Hearing Loss in Older Adults: Screening
March 23, 2021
Recommendations made by the USPSTF are independent of the U.S. government. They should not be construed as an official position of the Agency for Healthcare Research and Quality or the U.S. Department of Health and Human Services.
By Cynthia Feltner, MD, MPH; Ina F. Wallace, PhD; Christine E. Kistler, MD, MASc; Manny Coker-Schwimmer, MPH; Daniel E. Jonas, MD, MPH
The information in this article is intended to help clinicians, employers, policymakers, and others make informed decisions about the provision of health care services. This article is intended as a reference and not as a substitute for clinical judgment.
This article may be used, in whole or in part, as the basis for the development of clinical practice guidelines and other quality enhancement tools, or as a basis for reimbursement and coverage policies. AHRQ or U.S. Department of Health and Human Services endorsement of such derivative products may not be stated or implied.
This article was published online in JAMA on March 23, 2021 (JAMA. 2021;325(12):1202-1215. doi:10.1001/jama.2020.24855).
Importance: Hearing loss is common in older adults and associated with adverse health and social outcomes.
Objective: To update the evidence review on screening for hearing loss in adults 50 years or older to inform the US Preventive Services Task Force.
Data Sources: MEDLINE, Cochrane Library, EMBASE, and trial registries through January 17, 2020; references; and experts; literature surveillance through October 8, 2020.
Study Selection: English-language studies of accuracy, screening, and interventions for screen-detected or newly detected hearing loss.
Data Extraction and Synthesis: Dual review of abstracts, full-text articles, and study quality. Meta-analysis of screening test accuracy studies.
Main Outcomes and Measures: Quality of life and function, other health and social outcomes, test accuracy, and harms.
Results: Forty-one studies (N = 26,386) were included, 18 of which were new since the previous review. One trial enrolling US veterans (n = 2305) assessed the benefits of screening; there was no significant difference in the proportion of participants experiencing a minimum clinically important difference in hearing-related function at 1 year (36%-40% in the screened groups vs 36% in the nonscreened group). Thirty-four studies (n = 23,228) evaluated test accuracy. For detecting mild hearing loss (>20-25 dB), single-question screening had a pooled sensitivity of 66% (95% CI, 58%-73%) and a pooled specificity of 76% (95% CI, 68%-83%) (10 studies, n = 12,637); for detecting moderate hearing loss (>35-40 dB), pooled sensitivity was 80% (95% CI, 68%-88%) and pooled specificity was 74% (95% CI, 59%-85%) (6 studies, n = 8774). In 5 studies (n = 2820) on the Hearing Handicap Inventory for the Elderly–Screening to detect moderate hearing loss (>40 dB), pooled sensitivity was 68% (95% CI, 52%-81%) and pooled specificity was 78% (95% CI, 67%-86%). Six trials (n = 853) evaluated amplification vs control in populations with screen-detected or recently detected hearing loss over 6 weeks to 4 months. Five measured hearing-related function via the Hearing Handicap Inventory for the Elderly; only 3 that enrolled veterans (n = 684) found a significant difference considered to represent a minimal important difference (>18.7 points). Few trials reported on other eligible outcomes, and no studies reported on harms of screening or interventions.
Conclusions and Relevance: Several screening tests can adequately detect hearing loss in older adults; no studies reported on the harms of screening or treatment. Evidence showing benefit from hearing aids on hearing-related function among adults with screen-detected or newly detected hearing loss is limited to studies enrolling veterans.
Age-related hearing loss, the most common cause of hearing loss in older adults, is a type of sensorineural hearing loss related to age-related degeneration. It is typically gradual, progressive, and bilateral and affects higher hearing frequencies first.1 Pure-tone audiometry is the standard objective test for hearing loss and tests the ability to hear tones at a series of discrete frequencies, typically in the range of 250 to 8000 Hz, at various decibel levels. There is no universally accepted definition for hearing loss, although many guidelines define mild hearing loss as the inability to detect frequencies associated with speech understanding under 25 dB and moderate hearing loss as the inability to detect those frequencies under 40 dB. There is often discordance between objectively measured hearing loss on pure-tone audiometry and subjective perceptions of hearing problems.2,3
The prevalence of mild or worse speech-frequency hearing loss is estimated to be 14.1% among adults aged 20 to 65 years and increases significantly with age, up to 39.3% for adults aged 60 to 69 years.4 Observational studies indicate that hearing loss is associated with higher rates of incident disability and need for nursing care, social isolation, depressive symptoms, and cognitive decline or dementia.5-8
Use of hearing aids is the primary intervention for persons with newly detected mild or moderate hearing loss. Hearing aid use does not slow progression of hearing loss; the goal is to amplify sound reaching the middle or inner ear to improve communication and function associated with hearing impairment. In 2012, the US Preventive Services Task Force (USPSTF) concluded that evidence was insufficient to assess the balance of benefits and harms of screening for hearing loss in asymptomatic adults 50 years or older (I statement).9 This updated review evaluates the current evidence on screening for hearing loss for populations and settings relevant to primary care in the US to inform an updated recommendation by the USPSTF.
Scope of Review
Data Sources and Searches
PubMed/MEDLINE, the Cochrane Library, EMBASE, and ClinicalTrials.gov were searched for English-language articles from 2010 through January 17, 2020. Studies published before 2010 were identified from the prior systematic review for the USPSTF.12 To supplement searches, investigators reviewed reference lists of pertinent articles suggested by peer reviewers and public comment respondents. Since January 2020, ongoing surveillance was conducted through article alerts and targeted searches of journals to identify major studies published in the interim that may affect the conclusions or understanding of the evidence and the related USPSTF recommendation. Two studies of screening test accuracy were identified by ongoing surveillance (last conducted on October 8, 2020). One evaluated the Hearing Handicap Inventory for the Elderly–Screening (HHIE-S) and single-question screening,13 and the second evaluated a tablet-based pure-tone screening test and a word-in-noise test.14 Findings were similar to those reported by other studies of similar screening tests included in this review and did not change conclusions or the strength of evidence.
Two investigators independently reviewed titles, abstracts, and full-text articles using prespecified eligibility criteria. Disagreements were resolved by discussion and consensus. English-language studies of adults 50 years or older conducted in settings generalizable to primary care and in countries categorized as “very high” on the United Nations Human Development Index were included.15 The age criterion was chosen because of a higher prevalence of agerelated hearing loss in persons older than 50 years (compared with younger adults) and is consistent with the prior review for the USPSTF.
For KQ1 and KQ3 (direct evidence of benefits and harms of screening), randomized clinical trials (RCTs), nonrandomized controlled intervention studies, and cohort studies enrolling adults with asymptomatic or undetected hearing loss and comparing screening with no screening were eligible. For KQ2 (test accuracy), studies of asymptomatic or unselected older adults comparing 1 or more screening tests with diagnostic pure-tone audiometry were included. For KQs 1 through 3, eligible screening tests included those used, available, or feasible for use in primary care settings.
For KQs on benefits (KQ4) and harms (KQ5) of amplification, RCTs, nonrandomized controlled intervention studies, and cohort studies of adults with screen-detected or newly detected sensorineural hearing loss were included. Eligible studies compared amplification using any type of hearing aid, personal assistive listening devices, or personal sound amplification device (with or without additional education or counseling) with a no-amplification control group (no treatment, wait-list, or placebo amplification device). Eligible outcomes for KQs on the benefit of screening and treatment (KQ1 and KQ4) include measures of hearing-related quality of life (QOL) or function, general health-related QOL and function, depression, cognitive impairment, falls, and social isolation.
Data Extraction and Quality Assessment
For each study, 1 investigator extracted information about populations, tests or interventions, comparators, outcomes, settings, and designs, and a second investigator reviewed for completeness and accuracy. Two independent investigators assessed the quality of each study as good, fair, or poor. For RCTs, the most recent versions of the Cochrane Risk of Bias Tool available for parallel16 and crossover trials were used.17 For nonrandomized controlled intervention studies, the ROBINS-I tool was used.18 For studies of diagnostic test accuracy, the QUADAS-2 instrument was used.19 Risk-of-bias assessments using these instruments were translated into an overall study quality rating of good, fair, or poor using predefined criteria developed by the USPSTF and adapted for this topic.11 Only studies rated as good or fair quality were included. Individual study quality ratings are provided in eTables 2-12 and eTables 14-17 in the JAMA Supplement.
Data Synthesis and Analysis
Findings for each question were summarized in tables, figures, and narrative format. For KQ2, pooled sensitivities and specificities for screening tests were calculated using a hierarchical summary receiver operating characteristic curve analysis when at least 4 similar studies were available. Results were synthesized by type of screening test, as well as severity of hearing loss (eg, detection of mild vs moderate hearing loss). For studies that reported on multiple definitions of hearing loss, estimates included in pooled analyses were chosen based on similarity in decibel level, frequencies included in pure-tone audiometry, and laterality to other included studies. The metandi program in Stata version 14 was used to conduct all quantitative analyses.20
The overall strength of the body of evidence was assessed for each KQ as high, moderate, low, or insufficient using methods developed for the USPSTF (and the Evidence-based Practice program), based on the overall quality of studies, consistency of results between studies, precision of findings, and risk of reporting bias.11 The applicability of the findings to US primary care populations and settings was also assessed. Discrepancies were resolved through consensus discussion.
A total of 41 studies (45 articles) with 26,386 participants were included (Figure 2). Eighteen studies (20 articles)21-40 were newly identified in this review, and 23 studies (25 articles)41-65 were carried forward from the prior review for the USPSTF. Of these, 1 RCT evaluated the benefit of screening, 34 studies assessed test accuracy, and 6 trials evaluated the benefit of treatment among populations with screen-detected or recently detected hearing loss.
Benefits of Screening
Key Question 1A. Does screening for hearing loss in asymptomatic adults 50 years or older lead to improved health outcomes?
One fair-quality RCT included in the prior USPSTF review12 evaluated screening for hearing loss (n = 2305): the Screening for Auditory Impairment—Which Hearing Assessment Test (SAI-WHAT) trial.44,65 Participants were recruited from a VA Medical Center and randomized to usual care (no screening) or 1 of 3 screening approaches: a handheld screening audiometer (based on the inability to hear a 40-dB tone at 2000 Hz in either ear), a screening questionnaire (HHIE-S, based on a score ≥10), or both screening tests. Participants were predominantly male (94%), 50 years or older (mean, 61 years), and all were eligible to receive free, Veterans Administration–issued hearing aids. The study aimed to compare screening with usual care; however, baseline assessment (before randomization) included an assessment of self-perceived hearing loss; most participants (74%) reported perceived hearing loss at enrollment (based on a “yes” or “maybe” response to the question “Do you think you have hearing loss?”). Participants who screened positive for hearing loss in any of the screening groups were told that they might have hearing loss and were given written instructions to call the audiology clinic for an evaluation. Participants in the nonscreened group were provided with a telephone number for the audiology clinic if they wanted further assessment.
The proportion who screened positive in the groups randomized to screening was lowest in the screening audiometry group (19%) and higher in the HHIE-S group (59%) and combined group (64%). Hearing aid use at 1 year, the trial’s primary outcome, was significantly higher among participants in the screening audiometry group and combined group than among those in the nonscreened group (6.3% and 7.4% vs 3.3%, respectively; P < .01) but not among participants in the HHIE-S group compared with those in the nonscreened group (4.1% vs 3.3%; P > .40).
Therewas no significant difference in the proportion of participants who experienced a minimum clinically important difference (>6 points of improvement on a 0-100 scale) on the Inner Effectiveness of Aural Rehabilitation scale (a measureof hearing-related function) at 1 year (36%-40% in the screened groups vs 36% in the nonscreened group; P = .39).
Key Question 1B. Does the effectiveness of screening differ for subpopulations defined by age, sex, race/ethnicity, risk of past noise exposure, or comorbidity?
The SAI-WHAT trial conducted post hoc analyses of hearing-related function for subpopulations defined by age.44,65 There were no significant differences between screened and nonscreened groups in the proportion who experienced improvement on the Inner Effectiveness of Aural Rehabilitation scale when groups were stratified by age (50-64 years vs ≥65 years) and according to whether they had perceived hearing loss at baseline, except in a subgroup that both had perceived hearing loss at baseline and was 65 years or older (54% in the screening audiometry group, 34% in the HHIE-S group, 40% in the combined group, and 34% in the control group; P = .04).
Key Question 2. What is the accuracy of primary care–relevant screening tests for hearing loss in adults 50 years or older?
Thirty-four studies (reported in 35 articles) (n = 23,228) evaluated the diagnostic accuracy of clinical tests, a single question, a questionnaire, a handheld audiometric device, or a mobile-based audiometric application for identifying mild to moderate hearing loss in older adults. Some studies assessed the accuracy of multiple screening tests. All studies used pure-tone audiometry as the reference standard, although the thresholds and the criteria used to diagnose hearing loss varied both across and within studies.
Most studies included community-dwelling older adults enrolled from various outpatient clinical or community settings; 4 studies included adults who were in chronic care/rehabilitation facilities.53,54,57,62 Across the 28 studies that reported on the age of enrolled participants (mean, median, or range), the median age of participants was 69 years. Most studies (17) were set in the US;25,26,38,41,46,47,50-52,54-56,58,59,61-64 others were set in Canada,23,53 the UK,33,57,60 Australia,21,49 various European countries,22,24,27,29,30,39,40,48 and Asia.28,34 Six studies were rated as good quality21,23,39,50,59,64 and the remainder as fair quality.
Table 1 provides a summary of accuracy data by screening test, and eTables 20-23 in the JAMA Supplement present detailed evidence tables for each screening test type. For detecting mild hearing loss (>20-25 dB), single-question screening had a pooled sensitivity of 66% (95% CI, 58%-73%) and pooled specificity of 76% (95% CI, 68%-83%) (10 studies, n = 12,637);21,27,39,41,49,51,58,61,62,64 for single-question screening for detecting moderate hearing loss (>35-40 dB averaged over 2-4 frequencies), pooled sensitivity was 80% (95% CI, 68%-88%) and pooled specificity was 74% (95% CI, 59%-85%) (6 studies, n = 8774).21,28,39,49,51,55 Too few studies reported sufficient data to pool accuracy of the HHIE-S for detecting mild hearing loss (>25 dB at 2-4 frequencies); across 4 studies (n = 7194), sensitivity of HHIE-S (score >8) ranged from 34% to 58% and specificity from 76% to 95%.34,49,50,58 For detecting moderate hearing loss (>40 dB at 2-4 frequencies), the pooled sensitivity of HHIE-S using a score of greater than 8 (5 studies, n = 2820) was 68% (95% CI, 52%-81%) and pooled specificity was 78% (95% CI, 67%-86%).46,47,49,50,55 For detecting mild hearing loss (>25-30 dB), pooled sensitivity of the whispered voice test was 94% (95% CI, 31%-100%) and pooled specificity was 87% (82%- 90%) (5 studies, n = 669).33,41,48,57,60 Fewer studies reported on the accuracy of whispered voice to detect moderate hearing loss (>40 dB); sensitivity ranged from 30% to 60% and specificity from 80% to 98% (3 studies, n = 296).22,33,41 Two studies (n = 215) assessed the accuracy of a screening audiometer to detect at least mild hearing loss (>25 to >30 dB); sensitivity ranged from 64% to 93% and specificity from 70% to 91%.50,52 For detecting moderate hearing loss (>40 dB), 4 studies (n = 411) found relatively high sensitivity (94%-100%) and variable specificity (24%-80%) for the screening audiometer.47,48,50,53
Harms of Screening
Key Question 3A. What are the harms of screening for hearing loss in adults 50 years or older?
Key Question 3B. Do the harms of screening for hearing loss differ for subpopulations defined by age, sex, race/ethnicity, risk of past noise exposure, or comorbid condition?
No eligible studies were identified.
Benefits of Interventions
Key Question 4A. What is the efficacy of interventions for screendetected hearing loss in improving health outcomes in adults 50 years or older?
Six trials (reported in 8 articles) evaluated benefits of amplification compared with no amplification among populations with screen-detected or recently detected, untreated age-related hearing loss over 6 weeks to 4 months (Table 2 reports study characteristics; eTables 24 and 25 in the JAMA Supplement report results).31,32,35-37,42,43,45 In 5 trials reporting on the HHIE, 4 found statistically significant benefit in favor of hearing aids compared with no amplification (difference between groups in reduction from baseline score ranged from −34.0 to −6.8), and 1 crossover RCT found no significant differences between groups.42 Three35,43,45 of the 4 trials that found statistically significant benefit enrolled veterans (2 RCTs35,43 and 1 nonrandomized controlled intervention study45); the difference in HHIE score changes from baseline in all 3 trials was greater than the 18.7- point difference considered to represent a minimal important difference (range,–34.0 to –19.3).67 One RCT enrolling community volunteers found higher HHIE score changes from baseline among groups receiving 2 different hearing aid interventions (−18.2 points and −12.3 points) than placebo (−5.5 points); although comparisons were statistically significant for either intervention vs placebo (P < .001), differences between groups were less than the minimal important difference. Four studies reported on other non–hearing-related health outcomes (depression, general QOL, cognitive function);31,42,43,45 of these, 1 found significant benefit in favor of the intervention on the Short Portable Mental Status Questionnaire and the Geriatric Depression Scale (−0.28 points and −0.80 points, respectively).43 No outcome measure was assessed by more than 1 study. Three studies reported outcomes but either did not provide numerical results42 or did not report sufficient information to determine whether differences between groups were significant.31,45 No study examined the effect of interventions on the incidence of dementia or neurocognitive impairment. The results are most applicable to older male populations with improved access to screening and no-cost hearing aids, such as veterans’ groups.
Key Question 4B. Does the efficacy of interventions for screen-detected hearing loss differ for subpopulations defined by age, sex, race/ethnicity, risk of past noise exposure, or comorbid condition?
No subpopulation analyses were reported by the included studies.
Harms of Interventions
Key Question 5A. What are the harms of interventions for screen-detected hearing loss in adults 50 years or older?
Key Question 5B. Do the harms of interventions for screen-detected hearing loss differ for subpopulations defined by age, sex, race/ethnicity, risk of past noise exposure, or comorbid condition?
No eligible studies were identified.
This systematic review evaluated evidence related to screening for hearing loss in older adults. A summary of findings, including an assessment of the strength of evidence for each KQ, is presented in Table 3. The SAI-WHAT trial (n = 2305), included in the prior USPSTF review, found that screening was not associated with any statistically significant difference in hearing-related QOL compared with no screening at 1 year but was associated with greater hearing aid use among those screened with a handheld screening audiometer or combined screening with a screening audiometer and HHIE-S questionnaire compared with no screening (the primary outcome of SAI-WHAT).44,65 Most enrolled participants (74%) reported perceived hearing loss at baseline (based on the single question “Do you think you have a hearing loss?”), and effects of screening on hearing aid use appeared to be limited to patients with perceived hearing loss at baseline based on stratified analyses. The SAI-WHAT trial was not powered to assess improvements in hearing-related function, and rates of hearing aid use at 1 year were relatively low (less than 10% in all groups) despite being provided at no cost. However, 36% to 40% of participants (screened or unscreened) experienced a clinically significant improvement in hearing-related function, suggesting that factors other than hearing aid use may affect functional outcomes. Although no new studies directly evaluating screening were identified, findings from a recent uncontrolled intervention study (n = 14,411) of an electronic alert to encourage primary care clinicians to screen for hearing loss using a single question (“Do you have difficulty with your hearing?”) are consistent with those from the SAI-WHAT trial in showing an increase in referrals associated with screening (from 2.2% at baseline to 10.7% during the study period).68 Among those referred (n = 1660), 43% were evaluated by an audiologist and 59% (n = 421) were considered candidates for hearing aids. Rates of hearing aid use or changes in health outcomes were not reported; however, in a subset of participants who agreed to a 3-month follow-up (n = 557), only 50% of those who had hearing aids recommended planned to get them, primarily because of cost.68 Multiple factors may explain low uptake of hearing aids among those with perceived hearing impairment, confirmed hearing impairment, or both, including a perception that symptoms are not severe enough, concerns about cost or stigma, and (for those who receive hearing aids) concerns about comfort and maintenance (eg, difficulty replacing batteries, cost of repairs).69-72 The eContextual Questions in the JAMA Supplement provide a detailed overview of issues related to adherence, potential barriers to obtaining hearing aids, adherence, and reasons for low uptake.
Similar to the 2012 review for the USPSTF,12 no direct evidence on harms of screening was found. Potential harms include falsepositive results that lead to unnecessary testing and/or treatment, labeling, and anxiety. For example, based on the pooled analyses of HHIE-S for detecting moderate hearing loss (5 studies; n = 2820), the expected rate of false-positive test results would be 22% (Table 3). Other harms of screening are likely to be minimal because screening is noninvasive, and the reference standard (audiometric testing) is also noninvasive.
Most included studies reported on the accuracy of various screening tests to identify hearing loss (34 studies). Although available screening tools for clinical practice may reasonably identify asymptomatic older adults with hearing loss, this systematic review highlights the variability in estimates of screening test accuracy. The use of different thresholds and criteria to define hearing loss is a major limitation in interpreting studies and making stronger conclusions about the accuracy of available tests. Several studies found inconsistent screening test accuracy results when comparing the same screening test (and cutpoint) with different definitions for mild or moderate hearing loss (ie, measured at different frequencies or defined by hearing thresholds in the better vs worse ear). Screening tests evaluated in the included studies differ in factors such as cost, complexity/ time, and convenience. Relatively simple tests, such as a single question regarding perceived hearing loss, appeared to be nearly as accurate as a more detailed hearing loss questionnaire or a handheld audiometric device for detecting hearing loss. Some studies were limited by unclear applicability to primary care (14 of 34 studies enrolled participants from audiology clinics or other hearing-related specialties). Overall, accuracy estimates were derived from populations with a prevalence of hearing loss (based on pure-tone audiometry) of approximately 14% to 63% for mild (>25 dB) and 11% to 69% for moderate (>40 dB) hearing loss. The clinical relevance of detection of mild (25-40 dB) hearing loss as it pertains to effectiveness of screening is uncertain because the only trial showing benefits of hearing aids among participants screen-detected limited eligibility to those with moderate (>40 dB) hearing loss.44
Despite a relatively large body of observational studies indicating an association between hearing loss and higher rates of disability,5 depressive symptoms,7 cognitive decline,8 and other adverse health and social outcomes, evidence on the efficacy of treatments for screen-detected hearing loss in primary care settings remains limited. The 6 included studies in this review are heterogeneous in terms of enrolled populations and amplification interventions; few reported on outcomes other than hearing-related function, and follow-up duration was relatively short (ranging from 6 weeks to 4 months).31,32,35-37,42,43,45 No new studies enrolling screen-detected populations from primary care settings were identified. Trials showing clinically meaningful benefit in hearing-related function associated with hearing aids enrolled veterans with baseline HHIE scores indicating at least mild to moderate hearing-related handicap.35,43,45 Only 1 of these trials enrolled participants detected by screening in a primary care center and almost exclusively enrolled White men eligible for free VA hearing aids, and its applicability to other settings may be limited.37,43
The conclusions of this review that hearing aid use is associated with improved hearing-related function are similar to those from a 2017 Cochrane review (5 RCTs, n = 825), despite differences in eligible populations and study designs. Authors concluded that hearing aids significantly improve hearing-related function measured by the HHIE compared with the unaided/placebo condition (mean difference, −26.47 [95% CI, −42.16 to −10.77]; 3 studies, n = 722).73 Research is needed to determine if hearing aids or other amplification devices among populations with screen-detected hearing loss translate into longer-term benefits, such as lower rates of functional impairment or dementia. Populations enrolled in studies recruiting from the community may be more likely to include those who have known or perceived hearing loss but have not yet sought care because of various barriers. Whether earlier detection due to screening and provision of amplification improves outcomes is not clear based on existing evidence.
No direct evidence on harms associated with amplification was detected. However, harms are likely to be minimal because hearing aid use is not known to be associated with serious adverse events.
This review has several limitations. First, studies enrolling persons with symptomatic hearing loss and head-to-head comparisons of different interventions were excluded because the scope was designed to provide evidence on benefits of treatments compared with no treatment rather than assess the comparative effectiveness of amplification devices or other interventions. Second, for studies related to benefits of screening and interventions for screen-detected populations, the review was limited to study designs that included a control group and those that reported on health outcomes. Intermediate outcomes, including increased rates of audiology referrals associated with screening, may not indicate that people identified by routine screening have better long-term health outcomes than those who are identified and referred for treatment in the context of routine primary care. Third, the review excluded studies focused on adults younger than 50 years and studies focused on other causes of hearing loss (eg, prevention of noise-induced hearing loss) because it was intended to inform screening for age-related hearing loss in primary care settings.
Several screening tests can adequately detect hearing loss in older adults; no studies reported on the harms of screening or treatment. Evidence showing benefit from hearing aids on hearing-related function among adults with screen-detected or newly detected hearing loss is limited to studies enrolling veterans.
Source: This article was first published online in the Journal of the American Medical Association on March 23, 2021 (JAMA. 2021;325(12):1202-1215. doi:10.1001/jama.2020.24855).
Conflict of Interest Disclosures: None were reported.
Funding/Support: This research was funded under contract HHSA-290-2015-00011-I, Task Order 11, from the Agency for Healthcare Research and Quality (AHRQ), US Department of Health and Human Services, under a contract to support the US Preventive Services Task Force (USPSTF).
Role of the Funder/Sponsor: Investigators worked with USPSTF members and AHRQ staff to develop the scope, analytic framework, and key questions for this review. AHRQ had no role in study selection, quality assessment, or synthesis. AHRQ staff provided project oversight, reviewed the report to ensure that the analysis met methodological standards, and distributed the draft for peer review. Otherwise, AHRQ had no role in the conduct of the study; collection, management, analysis, and interpretation of the data; and preparation, review, or approval of the manuscript findings. The opinions expressed in this document are those of the authors and do not reflect the official position of AHRQ or the US Department of Health and Human Services.
Additional Information: A draft version of the research plan underwent review by a clinical expert (Patricia Johnson, AuD, UNC Chapel Hill). A draft version of the full evidence report underwent external peer review from 5 content experts (Karen Cruickshanks, PhD, University of Wisconsin-Madison; Rachel McArdle, PhD, MA, Bay Pines US Veterans Administration Healthcare System; Teresa Chisolm, PhD, University of South Florida; Meg Wallhagen, RN, PhD, University of California, San Francisco; Jennifer A. Deal, PhD, Johns Hopkins University) and 2 federal partner reviewers (Centers for Disease Control and Prevention and the National Institutes of Health). Comments from reviewers were presented to the USPSTF during its deliberation of the evidence and were considered in preparing the final evidence review.
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28. Lee AT, Tong MC, Yuen KC, Tang PS, Vanhasselt CA. Hearing impairment and depressive symptoms in an older Chinese population. J Otolaryngol Head Neck Surg. 2010;39(5):498-503.
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31. Nieman CL, Marrone N, Mamo SK, et al. The Baltimore HEARS Pilot study: an affordable, accessible, community-delivered hearing care intervention. Gerontologist. 2017;57(6):1173-1186. doi:10.1093/geront/gnw153
32. Humes LE, Rogers SE, Quigley TM, Main AK, Kinney DL, Herring C. The effects of service-delivery model and purchase price on hearing-aid outcomes in older adults: a randomized double-blind placebo-controlled clinical trial. Am J Audiol. 2017;26(1):53-79. doi:10.1044/2017_AJA-16-0111
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35. McArdle R, Chisolm TH, Abrams HB, Wilson RH, Doyle PJ. The WHO-DAS II: measuring outcomes of hearing aid intervention for adults. Trends Amplif. 2005;9(3):127-143. doi:10.1177/108471380500900304
36. Chisolm TH, Abrams HB, McArdle R, Wilson RH, Doyle PJ. The WHO-DAS II: psychometric properties in the measurement of functional health status in adults with acquired hearing loss. Trends Amplif. 2005;9(3):111-126. doi:10.1177/108471380500900303
37. Mulrow CD, Tuley MR, Aguilar C. Sustained benefits of hearing aids. J Speech Hear Res. 1992;35(6):1402-1405. doi:10.1044/jshr.3506.1402
38. Kelly EA, Stadler ME, Nelson S, Runge CL, Friedland DR. Tablet-based screening for hearing loss: feasibility of testing in nonspecialty locations. Otol Neurotol. 2018;39(4):410-416. doi:10.1097/MAO.0000000000001752
39. Oosterloo BC, Homans NC, Baatenburg de Jong RJ, Ikram MA, Nagtegaal AP, Goedegebure A. Assessing hearing loss in older adults with a single question and person characteristics: comparison with pure tone audiometry in the Rotterdam Study. PLoS One. 2020;15(1):e0228349-e. doi:10.1371/journal.pone.0228349
40. López-Torres Hidalgo J, Boix Gras C, Téllez Lapeira J, López Verdejo MA, del Campo del Campo JM, Escobar Rabadán F. Functional status of elderly people with hearing loss. Arch Gerontol Geriatr. 2009;49(1):88-92. doi:10.1016/j.archger.2008.05.006
41. Boatman DF, Miglioretti DL, Eberwein C, Alidoost M, Reich SG. How accurate are bedside hearing tests? Neurology. 2007;68(16):1311-1314. doi:10.1212/01.wnl.0000259524.08148.16
42. Jerger J, Chmiel R, Florin E, Pirozzolo F, Wilson N. Comparison of conventional amplification and an assistive listening device in elderly persons. Ear Hear. 1996;17(6):490-504. doi:10.1097/00003446-199612000-00005
43. Mulrow CD, Aguilar C, Endicott JE, et al. Quality-of-life changes and hearing impairment: a randomized trial. Ann Intern Med. 1990;113(3):188-194. doi:10.7326/0003-4819-113-3-188
44. Yueh B, Collins MP, Souza PE, et al. Long-term effectiveness of screening for hearing loss: the Screening for Auditory Impairment—Which Hearing Assessment Test (SAI-WHAT) randomized trial. J Am Geriatr Soc. 2010;58(3):427-434. doi:10.1111/j.1532-5415.2010.02738.x
45. Yueh B, Souza PE, McDowell JA, et al. Randomized trial of amplification strategies. Arch Otolaryngol Head Neck Surg. 2001;127(10):1197-1204. doi:10.1001/archotol.127.10.1197
46. Ventry IM, Weinstein BE. Identification of elderly people with hearing problems. ASHA. 1983;25(7):37-42.
47. Lichtenstein MJ, Bess FH, Logan SA. Validation of screening tools for identifying hearing-impaired elderly in primary care. JAMA. 1988;259(19): 2875-2878. doi:10.1001/jama.1988.03720190043029
48. Eekhof JA, de Bock GH, de Laat JA, Dap R, Schaapveld K, Springer MP. The whispered voice: the best test for screening for hearing impairment in general practice? Br J Gen Pract. 1996;46(409):473-474.
49. Sindhusake D, Mitchell P, Smith W, et al. Validation of self-reported hearing loss: the Blue Mountains Hearing Study. Int J Epidemiol. 2001;30(6):1371-1378. doi:10.1093/ije/30.6.1371
50. McBride WS, Mulrow CD, Aguilar C, Tuley MR. Methods for screening for hearing loss in older adults. Am J Med Sci. 1994;307(1):40-42. doi:10.1097/00000441-199401000-00007
51. Clark K, Sowers M, Wallace RB, Anderson C. The accuracy of self-reported hearing loss in women aged 60-85 years. Am J Epidemiol. 1991;134(7):704-708. doi:10.1093/oxfordjournals.aje.a116147
52. Bienvenue GR, Michael PL, Chaffinch JC, Zeigler J. The AudioScope: a clinical tool for otoscopic and audiometric examination. Ear Hear. 1985;6(5):251-254. doi:10.1097/00003446-198509000-00005
53. Ciurlia-Guy E, Cashman M, Lewsen B. Identifying hearing loss and hearing handicap among chronic care elderly people. Gerontologist. 1993;33(5):644-649. doi:10.1093/geront/33.5.644
54. Frank T, Petersen DR. Accuracy of a 40 dB HL Audioscope and audiometer screening for adults. Ear Hear. 1987;8(3):180-183. doi:10.1097/00003446-198706000-00009
55. Gates GA, Murphy M, Rees TS, Fraher A. Screening for handicapping hearing loss in the elderly. J Fam Pract. 2003;52(1):56-62.
56. Koike KJ, Hurst MK, Wetmore SJ. Correlation between the American Academy of Otolaryngology–Head and Neck Surgery five-minute hearing test and standard audiologic data. Otolaryngol Head Neck Surg. 1994;111(5):625-632. doi:10.1177/019459989411100514
57. Macphee GJ, Crowther JA, McAlpine CH. A simple screening test for hearing impairment in elderly patients. Age Ageing. 1988;17(5):347-351. doi:10.1093/ageing/17.5.347
58. Nondahl DM, Cruickshanks KJ, Wiley TL, Tweed TS, Klein R, Klein BE. Accuracy of self-reported hearing loss. Audiology. 1998;37(5):295-301. doi:10.3109/00206099809072983
59. Sever JC Jr, Harry DA, Rittenhouse TS. Using a self-assessment questionnaire to identify probable hearing loss among older adults. Percept Mot Skills. 1989;69(2):511-514. doi:10.2466/pms.19188.8.131.521
60. Swan IR, Browning GG. The whispered voice as a screening test for hearing impairment. J R Coll Gen Pract. 1985;35(273):197.
61. Torre P, Moyer CJ, Haro NR. The accuracy of self-reported hearing loss in older Latino-American adults. Int J Audiol. 2006;45(10):559-562. doi:10.1080/14992020600860935
62. Voeks SK, Gallagher CM, Langer EH, Drinka PJ. Self-reported hearing difficulty and audiometric thresholds in nursing home residents. J Fam Pract. 1993;36(1):54-58.
63. Wiley TL, Cruickshanks KJ, Nondahl DM, Tweed TS. Self-reported hearing handicap and audiometric measures in older adults. J Am Acad Audiol. 2000; 11(2):67-75.
64. Rawool VW, Keihl JM. Perception of hearing status, communication, and hearing aids among socially active older individuals. J Otolaryngol Head Neck Surg. 2008;37(1):27-42.
65. Yueh B, Collins MP, Souza PE, et al. Screening for Auditory Impairment–Which Hearing Assessment Test (SAI-WHAT): RCT design and baseline characteristics. Contemp Clin Trials. 2007;28(3):303-315. doi:10.1016/j.cct.2006.08.008
66. Kim TY, Park DW, Lee YJ, et al. Comparison of inner ear contrast enhancement among patients with unilateral inner ear symptoms in MR images obtained 10 minutes and 4 hours after gadolinium injection. AJNR Am J Neuroradiol. 2015;36(12):2367-2372. doi:10.3174/ajnr.A4439
67. Weinstein BE, Spitzer JB, Ventry IM. Test-retest reliability of the Hearing Handicap Inventory for the Elderly. Ear Hear. 1986;7(5):295-299. doi:10.1097/00003446-198610000-00002
68. Zazove P, Plegue MA, McKee MM, et al. Effective hearing loss screening in primary care: the Early Auditory Referral–Primary Care Study. Ann Fam Med. 2020;18(6):520-527. doi:10.1370/afm.2590
69. Kaplan-Neeman R, Muchnik C, Hildesheimer M, Henkin Y. Hearing aid satisfaction and use in the advanced digital era. Laryngoscope. 2012;122(9):2029-2036. doi:10.1002/lary.23404
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71. Wallhagen MI. The stigma of hearing loss. Gerontologist. 2010;50(1):66-75. doi:10.1093/geront/gnp107
72. Hickson L, Meyer C, Lovelock K, Lampert M, Khan A. Factors associated with success with hearing aids in older adults. Int J Audiol. 2014;53 (suppl 1):S18-S27. doi:10.3109/14992027.2013.860488
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Evidence reviews for the US Preventive Services Task Force (USPSTF) use an analytic framework to visually display the key questions that the review will address to allow the USPSTF to evaluate the effectiveness and harms of a preventive service. The questions are depicted by linkages that relate interventions and outcomes. Additional details are provided in the USPSTF Procedure Manual.11
|Test||Hearing loss severity (PTA dB range)||No. of studies (No. of participants)||% (95% CI)||LR (95% CI)|
|Single-question||Mild (>20 to 25)||10
|Pooled: 66 (58-73)||Pooled: 76 (68-83)||Pooled: 2.7 (2.2-3.4)||Pooled: 0.45 (0.38-0.53)|
|Moderate (>35 to 40)||6 (8774)21,28,39,49,51,55a||Pooled: 80 (68-88)||Pooled: 74 (59-85)||Pooled: 3.1 (2.0-4.7)||Pooled: 0.27 (0.18-0.41)|
|HHIE-S score >8b||Mild (>25)||4 (7194)34,49,50,58||58 (53-61)49||85 (83-87)49||3.9 (3.8-3.9)49||0.49 (0.49-0.50)49|
|58 (45-70)50||76 (69-84)50||2.4 (1.7-3.5)50||0.55 (NR)50|
|44 (NR)34||85 (NR)34||2.9 (1.6-4.9)34||0.7 (0.6-0.8)34|
|34 (31-37)58||95 (94-96)58||5.8 (6.6-7.0)58||0.69 (0.69-0.70)58|
|Moderate (>40)||5 (2820)46,47,49,50,55b||Pooled: 68 (52-81)||Pooled: 78 (67-86)||Pooled: 3.21 (2.4-4.2)||Pooled: 0.41 (0.28-0.59)|
|HSAQ score ≥15||Mild (>25)||1 (112)29||100 (89-100)||75 (64-84)||4 (2.7-5.9)||0|
|RFMHT score ≥15||Mild (>25)||1 (74)56||80 (NR)||55 (NR)||1.8 (NR)||0.36 (NR)|
|Whispered voice test||Mild (>25 to 30)||5 (669)33,41,48,57,60c||Pooled: 94 (31-100)||Pooled: 87 (82-90)||Pooled: 7.1 (5.1-9.7)||Pooled: 0.06 (0.00-1.94)|
|Moderate (>40)||3 (296)22,41,57||46 (36-56)41||78 (68-86)41||2.08 (NR)41||0.69 (NR)41|
|30d (8-65)22||100d (92-100)22||NR22||0.6922d|
|100 (95-100)57||84 (70-81)57||6.0 (4.7-7.7)57||0.0 (NR)57|
|Watch tick||Mild (>25)||1 (107)41||44 (35-53)||100 (NR)||NR||0.56 (NR)|
|Moderate (>40)||1 (107)41||60 (50-69)||99 (92-100)||60.0 (NR)||0.40 (NR)|
|Finger rub||Mild (>25)||1 (107)41||27 (20-36)||98 (85-100)||13.5 (NR)||0.74 (NR)|
|Moderate (>40)||1 (107)41||35 (26-46)||97 (90-99)||11.67 (NR)||0.67 (NR)|
|Digits in noise||Mild (>20 to 25)||3 (4110)24-26||79 (77-81)24||76 (74-78)24||3.3 (3.3-3.3)24||0.28 (0.27-0.28)24|
|80 (66-92)26||83 (69-92)26||4.7 (3.5-6.3)26||0.25 (0.20-0.30)26|
|81 (79-84)25||65 (60-70)25||2.3 (2.3-2.4)25||0.29 (0.28-0.29)25|
|Words in noise||Mild (>25)||1 (1049)25||97 (96-98)25||46 (39-52)25||1.8 (1.8-1.8)25||0.06 (0.05-0.06)24|
|Handheld screening audiometry||Mild (>25 to 30)||2 (215)50,52||71 (63-80)50||91 (84-97)50||7.5 (3.7-15.4)50||0.32 (NR)50|
|93 (NR)52||70 (NR)52||3.1 (NR)52||0.10 (NR)52|
|Moderate (>40)||4 (411)47,48,50,53e||100 (91-100)48||42 (32-57)48||1.72 (NR)48||048|
|96 (90-100)50||80 (74-87)50||4.9 (3.5-6.9)50||0.05 (NR)50|
|98 (NR)53||24 (NR)53||1.29 (NR)53||0.08 (NR)53|
|94 (85-98)47||72 (64-79)47||3.4 (3.2-3.6)47||0.08 (0.04-0.15)47|
|Pure-tone portable audiometer screener||Moderate (>40)||1 (405)54||50-59 y: 94 (NR)
60-69 y: 90 (NR)
70-79 y: 90 (NR)
80-89 y: 90 (NR)
90-96 y: 88 (NR)
|50-59 y: 93 (NR)
60-69 y: 94 (NR)
70-79 y: 92 (NR)
80-89 y: 90 (NR)
90-96 y: 93 (NR)
|50-59 y: 13.4 (NR)
60-69 y: 15.6 (NR)
70-79 y: 10.6 (NR)
80-89 y: 9.2 (NR)
90-96 y: 11.8 (NR)
|50-59 y: 0.06 (NR)
60-69 y: 0.11 (NR)
70-79 y: 0.11 (NR)
80-89 y: 0.11 (NR)
90-96 y: 0.13 (NR)
|uHear app||Moderate (>40)||2 (78)22,30d||68 (45-86)30||87 (76-94)30||NR||NR|
|100 (66-100)22||89 (77-96)22|
|EarTrumpet app||Moderate (>40 dB)||1 (33)23||88 (64-97)23||96 (86-99)23||21.4 (7.9-58.3)23||0.13 (0.05-0.35)23|
|Mild (>20 dB)||1 (35)38||Quiet examination room: 96.3 (NR)
Clinic waiting area: 100 (NR)
|Quiet examination room: 83.1 (NR)
Clinic waiting area: 72 (NR)
|ShoeBOX app||Moderate (>40 dB)||1 (33)23||100 (81-100)23||96 (86-99)23||24.5 (9.2-65.3)23||023|
|Audiogram mobile app||Mild (>20 dB)||1 (37)38||Quiet examination room: 85.3 (NR)
Clinic waiting area: 87.6 (NR)
|Quiet examination room: 95.1 (NR)
Clinic waiting area: 92.3 (NR)
|Hearing test with Audiogram app||Mild (>20 dB)||1 (35)38||Quiet examination room: 87.8 (NR)
Clinic waiting area: 89 (NR)
|Quiet examination room: 69.4 (NR)
Clinic waiting area: 68.2 (NR)
Abbreviations: HHIE-S, Hearing Handicap Inventory for the Elderly–Screening version; HSAQ, Hearing Self-Assessment Questionnaire; LR, likelihood ratio; NR, not reported; PTA, pure-tone average; RFMHT, Revised Five-Minute Hearing Test; WIN, words in noise; WVT, whispered voice test.
a One additional study of 1731 community-dwelling adults in Japan that did not report sufficient data to be included in pooled analyses of single-question screeners found a sensitivity of 54% and specificity of 78% for detecting mild hearing loss and a sensitivity of 88% and a specificity of 67% for detecting moderate hearing loss.34
b One additional study of 1731 community-dwelling adults in Japan that did not report sufficient data to be included in pooled analyses of HHIE-S using a cutoff score of greater than 8 found similar accuracy for detecting moderate hearing loss (81% sensitivity and 78% specificity).34
c Of these, 1 study (n = 62) also assessed the accuracy of conversational voice at 2 feet and reported low sensitivity (47%) and high specificity (100%) for detecting mild hearing loss.57
d Estimates here are based on a positive screening test definition of 2 or more consecutive hearing grades starting from the moderate-severe threshold zone ranging from 0.5 to 2.0 kHz. Using a scoring method that defined a positive screening test result based on PTA of 40 dB or greater at 0.5, 1.0, or 2.0 kHz, sensitivity was high in both cohorts (100%), but specificity was relatively low (38% and 36%).22,30
e One additional study assessed the accuracy of both the handheld screening audiometer and a portable audiometer to detect moderate hearing loss (45 dB) in subpopulations defined by age decades (50- to 90-year-olds). Across all age groups, the handheld screening audiometry sensitivities ranged from 85% to 90% and specificities from 89% to 94%. Similarly, sensitivities for the portable audiometer ranged from 88% to 94% and specificities from 90% to 94%.54
(No. of participants)
|Setting (country)||Source population||Eligibility criteria||Age,
mean (SD), y
|% Male||% White||Baseline hearing loss|
|Humes et al,32 2017||Double-blind RCT (154)||Community (US)||Participants recruited via ads posted in local newspapers and around the community for a trial at Indiana University, Bloomington||Aged 55-79 y; English-speaking; MMSE score>25; no prior hearing aid experience; PTA thresholds consistent with age-related, bilateral SNHL; no hearing-related pathologies specific to ear anatomy, medication use, or medical conditions; willingness to be randomized||69 (6)||56||98||Bilateral PTA (500, 1000, and 2000 Hz); mean, 28.1 (SD, 8.0) dB
Bilateral high-frequency PTA (1000, 2000, and 4000 Hz); mean, 38.8 (SD, 7.9) dB
|Jerger et al,42 1996||Crossover RCT (80)||Community (US)||Paid participants recruited via ads in community centers in Houston, Texas||Aged >60 y; bilateral high-frequency SNHL>15 dB in both ears; normal middle ear status; average score ≤3 on self-report physical health scale; normal MMSE score (≥24); no history of neurologic or psychiatric disorder||74 (range, 60-96)||63||NR||Bilateral PTA (500, 1000, and 2000 Hz); mean, 37.4 dB|
|McArdle et al,35 2005
Chisolm et al,36 2005
|Unblinded RCT (380)||VA audiology clinic (US)||Community-dwelling participants from the general audiology clinics at 4 VA medical centers who were eligible to receive no-cost hearing aids||Adult-onset SNHL; no asymmetry of PTA thresholds or speech-recognition scores in quiet; no prior HA use; “passing” MMSE score; at least a mild, high-frequency BEHL ≥30 dB at 2000, 3000, and 4000 Hz; no known conductive or retrocochlear pathologies, neurologic or psychiatric disorders, or significant comorbid diseases; access to a telephone||69.4 (9.0)||98||NR||NR|
|Mulrow et al,43 1990||Unblinded RCT (194)||VA primary care clinic (US)||Participants from 1 VA general medicine clinic invited for hearing screening and follow-up diagnostic testing to determine eligibility; or from other VA clinics at same institution with hearing impairment referred by primary care providers||Aged >64 y; formal audiologic testing confirmed hearing loss; residence <100 mi from clinic; no current hearing aid use; no severe disabling comorbiditiesa||72 (NR)||Hearing aid group: 100
|Hearing aid group: 98
|Better ear PTA (1000, 2000, and 4000 Hz); mean, 52 dB|
|Nieman et al,31 2017||Unblinded RCT (15)||Community (US)||Community-dwelling adults recruited from 3 buildings that house low- to middle-income, predominantly African American older adults subsidized by a nonprofit in Baltimore, Maryland, recruited via flyers and invitations from service coordinators in each building||Aged ≥60 y; English speaking clinically significant mild or worse hearing loss; no current hearing aid use; had communication partner who would participate in study (≥18 y who spoke with participant daily)||Median (IQR): 70 (67-76)||47||40||Better ear PTA (1000, 2000, and 4000 Hz); median, 40 (IQR, 32.5-53.3) dB|
|Yueh et al,45 2001||Unblinded RCT (30)||VA audiology clinic (US)||Veterans seeking diagnostic visits or hearing aid evaluations at the audiology clinic of VA Puget Sound Health Care System||Aged ≥50 y; diagnosed with symmetric, bilateral, mild to moderately severe sensorineural hearing loss; no asymmetric or conductive hearing loss; or atypical causes of SNHL; no prior hearing aid use; good cognitive function; and normal manual dexterity||69 (NR)||100||NR||Mean PTA, right ear: 32.9 dB
Mean PTA, left ear: 32.4 dB
Abbreviations: BEHL, best ear hearing level; HA, hearing aid; IQR, interquartile range; MMSE, Mini-Mental State Examination; NR, not reported; PTA, pure-tone average; RCT, randomized clinical trial; SNHL, sensorineural hearing loss; VA, Veterans Administration.
a Terminal cancer, hepatic encephalopathy, and end-stage pulmonary disease requiring home oxygen therapy; residence more than 100 miles from clinic.
|No. of studies
(No. of participants)
|Summary of findings||Consistency and precision||Limitations (including reporting bias)||Overall strength of evidence||Applicability|
|KQ 1: Benefits of screening|
|1 RCT (2305)||One RCT found that screening with HHIE-S, handheld screening audiometer, or both was not associated with any significant differences in hearing-related QOL compared with no screening||Consistency unknown; imprecise||High overall attrition (23% for hearing-related function); not designed to assess differences in hearing-related QOL||Insufficient||Participants recruited from a VA setting with high prevalence of hearing loss (74% reported perceived hearing loss at baseline) and all patients were eligible to receive free hearing aids; results may not be applicable to lower-prevalence settings in which the cost of or access to hearing aids is a barrier|
|KQ2: Accuracy of screening|
Single question for mild (>20 to 25 dB) hearing loss
|Pooled sensitivity: 66% (58%-73%)
Pooled specificity: 76% (68%-83%)
|Mostly consistenta; imprecise (more imprecise for sensitivity than for specificity)||Only 1 study specified how equivocal screening test responses were handled; hearing loss definitions varied in frequencies measured and ears affected||Moderate for adequate accuracy||Most studies conducted in specialty or other high-prevalence settings|
HHIE-S score >8 for mild (>20 to 25 dB) hearing loss
|Sensitivity range, 34% to 58% across studies
Specificity range, 76% to 95% across studies
|Mostly consistent (more consistent for specificity than for sensitivity); imprecise||Hearing loss definitions varied in frequencies measured and ears affected||Low for adequate accuracy||Most studies conducted in specialty or other high-prevalence settings|
WVT for mild (>20 to 25 dB) hearing loss
|Pooled sensitivity: 94% (31%-100%)
Pooled specificity: 87% (82%-90%)
|Inconsistent; imprecise (more imprecise for sensitivity than for specificity)b||Hearing loss definitions varied in thresholds (>25, >29, and>30 dB) and number of frequencies measured; 1 study found inconsistent results based on experience level of whisperer33||Low for adequate accuracy||Most studies conducted in specialty or other high-prevalence settings where screening was delivered by hearing specialists|
Handheld screening audiometry for mild (>20 to 25 dB) hearing loss
|Sensitivity range, 71% to 93% across studies
Specificity range, 70% to 91% across studies
|Inconsistent; imprecise||Studies used different criteria to determine a positive screen, based on the handheld screening audiometer (number of frequencies; specific frequencies included)||Insufficient||Both studies conducted in specialty settings|
DIN for mild (>20 to 25 dB) hearing loss
|Sensitivity range, 79% to 80% across studies
Specificity range, 76% to 83% across studies
|Consistent; imprecise (more imprecise for specificity than for sensitivity)||Methods of administering screening test varied across studies||Low for adequate accuracy||Screening tests were administered by audiologists|
Single question for moderate (>35 to 40 dB) hearing loss
|Pooled sensitivity: 80% (68%-88%)
Pooled specificity: 74% (59%-85%)
|Inconsistentc; precise (more precise for sensitivity than for specificity)||Only 1 study specified how equivocal screening test responses were handled; hearing loss definitions varied in frequencies measured and ears affected||Moderate for adequate accuracy||Most studies conducted in specialty or other high-prevalence settings|
HHIE-S score >8 for moderate (>35 to 40 dB) hearing loss
|Pooled sensitivity: 68% (52%-81%)
Pooled specificity: 66% (55%-7
|Mostly consistent; imprecised||HL definitions varied in frequencies measured and ears affected||Moderate for adequate accuracy||Most studies were conducted in specialty or other high-prevalence settings|
WVT for moderate (>35 to 40 dB) hearing loss
|Sensitivity range, 30% to 100% across studies
Specificity range, 79% to 100% across studies
|Inconsistent; imprecise (more imprecise for sensitivity)||Hearing loss definitions varied in terms of frequencies measured and ears affected; 1 study found inconsistent results based on experience level of whisperer33||Low for adequate accuracy||Studies were conducted in specialty or other high-prevalence settings in which screening was delivered by hearing specialists|
Handheld screening audiometry for moderate (>35 to 40 dB) hearing loss
|Sensitivity range, 94% to 100% across studies
Specificity range, 24% to 80% across studies
|Mostly consistent (more consistent for sensitivity than for specificity); precise (more precise for sensitivity than for specificity)||Studies used different criteria to define a positive screen on screening audiometry; hearing loss definitions varied in frequencies measured||Moderate for adequate accuracy||Studies were conducted in specialty settings or other high-prevalence settings|
uHear app for moderate (>35 to 40 dB) hearing loss
|Sensitivity range, 68% to 100% across studies
Specificity range, 87% to 89% across studies
|Inconsistent (more for sensitivity than for specificity); imprecise (more for sensitivity than for specificity)||Sensitivity varied within studies based on positive screening test definition and between studies using the same screening test definition||Insufficient||Both studies enrolled older adults with cancer undergoing a comprehensive geriatric assessment|
|KQ 3: Harms of screening|
|0||No eligible studies||NA||NA||Insufficient||NA|
|KQ 4: Benefits of interventions for screen-detected hearing loss|
|6 RCTs (3188) (8 publications)||In 5 trials (n = 3173) reporting on the HHIE, 4 found significant benefit in favor of hearing aids vs no amplification over 6 wk to 4 mo, and 1 crossover trial found no significant difference between groups over 6 wk
Few studies reported on other hearing-related outcomes
|Consistent, imprecise||Most studies were unblinded; follow-up duration was relatively short (6 wk to 4 mo); only 1 study enrolled participants identified by screening in primary care||Low||Three of 4 studies showing benefit enrolled populations from VA settings with baseline HHIE scores indicating moderate hearing loss handicap (46-51) and who were eligible to receive free hearing aids|
|KQ 5: Harms of interventions for screen-detected hearing loss|
|0||No eligible studies||NA||NA||Insufficient||NA|
Abbreviations: HHIE-S, Hearing Handicap Inventory for the Elderly–Screening; KQ, key question; NA, not applicable; QOL, quality of life; RCT, randomized clinical trial; VA, Veterans Affairs; WVT, whispered voice test.
a Based on eFigure 1 in the Supplement, the 95% prediction region indicates that the results are reasonably consistent; based on the 95% confidence interval, estimates are imprecise.
b Based on eFigure 4 in the Supplement, the 95% prediction region indicates the results are moderately inconsistent; based on the 95% confidence region, estimates are imprecise (more imprecise for sensitivity than specificity).
c Based on eFigure 2 in the Supplement, the 95% prediction region indicates the results are moderately inconsistent; based on the 95% confidence region, estimates are imprecise.
d Based on eFigure 3 in the Supplement, the 95% prediction region is relatively large, covering approximately one-third of the receiver operating characteristic space; the 95% confidence region is relatively precise (more precise for sensitivity than specificity).