of hearing loss completed the Inner EAR scale and the PROMIS instrument. Summary statistics, including means, percentiles, and measures of variance, were calculated. The Spearman ρ statistic was used to test the null hypothesis that there were no correlations between the Inner EAR composite or global score and PROMIS scores. Results The mean Inner EAR composite score was 35.6, while the global item had a mean score of 4.8. Mean PROMIS-10 scores were 16.0 for physical health and 15.3 for mental health. The global item and social item had mean scores of 3.6 and 3.8, respectively. Inner EAR composite scores were significantly correlated with the PROMIS mental health summary scores (Spearman ρ = 0.3, P = .0066) and the PROMIS social item score (Spearman ρ = 0.4, P = .0005). The Inner EAR global item was moderately correlated with the PROMIS social item score (Spearman ρ = 0.3, P = .0118), while there was no significant correlation between the Inner EAR global item and the PROMIS physical health, mental health, or global item scores. Conclusions Inner EAR and a subset of PROMIS scores have weak to moderate correlations. Disease-specific assessment still confers independent value.

Introduction and Objectives: It is becoming increasingly important to have reliable and valid questionnaires. This becomes especially important when evaluating hearing loss., The Aim of This Work Was to Validate: the "Effectiveness of Auditory Rehabilitation" (EAR) questionnaire for the Spanish-speaking population. This instrument assesses quality of life and hearing aspects in patients using hearing aids., Material and Method: Cross-sectional validation study. A cultural adaptation through the use of English to Spanish translations and re-translations was carried out. The validity and reliability of the newly adapted instrument were evaluated., Results: A total of 69 individuals (44 older adults and 25 younger adults) were examined. The pure-tone averages (PTA, 500, 1,000 and 2,000 Hz) were 47.3 dB HL and 47.1 dB HL for the left and right ears, respectively. The mean maximum speech discrimination in silence for monosyllables were 83.3% and 82.9% for the left and right ears, respectively. Internal consistency presented Cronbach alpha values of 0.85 and 0.77 for the internal and external dimensions, respectively. The intraclass correlation coefficients were 0.80 for the internal module and 0.85 for the external module. Construct validity reported a correlation coefficient of 0.71 at baseline and 0.76 at 3 months after the initial assessment for the internal module, and 0.62 at baseline and 0.74 at 3 months after the initial assessment for the external module. The size effects were 1.3 and 1.1 for the internal and external modules, respectively., Discussion: The Spanish version of the EAR questionnaire seems to be a reliable and valid instrument. The evaluation of audiological aspects, as well as aspects relating to aesthetics and comfort are the main strengths of this instrument. Finally, the EAR scale is more sensitive to change than other scales., (Copyright © 2013 Elsevier España, S.L. All rights reserved.)

Hearing loss is common in older adults. Patients, clinicians, and health care staff often do not recognize hearing loss, particularly in its early stages, and it is undertreated. Age-related hearing loss or presbycusis, the most common type of hearing loss in older adults, is a multifactorial sensorineural loss that frequently includes a component of impaired speech discrimination. Simple office-based screening and evaluation procedures can identify potential hearing disorders, which should prompt audiologic referral to confirm the diagnosis with audiometric testing. The mainstay of treatment is amplification. For many older adults, accepting the need for amplification, selecting and purchasing a hearing aid, and getting accustomed to its use is a daunting and often frustrating process. There are numerous barriers to hearing aid use, the most common of which is dissatisfaction with its performance across a range of sonic environments. Newer digital hearing aids have many features that improve performance, making them potentially more acceptable to users, but they are expensive and are not covered by Medicare. Hearing aids have been demonstrated to improve hearing function and hearing-related quality of life (QOL), but evidence is less robust for improving overall QOL. Depending upon the etiology of the hearing loss, other medical and surgical procedures, including cochlear implantation, may benefit older adults. Older adults with multiple morbidities and who are frail pose specific challenges for the management of hearing loss. These patients may require integration of hearing assessment and treatment as part of functional assessment in an interdisciplinary, team-based approach to care.

Routine hearing screening can identify patients who are motivated to seek out and adhere to treatment, but little information exists on the cost-effectiveness of hearing screening in a general population of older veterans. We compared the cost-effectiveness of three screening strategies (tone-emitting otoscope, hearing handicap questionnaire, and both together) against no screening (control group) in 2,251 older veterans. The effectiveness measure for each group was the proportion of hearing aid use 1 year after screening. The audiology cost measure included costs of hearing loss screening and audiology care for 1 year after screening. Incremental cost-effectiveness was the audiology cost of additional hearing aid use for each screening group compared with the control group. The mean total audiology cost per patient was $77.04, $122.70, $121.37, and $157.08 for the control, otoscope, questionnaire, and dual screening groups, respectively. The tone-emitting otoscope appears to be the most cost-effective approach for hearing loss screening, with a significant increase in hearing aid use 1 year after screening (2.8%) and an insignificant incremental cost-effectiveness of $1,439.00 per additional hearing aid user compared with the control group. For this population of older veterans, screening for hearing loss with the tone-emitting otoscope is cost-effective.

Objectives: To evaluate the effect of hearing screening on long-term hearing outcomes in a general population of older veterans., Design: Hearing loss in the elderly is underdetected and undertreated. Routine hearing screening has been proposed, but it is not clear whether screening identifies patients who are sufficiently motivated to adhere to treatment. A four-arm randomized clinical trial was conducted to compare three screening strategies with no screening in 2,305 older veterans seeking general medical care., Setting: Veterans Affairs Puget Sound Health Care System., Interventions: The screening strategies were a tone-emitting otoscope, a widely used questionnaire about hearing handicap, and a combination of both tools., Measurements: Hearing aid use 1 year after screening., Results: Of participants who underwent screening with the tone-emitting otoscope, questionnaire, and combined testing, 18.6%, 59.2%, and 63.6%, respectively, screened positive for hearing loss (P<.01 for test of equality across three arms). Patients proceeded to formal audiology evaluation 14.7%, 23.0%, and 26.6% of the time in the same screening arms, compared with 10.8% in the control arm (P<.01 for test of equality across four arms). Hearing aid use 1 year after screening was 6.3%, 4.1%, and 7.4% in the same arms, compared with 3.3% in the control arm (P<.01). Hearing aid users experienced significant improvements in hearing-related function and communication ability., Conclusion: In older veterans, screening for hearing loss led to significantly more hearing aid use. Screening with the tone-emitting otoscope was more efficient. The results are most applicable to older populations with few cost barriers to hearing aids.

Background: Hearing impairment is the most common body system disability in veterans. In 2008, nearly 520,000 veterans had a disability for hearing loss through the Department of Veterans Affairs (VA). Changes in eligibility for hearing aid services, along with the aging population, contributed to a greater than 300% increase in the number of hearing aids dispensed from 1996 to 2006. In 2006, the VA committed to having no wait times for patient visits while providing quality clinically-appropriate care. One approach to achieving this goal is the use of group visits as an alternative to individual visits. We sought to determine: 1) if group hearing aid fitting and follow-up visits were at least as effective as individual visits, and 2) whether group visits lead to cost savings through the six month period after the hearing aid fitting. We describe the rationale, design, and characteristics of the baseline cohort of the first randomized clinical trial to study the impact of group versus individual hearing aid fitting and follow-up visits., Methods: Participants were recruited from the VA Puget Sound Health Care System Audiology Clinic. Eligible patients had no previous hearing aid use and monaural or binaural air-conduction hearing aids were ordered at the evaluation visit. Participants were randomized to receive the hearing aid fitting and the hearing aid follow-up in an individual or group visit. The primary outcomes were hearing-related function, measured with the first module of the Effectiveness of Aural Rehabilitation (Inner EAR), and hearing aid adherence. We tracked the total cost of planned and unplanned audiology visits over the 6-month interval after the hearing aid fitting., Discussion: A cohort of 659 participants was randomized to receive group or individual hearing aid fitting and follow-up visits. Baseline demographic and self-reported health status and hearing-related measures were evenly distributed across the treatment arms.Outcomes after the 6-month follow-up period are needed to determine if group visits were as least as good as those for individual visits and will be reported in subsequent publication., Trial Registration: NCT00260663.

Objectives: Assessment of cochlear implant outcomes centers around speech discrimination. Despite dramatic improvements in speech perception, music perception remains a challenge for most cochlear implant users. No standardized test exists to quantify music perception in a clinically practical manner. This study presents the University of Washington Clinical Assessment of Music Perception (CAMP) test as a reliable and valid music perception test for English-speaking, adult cochlear implant users., Design: Forty-two cochlear implant subjects were recruited from the University of Washington Medical Center cochlear implant program and referred by two implant manufacturers. Ten normal-hearing volunteers were drawn from the University of Washington Medical Center and associated campuses. A computer-driven, self-administered test was developed to examine three specific aspects of music perception: pitch direction discrimination, melody recognition, and timbre recognition. The pitch subtest used an adaptive procedure to determine just-noticeable differences for complex tone pitch direction discrimination within the range of 1 to 12 semitones. The melody and timbre subtests assessed recognition of 12 commonly known melodies played with complex tones in an isochronous manner and eight musical instruments playing an identical five-note sequence, respectively. Testing was repeated for cochlear implant subjects to evaluate test-retest reliability. Normal-hearing volunteers were also tested to demonstrate differences in performance in the two populations., Results: For cochlear implant subjects, pitch direction discrimination just-noticeable differences ranged from 1 to 8.0 semitones (Mean = 3.0, SD = 2.3). Melody and timbre recognition ranged from 0 to 94.4% correct (mean = 25.1, SD = 22.2) and 20.8 to 87.5% (mean = 45.3, SD = 16.2), respectively. Each subtest significantly correlated at least moderately with both Consonant-Nucleus-Consonant (CNC) word recognition scores and spondee recognition thresholds in steady state noise and two-talker babble. Intraclass coefficients demonstrating test-retest correlations for pitch, melody, and timbre were 0.85, 0.92, and 0.69, respectively. Normal-hearing volunteers had a mean pitch direction discrimination threshold of 1.0 semitone, the smallest interval tested, and mean melody and timbre recognition scores of 87.5 and 94.2%, respectively., Conclusions: The CAMP test discriminates a wide range of music perceptual ability in cochlear implant users. Moderate correlations were seen between music test results and both Consonant-Nucleus-Consonant word recognition scores and spondee recognition thresholds in background noise. Test-retest reliability was moderate to strong. The CAMP test provides a reliable and valid metric for a clinically practical, standardized evaluation of music perception in adult cochlear implant users.

Background: Effective screening programs should not merely detect presence of disease, but also lead to long-term benefit. We describe the rationale and design of the first randomized clinical trial to study the long-term effects of routine screening for hearing loss. We also describe the baseline characteristics of the randomized cohort., Methods: We randomized 2305 veterans age 50 years or older to a control arm without screening, or to screening with: physiologic testing (AudioScope), a self-administered questionnaire (Hearing Handicap Inventory for the Elderly-Screening version [HHIE-S]), or both tests. The primary outcome measure will be hearing aid use one year after screening. We will also study a number of secondary outcomes, including appointments made with and visits to an audiologist, cases of aidable hearing loss, hearing aids dispensed, self-rated communication ability, and hearing-related quality of life., Results: Baseline demographic and health status measures were evenly distributed across the screening arms. The percentage of patients who screened positive for hearing loss was 18.6%, 59.2%, and 63.6% for the AudioScope, HHIE-S, and combined screening arms, respectively., Implications: Long-term results are needed to gain insight into whether the AudioScope is associated with high rates of false negative screening, the HHIE-S is associated with high rates of false positive screening, or a combination of both. Identifying the best screening program will depend on determining which strategy leads to successful hearing aid use.

Demand for hearing aid services in the Veterans Health Administration increased over 300% from 1996 to 2005, challenging the delivery of timely, high-quality care. Using group visits may help meet these needs, but whether this approach would still provide high-quality rehabilitation is unclear. This study determined whether group visits worsen hearing aid outcomes. It included a retrospective observational cohort in veterans seeking hearing aids at the Department of Veterans Affairs Puget Sound Health Care System from September 2004 to March 2005, when the clinic was using both individual and group visits. Medical records were reviewed for all new hearing aid patients seen during this period. Hearing-related outcome questionnaires were compared between patients seen for individual versus group fitting and/or follow-up visits. Results revealed that hearing thresholds were similar between patients seen individually and in groups. Of 74 patients who returned self-administered questionnaires after the follow-up, those who received both fitting and follow-up in a group format reported similar hearing handicap and better hearing-related function, satisfaction, and adherence than patients who received individual visits. Group visits did not appear to yield worse outcomes in this nonrandomized retrospective chart review. Definitive statements must await randomized comparisons.

Context: Hearing loss is the third most prevalent chronic condition in older adults and has important effects on their physical and mental health. Despite these effects, most older patients are not assessed or treated for hearing loss., Objective: To review the evidence on screening and management of hearing loss of older adults in the primary care setting., Data Sources and Study Selection: We performed a search from 1985 to 2001 using MEDLINE, HealthSTAR, EMBASE, Ageline, and the National Guideline Clearinghouse for articles and practice guidelines about screening and management of hearing loss in older adults, as well as reviewed references in these articles and those suggested by experts in hearing impairment., Data Extraction: We reviewed articles for the most clinically important information, emphasizing randomized clinical trials, where available, and identified 1595 articles., Data Synthesis: Screening tests that reliably detect hearing loss are use of an audioscope, a hand-held combination otoscope and audiometer, and a self-administered questionnaire, the Hearing Handicap Inventory for the Elderly-Screening version. The value of routine screening for improving patient outcomes has not been evaluated in a randomized clinical trial. Screening is endorsed by most professional organizations, including the US Preventive Services Task Force. While most hearing loss in older adults is sensorineural and due to presbycusis, cerumen impaction and chronic otitis media may be present in up to 30% of elderly patients with hearing loss and can be treated by the primary care clinician. In randomized trials, hearing aids have been demonstrated to improve outcomes for patients with sensorineural hearing loss. Nonadherence to use of hearing aids is high. Prompt recognition of potentially reversible causes of hearing loss, such as sudden sensorineural hearing loss, is important to maximize the possibility of functional recovery., Conclusion: While untested in a clinical trial, older adults can be screened for hearing loss using simple methods, and effective treatments exist and are available for many forms of hearing loss.

Hearing loss is one of the most common chronic health conditions and has important implications for patient quality of life. However, hearing loss is substantially underdetected and undertreated. We present clinical cases to illustrate common situations in which primary care physicians may be called on to identify or to manage hearing loss. With the data reported in the companion scientific review as a guide, we present potential answers to important questions pertaining to hearing loss and suggest ways in which primary care physicians can improve the detection, evaluation, and treatment of hearing loss. The cases focus on screening for chronic hearing loss, evaluation of hearing loss, and treatment of patients with presbycusis.