Effective Hearing Loss Screening in Primary Care

The Early Auditory Referral-Primary Care Study

Philip Zazove, MD, MM; Melissa A. Plegue, MA; Michael M. McKee, MD, MPH; Melissa DeJonckheere, PhD; Paul R. Kileny, PhD; Lauren S. Schleicher, MA; Lee A. Green, MD, MPH; Ananda Sen, PhD; Mary E. Rapai, MA; Elie Mulhem, MD


Ann Fam Med. 2020;18(6):520-527. 

In This Article

Abstract and Introduction


Purpose: Hearing loss, the second most common disability in the United States, is under-diagnosed and under-treated. Identifying it in early stages could prevent its known substantial adverse outcomes.

Methods: A multiple baseline design was implemented to assess a screening paradigm for identifying and referring patients aged ≥55 years with hearing loss at 10 family medicine clinics in 2 health systems. Patients completed a consent form and the Hearing Handicap Inventory for the Elderly (HHI). An electronic alert prompted clinicians to screen for hearing loss during visits.

Results: The 14,877 eligible patients during the study period had 36,701 encounters. Referral rates in the family medicine clinics increased from a baseline rate of 3.2% to 14.4% in 1 health system and from a baseline rate of 0.7% to 4.7% in the other. A general medicine comparison group showed referral rate increase from the 3.0% baseline rate to 3.3%. Of the 5,883 study patients who completed the HHI 25.2% (n=1,484) had HHI scores suggestive of hearing loss; those patients had higher referral rates, 28% vs 9.2% (P <.001). Of 1,660 patients referred for hearing testing, 717 had audiology data available for analysis: 669 (93.3%) were rated appropriately referred and 421 (58.7%) were considered hearing aid candidates. Overall, 71.5% of patients contacted felt their referral was appropriate.

Conclusion: An electronic alert used to remind clinicians to ask patients aged ≥55 years about hearing loss significantly increased audiology referrals for at-risk patients. Audiologic and audiogram data support the effectiveness of the prompt. Clinicians should consider adopting this method to identify patients with hearing loss to reduce its known and adverse sequelae.


Hearing loss affects over 30% of those aged ≥55 years, with over one-half suffering morbidity that includes reduced quality of life.[1–14] Untreated hearing loss is a major risk factor for substantial health conditions (hypertension, diabetes, dementia, depression)[2–4,10,11,15–22] as well as increased health care cost and use.[23–26] Patients with hearing loss are reluctant to reveal it, and most non-otolaryngologist physicians provide inadequate hearing care to these patients. It is a condition physicians often do not suspect, are uncomfortable with, or consider unimportant despite growing recognition of its impact on health.[27,28] In fact, 75% of hearing loss remains underdiagnosed and undertreated.[27–30]

Common screening tests can effectively identify patients with hearing loss,[15,31–33] yet physicians rarely use them.[7] Primary care physicians, the vanguard for screening and prevention, juggle multiple office demands ranging from treating ill patients to addressing quality metrics;[34,35] thus implementing new interventions, regardless of importance, is hard.[35–38] Other barriers to screening are poor understanding of hearing loss, optimal screening, counseling, and referral approaches.[3,6,27,29,30,39] Despite effective treatments being available, there are multiple barriers that reduce the likelihood of screening in the primary care setting. Most patients are reluctant to reveal their hearing loss.[40–43] However, those with established primary care physicians, if asked, will discuss their hearing and often follow treatment recommendations that are known to be effective.[27,30,32,39,40,44]

The US Preventive Services Task Force acknowledges the adverse outcomes from untreated hearing loss.[15] They state, however, that "adequately powered studies are needed to better evaluate the effect of screening for hearing loss on health outcomes (in older persons)…particularly among adults without self-perceived or established hearing loss at baseline."[15] Thus, hearing loss screening is rated "I," ie, "…evidence is insufficient to assess the balance of benefits and harms of screening in asymptomatic adults aged 50 years or older."[15]

The Early Auditory Referral-Primary Care study was designed to address the lack of data about hearing loss screening.[15] Implemented in real-world, community-based clinics, it evaluated the effect of a tailored electronic alert appearing at all visits of patients aged ≥55, to encourage clinicians to ask the single question screener: "Do you have difficulty with your hearing?" This article summarizes the findings.