Interventions to support the use of hearing aids

National Guideline Centre (UK)

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National Guideline Centre (UK). Hearing loss in adults: assessment and management. London: National Institute for Health and Care Excellence (NICE); 2018 Jun. (NICE Guideline, No. 98.)

Hearing loss in adults: assessment and management.

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18Interventions to support the use of hearing aids

18.1. Introduction

Many people choose to use hearing aids as part of the management of their hearing and communication difficulties. Hearing aids are the primary management option for hearing loss and have been shown to be effective in reducing the participation restrictions associated with hearing and communication needs, and improving listening abilities and health-related quality of life.

While the majority of people go on to use their hearing aids successfully, others stop using their hearing aids. Reported rates of non-use of hearing aids vary widely.⁴³ The reasons for non-use are reported as many and varied including: unrealistic expectations, unsatisfactory sound quality, poor hearing aid handling skills, discomfort, limited knowledge about and access to support, psychosocial factors, poor manual dexterity, low self-efficacy, limited support from family members, and the attitude of healthcare professionals.

Clinical practice across the UK is variable. Some services may include assessment of motivation, offer follow-up appointments, peer or volunteer support or self-management courses, or provide more personalised information. However, it is unclear which of these, or other interventions, contribute to continued and effective use of hearing aids. Other services provide no follow-up (or follow-up only if requested), no support and no signposting to other services.

This chapter aims to examine which interventions support the continued effective use of hearing aids and which interventions or approaches may reduce the non-use of hearing aids.

18.2. Review question: What is the clinical and cost effectiveness of interventions to support continuing use of hearing aids?

For full details see review protocol in appendix C.

Table 98

PICO characteristics of review question.

18.2.1. Clinical evidence

A recent Cochrane review⁹ was identified that addresses our clinical question, and an expanded search was performed to fully cover our protocol and broaden the search, adding terms for aftercare, repairs, maintenance, batteries and peer support. These terms were not specifically excluded from the Cochrane search but were identified by the committee as important terms to include in our search strategy. No further studies were identified for inclusion from this expanded Cochrane search. A further 3 studies were identified⁴²^,¹²⁹^;¹ from searches on decision tools and were thought to fit better within this review, therefore 4 studies were included in the review; these are summarised in Table 99 below. Evidence from these studies is summarised in the clinical evidence summary tables below (Table 100 to Table 105).

Table 99

Summary of studies included in the review.

Table 100

Clinical evidence summary: self-management support (SMS) interventions versus control.

Table 105

Clinical evidence summary: motivational engagement versus usual care.

The published review⁹ was incorporated into our guideline in the following ways:

Article selection and risk of bias assessment per study were directly adopted without further checking.
GRADE assessments for risk of bias, imprecision and inconsistency per outcome were checked. If differences with the standard methodology used within this guideline were found, GRADE ratings and subgroup analyses were amended accordingly to ensure consistency across the reviews within this guideline.
Data for all outcomes were incorporated into the summary of findings table, including short and medium term outcomes that were not fully assessed in the published review.⁹

See also the study selection flow chart in appendix E, forest plots in appendix K, study evidence tables in appendix H, GRADE tables in appendix J and excluded studies list in appendix L. All amendments made to the published review⁹ are detailed in appendix R.

The Cochrane review aimed to identify whether any interventions can improve hearing aid use in adults. This systematic review included RCTs and quasi-randomised studies and reported on 37 studies involving 4,129 participants. The interventions included varied widely between studies and were categorised as:

Self-management support (SMS) interventions, which aim to enable patients to optimally manage their own health, such as:
- training and practice in skills and coping strategies for communication
- psychosocial exercises addressing the impact of hearing loss
- information on hearing aids and practice/problem-solving opportunities
- self-help literature.
Delivery system design (DSD) interventions that change the mode, format, timing or follow-up pattern of self-management support. This may include:
- remote online fitting versus face-to-face fitting
- telephone follow-up versus face-to-face follow-up
- group versus individual training session
- post-fitting adjustment versus no post-fitting adjustment.
Combined self-management support and delivery system design interventions.

Table 101

Clinical evidence summary: delivery system design (DSD) interventions versus control.

Table 102

Clinical evidence summary: combined self-management support (SMS)/delivery system design (DSD) interventions versus control.

Table 103

Clinical evidence summary: motivational interviewing versus usual care (first time hearing aid users).

Table 104

Clinical evidence summary: motivational interviewing versus usual care (hearing aid users reporting ≤4 hours use per day).

18.2.2. Economic evidence

18.2.2.1. Published literature

One health economic study was identified with the relevant comparison and has been included in this review.¹²⁰ This is summarised in the health economic evidence profile below (Table 106) and the health economic evidence table in appendix I.

Table 106

Health economic evidence profile: before and after additional follow-up visit.

See also the health economic study selection flow chart in appendix F.

18.2.2.2. Unit costs

See appendix P.

18.2.3. Evidence statements

Clinical

Self-management support (SMS) interventions versus control

There was a clinically important benefit of SMS short term (8–10 weeks) for hearing aid use (>8 h/day; very low quality evidence, 1 study).
There was no clinically important difference in quality of life (World Health Organization’s Disability Assessment Schedule II; very low quality evidence, 1 study), self-reported hearing handicap (HHIE scale; low quality evidence, 1 study) and for communication (verbal subscale of the CPHI; low quality evidence, 1 study).
There was no evidence for adherence, adverse effects and hearing aid benefit.

Delivery system design (DSD) interventions versus control

There was a clinically important benefit of DSD long term (≥12 months) for number of outstanding complaints (low quality evidence, 1 study).
There was no clinically important difference in adherence (number of people fitted with hearing aid/number of people who use the aids; high quality evidence, 2 studies), daily hours of hearing aid use (high quality evidence, 4 studies), self-reported hearing handicap (HHIE scale; high quality evidence, 2 studies), hearing aid benefit (Outer Ear scale; high quality evidence, 1 study) and use of verbal communication strategy (verbal subscale of the CPHI scale; moderate quality evidence, 1 study).
No evidence was identified for quality of life scales.

Combined self-management support (SMS)/delivery system design (DSD) interventions versus control

There was a clinically important benefit of combined SMS/DSD for quality of life (moderate quality evidence, 2 studies) and for self-reported hearing handicap in the long term (≥12 months) (activate and psychosocial domains; low quality evidence, 1 study).
There was no clinically important difference in adherence (high quality evidence, 1 study), long term daily hours of hearing aid use (very low quality evidence, 2 studies), short to medium term daily hours of use (high quality evidence, 9 studies), short to medium term quality of life (moderate quality evidence, 8 studies), self-reported hearing handicap for symptoms (moderate quality, 2 studies), Hearing aid benefit assessed by validated self-report measures (IOI-HA item 4; moderate quality, 2 studies), short/medium-term hearing aid benefit (high quality evidence, 7 studies) and short/medium-term use of verbal communication strategy (verbal subscale of the CPHI; very low quality evidence, 4 studies).
No evidence was identified for adverse events.

Motivational interviewing versus usual care (first time hearing aid users)

There was a clinically important benefit of motivational interviewing for measures of the International Outcome Inventory for Hearing Aids (very low quality evidence, 1 study).

Motivational interviewing versus usual care (hearing aid users reporting ≤4 hours use per day)

There was a clinically important benefit of motivational interviewing for change in hearing aid use and for measures of International Outcome Inventory for Hearing Aids- Significant Other (low quality evidence, 1 study).
There was no clinically important difference in quality of life as measured by the World Health Organization’s Disability Assessment Schedule II score (low quality evidence, 1 study, Hospital Anxiety and Depression Scale - Anxiety score (very low quality evidence, 1 study) and Hospital Anxiety and Depression Scale – depression score (low quality evidence, 1 study).

Motivational engagement versus usual care

There was a clinically important benefit of motivational engagement for hearing aid use and Measure of Audiologic Rehabilitation (Self-Efficacy for Hearing Aids - Advanced handling (very low quality evidence, 1 study).
There was no clinically important difference in Measure of Audiologic Rehabilitation (Self-Efficacy for Hearing Aids – aided listening and overall), GHABP (benefit, satisfaction, residual disability and overall), Short Form Patient Activation Measure, Hospital Anxiety and Depression Scale (anxiety, depression and overall) and Satisfaction with Amplification in Daily Life (very low quality evidence, 1 study).

Economic

One cost–consequences analysis found that adding a follow-up appointment to fitting a new hearing aid was more costly and more effective than no routine follow-up appointment after fitting a new hearing aid for adults with hearing loss but did not alter quality of life (£51 more per person, 16% increase in proportion of patients using their hearing aid regularly, 0 change in EQ-5D score). This analysis was assessed as partially applicable with potentially serious limitations.

18.2.4. Recommendations and link to evidence

Recommendations	34. Consider using motivational interviewing or engagement strategies and goal setting when discussing hearing aids with adults for the first time, to encourage acceptance and use of hearing aids. 35. Show the hearing aids when they are first offered and discuss their suitability with the person. 36. At the follow-up audiology appointment for adults with hearing aids: ask the person if they have any concerns or questions address any difficulties with inserting, removing or maintaining their hearing aids provide information on communication, social care or rehabilitation support services if needed tell the person how to contact audiology services in the future for aftercare, including repairs and adjustments to accommodate changes in their hearing ensure that the person’s hearing aids and other devices meet their needs by checking: the comfort, sound quality and volume of hearing aids, including microphone and noise reduction settings, and fine-tuning them if needed hearing aid cleaning, battery life and use with a telephone use of assistive listening devices hours the hearing aid has been used, if shown by automatic data-logging review the goals identified in the personalised care plan and agree how to address any that have not been met (for information on the personalised care plan see recommendation 14). update the personalised care plan and provide them with a copy. 37. Give adults with hearing aids information about getting used to hearing aids, cleaning and caring for their hearing aids, and troubleshooting.
Relative values of different outcomes	The following outcomes were identified as critical outcomes for this review: hearing aid use, adverse effects, hearing-specific health-related quality of life, health-related quality of life, restricted participation or activity limitation, hearing aid benefit and communication, outcomes reported by carers or relatives.
Quality of the clinical evidence	The evidence ranged from very low to high quality. Most of the studies had small numbers of participants and were at high risk of bias and this was one of the main reasons for downgrading the evidence. In particular, randomisation and allocation were unclear. Only a few studies adequately described these processes making it difficult to clearly assess the risk of selection bias. For the outcomes where clinical benefit was found, the quality of the evidence was as follows: Self-management support (SMS) interventions; short term (8–10 weeks), very low quality evidence of clinical benefit to support hearing aid use for more than 8 hours a day. Delivery system design (DSD) interventions; long term (≥12 months), low quality evidence of clinical benefit for adverse events (number of outstanding complaints). Combined interventions (SMS and DSD), moderate quality evidence of clinical benefit for quality of life validated self-report measures in the long term (≥12 months).and low quality evidence of clinical benefit for self-reported hearing handicap in the long term (≥12 months), specifically for interventions targeting the ‘activate –psychosocial’ domain but not the ‘activate – symptoms’ domain Motivational interviewing or motivational engagement, very low to low quality evidence of clinical benefit for increasing hearing aid use (1 month and 10 weeks) and low quality evidence of clinical benefit for motivational interviewing improving quality of life as experienced by the significant other (according to IOI-HA significant other) (1 month). Very low quality evidence of clinical benefit for motivational interviewing for quality of life (according to IOI-HA) in first time hearing aid users (3 months), but not in experienced users reporting ≤4h use per day (1 month). Very low quality evidence of clinical benefit of motivational engagement for improving hearing aid benefit assessed by MARS-HA advanced handling subscale (10 weeks).
Trade-off between clinical benefits and harms	Two types of interventions were considered in the systematic review: self-management support (SMS) interventions, which aim to enable patients to optimally manage their own health and delivery system design (DSD) interventions that change the mode, format, timing or follow-up pattern of self-management support. For self-management support alone, there was a clinical benefit for hearing aid use (>8 hours per day). The guideline committee noted that the clinical difference found was based on increased hearing aid use for those who received verbal pre-fitting counselling (during the fitting appointment) plus simulations representing the listening situations they identified as important to them compared with verbal pre-fitting counselling alone. All outcomes for self-management favoured the intervention, even if not reaching clinical importance. Hearing aid pre-fitting interventions included counselling or awareness training and demonstrations of listening situations. The committee agreed based on the evidence and its experience that providing information about hearing aids, how they work, what they offer, and demonstrating how to use them at the pre-fitting assessment would help improve adherence. The committee noted that hearing aid users may be reluctant or find it difficult to re-access services if their early listening experiences fall short of expectations. Therefore, providing sufficient information at the initial appointments will ensure realistic expectations as well as empower the individual to ask for support and also enable ongoing self-management. The committee noted the fewer number of outstanding complaints at 1 year follow-up and improved quality of life and self-reported hearing handicap for interventions targeting psychosocial elements of management in the long term. Methods of delivery of interventions described in the evidence included telephone follow-up post fitting of hearing aids. These were carried out at different time points including 4, 6, 9 and 12 weeks. The committee agreed usual practice would be to follow up at 6 to 12 weeks post-fitting and this might be carried out over the phone rather than in person, although it was noted that people with hearing loss find using a telephone difficult due to the narrow bandwidth and lack of visual cues. Follow-up earlier than 6 weeks was felt to be too soon but leaving this longer than 12 weeks could result in people with problems giving up rather than persisting with hearing aid use. It was felt that people would be reluctant to ask for follow-up if it were offered on a request basis only. Other interventions included pre-fitting sessions on how to use a hearing aid and allowing the person to use one at home before fitting a permanent device. Another study reported benefit from providing a post-fitting counselling session on hearing tactics and coping strategies. The committee agreed it is important to demonstrate how to use a hearing aid when first discussing the different management options. At the follow-up appointment an audiologist should check the hearing aid(s) are comfortable and fitted correctly and should make any adjustments or fine-tuning required. The audiologist should also ensure the person is able to insert the device and knows how to carry out basic maintenance and care, such as cleaning and replacing batteries. Further recommendations on follow-up for patients with hearing loss including those without hearing aids are included in section 17.3.4). The delivery of information varied between studies and included written information provided as booklets or a DVD to use at home. Some included interactive exercises on listening skills or in hearing aid management. The committee agreed that information formats should be tailored to the person’s needs and individual learning styles. Motivational interviewing and engagement were found to be of benefit for increasing use of hearing aids, which the committee valued as a key outcome. Therefore, a recommendation was made to encourage the use of these strategies when first discussing the use of hearing aids with patients to assess their readiness and levels of motivation for having a hearing aid. The committee discussed the training requirements necessary for these strategies to be successfully implemented and agreed that training in motivational interviewing and engagement should be included in standard training for audiologists. Although no consistent benefit was seen for the quality of life or hearing benefit outcomes, it was noted that the length of follow-up in the studies may be too short for any benefits in these outcomes to be identified. No clinical harms were identified for any of the outcomes, but there was no clinical difference for the other outcomes for each type of intervention. Usual practice is to provide follow-up individually, and the practicalities of providing follow-up appointments to groups of patients was discussed. The committee agreed that organising appointments would be more difficult and parts of what is covered in follow-up appointments, such as fine-tuning hearing aids or discussing programming options, needs to be carried out face-to-face with the individual concerned. However other elements such as teaching basic maintenance and cleaning of devices, and information about support services available could be carried out in group situations. The committee discussed what should be included as part of a follow-up appointment. There is currently variation in practice in how comprehensive this is, but the committee noted that the model adult service specification within the Commissioning Services for People with Hearing Loss report gives recommendations on what should be included and the committee agreed that this is what is usually offered in areas delivering a good service to patients, and should form the minimum of what is provided. The committee noted that individual needs and learning styles differ and one size does not fit all people. Group follow-up may not be wanted by some or may not be appropriate, such as for people with cognitive or learning disabilities.
Trade-off between net clinical effects and costs	One health economic study was identified. This found an increase in hearing aid usage between 6 months and 12 months after initial fitting when hearing aid users were given a follow-up appointment at 6 months to help them with the use of their hearing aids (the proportion of people regularly using their hearing aid(s) increased from 61% to 78%). The study showed increases in the ability of hearing aid users to put in their own hearing aid (from 69% to 83%) and to use the hearing aid with telephones (27% to 68%), which supports the hypothesis that the follow-up appointment had led to the increased hearing aid usage. The study was a before-and-after design, so although improvement is shown with the intervention it cannot be proved whether this was due to the intervention or not. However, the committee discussed that it would be expected for hearing aid use to decline between 6 and 12 months, and so an increase strongly suggests effectiveness. No benefit was shown to quality of life as measured by EQ-5D, however this is not surprising given the limited ability of EQ-5D to detect changes in quality of life, and so it is not clear what benefit, if any, an increase in people using their hearing aids had on quality of life. However, the committee noted the increase in quality of life due to adoption of hearing aids found in other studies, which is discussed in more detail in the original economic modelling for this guideline (see appendix N). A programme including both initial fitting and follow-up cost £867 for each person subsequently regularly using their hearing aid, whereas a programme of only initial fitting and no follow-up cost £1,015 per regular user. Therefore the programme including follow-up had a greater impact per pound spent, although for the same number of people that programme would of course have a higher total cost. The committee noted that the 2016/17 NHS reference cost for a face-to-face audiology appointment is £52, whilst the NHS tariff cost for a hearing aid assessment and fitting in 2016 was £268 for 1 hearing aid, or £370 for a pair of hearing aids,⁸⁷ and that this tariff included the cost of 1 follow-up appointment [note, NHS England has withdrawn this tariff since the committee first discussed this question]. These costs are lower than those used in the published study. With a follow-up appointment costing £52, this would require a benefit to quality of life of only 0.0026 QALYs to be cost effective, which the committee thought highly plausible given the benefits to hearing shown by follow-up appointments. The clinical evidence and the committee’s expert opinion did not support a follow-up intervention at 6 months as in that study, the committee instead preferred to keep the current UK practice of following up after 6–12 weeks, as discussed in the review of monitoring and follow-up (section 17.3.4). Motivational interviewing and engagement were found to be of benefit for increasing hearing aid use. This would therefore be expected to increase health-related quality of life as noted above. These methods can be carried out in a wide variety of ways, and therefore it is not possible to anticipate their possible cost. The committee therefore recommended that they be considered as additional tools, as they may be cost effective. The costs of adopting a particular motivational strategy, in particular initial training costs, will need to be considered locally before deciding to implement such a strategy. The other recommendations in this chapter relate to demonstrating hearing aids in the initial appointment and what should be included in a follow-up appointment. These appointments are already necessary or recommended, and are discussed further in other chapters of this guideline, particularly in section 17.3.4. The question of which issues should be covered in the follow-up appointment will influence costs insofar as it alters the average length of a follow-up appointment. It is likely that not all follow-up appointments currently conducted include all elements specified in this recommendation. As such the average follow-up appointment conducted in line with this recommendation is likely to be slightly longer in the case of face-to-face appointment, and significantly longer in the case of non-face-to-face appointments (which are currently cheaper, partly as a result of being typically shorter than face-to-face appointments). Hence the cost of delivering face-to-face appointments could rise modestly, and the cost of delivering non-face-to-face appointments would be expected to rise to similar to that of face-to-face appointments, if delivered at a similar high quality. The actions recommended will lead to hearing aids being used more often and more effectively, and so will increase the effectiveness of hearing aid use. There may also be cost savings from reducing the need for additional subsequent appointments. The cost effectiveness of providing follow-up appointments is addressed in section 17.3.4.
Other considerations	None.

Bookshelf ID: NBK536555

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