A Pragmatic Clinical Trial of Hearing Screening in Primary Care Clinics: Effect of Setting and Provider Encouragement.
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2024-01
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Abstract
Objectives
The prevalence of hearing loss increases with age. Untreated hearing loss is associated with poorer communication abilities and negative health consequences, such as increased risk of dementia, increased odds of falling, and depression. Nonetheless, evidence is insufficient to support the benefits of universal hearing screening in asymptomatic older adults. The primary goal of the present study was to compare three hearing screening protocols that differed in their level of support by the primary care (PC) clinic and provider. The protocols varied in setting (in-clinic versus at-home screening) and in primary care provider (PCP) encouragement for hearing screening (yes versus no).Design
We conducted a multisite, pragmatic clinical trial. A total of 660 adults aged 65 to 75 years; 64.1% female; 35.3% African American/Black completed the trial. Three hearing screening protocols were studied, with 220 patients enrolled in each protocol. All protocols included written educational materials about hearing loss and instructions on how to complete the self-administered telephone-based hearing screening but varied in the level of support provided in the clinic setting and by the provider. The protocols were as follows: (1) no provider encouragement to complete the hearing screening at home, (2) provider encouragement to complete the hearing screening at home, and (3) provider encouragement and clinical support to complete the hearing screening after the provider visit while in the clinic. Our primary outcome was the percentage of patients who completed the hearing screening within 60 days of a routine PC visit. Secondary outcomes following patient access of hearing healthcare were also considered and consisted of the percentage of patients who completed and failed the screening and who (1) scheduled, and (2) completed a diagnostic evaluation. For patients who completed the diagnostic evaluation, we also examined the percentage of those who received a hearing loss intervention plan by a hearing healthcare provider.Results
All patients who had provider encouragement and support to complete the screening in the clinic completed the screening (100%) versus 26.8% with encouragement to complete the screening at home. For patients who were offered hearing screening at home, completion rates were similar regardless of provider encouragement (26.8% with encouragement versus 22.7% without encouragement); adjusted odds ratio of 1.25 (95% confidence interval 0.80-1.94). Regarding the secondary outcomes, roughly half (38.9-57.1% depending on group) of all patients who failed the hearing screening scheduled and completed a formal diagnostic evaluation. The percentage of patients who completed a diagnostic evaluation and received a hearing loss intervention plan was 35.0% to 50.0% depending on the group. Rates of a hearing loss intervention plan by audiologists ranged from 28.6% to 47.5% and were higher compared with those by otolaryngology providers, which ranged from 15.0% to 20.8% among the groups.Conclusions
The results of the pragmatic clinical trial showed that offering provider encouragement and screening facilities in the PC clinic led to a significantly higher rate of adherence with hearing screening associated with a single encounter. However, provider encouragement did not improve the significantly lower rate of adherence with home-based hearing screening.Type
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Smith, Sherri L, Howard W Francis, David L Witsell, Judy R Dubno, Rowena J Dolor, Janet Prvu Bettger, Mina Silberberg, Carl F Pieper, et al. (2024). A Pragmatic Clinical Trial of Hearing Screening in Primary Care Clinics: Effect of Setting and Provider Encouragement. Ear and hearing, 45(1). pp. 23–34. 10.1097/aud.0000000000001418 Retrieved from https://hdl.handle.net/10161/34282.
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Scholars@Duke
Sherri L Smith
Dr. Smith's core research focuses on improving the assessment and treatment of hearing loss in older adults. Specifically, her work centers on comparing the effectiveness of current hearing interventions, developing new, innovative clinical tools, and examining alternative service-delivery approaches that help patients reach their individual hearing goals and improve their quality of life.
Dr. Smith also collaborates with multi-disciplinary teams to better understand the impact of hearing loss on other health conditions and services. Current projects involve understanding the impact of hearing loss on surgical outcomes in older adults, determining the mechanisms that may explain the independent association between hearing loss and falls in older adults, and comparing different models of hearing screenings for older adults in primary care settings.
Howard Wayne Francis
Dr. Howard W. Francis, is the Richard Hall Chaney, Sr professor of Otolaryngology and inaugural Chair of the Department of Head and Neck Surgery & Communication Sciences (HNS&CS) at Duke University Medical Center, where he is also the Chief of the Medical Staff of Duke University Hospital. He is a practicing neurotologist with research interests including practice innovations and clinical outcomes in the delivery of hearing health care. He is a senior editor of the Cummings Otolaryngology-Head and Neck Surgery Text, is a Director on the American Board of Otolaryngology-Head and Neck Surgery, a past member of the Otolaryngology Residency Review Committee of the ACGME, and a member of the Board of Directors of the Alexander Graham Bell Association for the Deaf and Hard of Hearing. Dr. Francis is a past president of the Society of University Otolaryngologists, past Education Director of the American Neurotology Society, and a recipient of the 2020 American Academy of Otolaryngology-Head and Neck Surgery Presidential Citation.
After completing his high-school education in Jamaica, and his bachelor’s degree at the University of Southern California in Los Angeles, Dr. Francis earned his medical degree from the Harvard-MIT division of Health, Science and Technology at Harvard Medical School, and then completed his internship, residency and fellowship training at the Johns Hopkins Hospital. He completed his Master’s in Business Administration with a focus in medical services management at the Johns Hopkins Carey Business School. After 19 years on the faculty at Johns Hopkins during which he served as Residency Program Director, Director of the Johns Hopkins Listening Center and Vice Director of the Department, he was appointed chief of HNS&CS at Duke in March 2017, and then the first Chair of the new Department in 2019.
David Latham Witsell
Rowena Joy Dolor
Rowena J. Dolor, MD, MHS did her medical training and internal medicine residency at Duke University Medical Center. She completed the Ambulatory Care/Health Services Research fellowship at the Durham VA Medical Center in 1996 and obtained her Masters in Health Sciences degree in Biometry (renamed MHS in Clinical Research) from the Duke University School of Medicine in 1998. Dr. Dolor was a staff physician in the Ambulatory Care Service at the Durham VA Medical Center and Research Associate at the Center for Health Services Research in Primary Care at the Durham VAMC from 1995-2012. She is currently an investigator of several federally-funded projects conducted in the community-based setting. Dr. Dolor served as a member of the AHRQ PBRN Resource Center Steering Committee and co-chaired the NAPCRG PBRN conference from 2012-2016.
Since 1996, Dr. Dolor has been the director of the Primary Care Research Consortium (PCRC), a network of primary care practices in the Duke University Health System and outlying communities. The PCRC has participated in over 100 industry- and investigator-initiated studies on hypertension, hyperlipidemia, asthma, otitis, obesity, diabetes, depression, anticoagulation, and vaccines. In 2002, the Duke PCRC received grant funding from the Agency for Healthcare Research and Quality (AHRQ) for Primary Care Practice-based Research Networks (PBRNs). The focus of her research pertains to primary care clinical and outcomes research. She has helped lead a number of comparative effectiveness studies and large, pragmatic trials in the primary care setting. In addition, Dr. Dolor has led or co-led networks in otolaryngology and integrative medicine.
Dr. Dolor has contributed to the development and methodology of Practice-based Research Networks (PBRNs). She has served as a co-investigator on three online resources to help researchers conduct multi-center research in the primary care practice-based setting – (1) A toolkit for building and sustaining health research partnership with practices and communities, http://www.researchtoolkit.org/index.php (2) Toolkit for Developing and Conducting Multi-site Clinical Trials in Practice Based Research Networks, http://www.dartnet.info/ClinicalTrialsPBRNToolkit.htm ; and (3) PBRN Research Good Practices (PRGP), http://www.napcrg.org/PBRNResearchGoodPractice
From July 2009-June 2012, she served as the Associate Director for the Duke EPC. She worked closely with the Director, Gillian Sanders PhD, in overseeing the day-to-day functioning of EPC projects and supervising EPC personnel. The Duke EPC was awarded a contract entitled “American Recovery and Reinvestment Act of 2009: Comprehensive EPC Comparative Effectiveness Reviews for Effective Health Care” to serve within a core group of EPCs to focus on a comprehensive approach to comparative effectiveness review (CER) and evidence synthesis. The Duke EPC area of concentration was cardiovascular and pulmonary disorders.
She previously served as the principal investigator for the systematic literature review for the AHA Scientific Statement: Evidence-based guidelines for cardiovascular disease prevention in women published in 2004 and updated in 2007. She was the PI of four CER projects on “Noninvasive Technologies for the Diagnosis of Coronary Artery Disease in Women” and “Treatment Strategies for Women with CAD”, “PAD”, and “UA/NSTEMI” as well as upcoming CER topics on pulmonary arterial hypertension, peripheral artery disease and unstable angina/non-ST elevation myocardial infarction.
Within the Duke Clinical and Translational Institute (CTSI), Dr. Dolor directs the collaboration with CTSI researchers on community-based PBRN projects. From 2011- 2014, she was co-chair of the CTSA PBRN Collaboration Workgroup, and a member of the Community Engagement Key Function Committee, the CTSA Strategic Goal 4 Combined Networking Group committee, and the CTSA Comparative Effectiveness Research Key Function Committee (CER KFC). Since September 2016, she serves as a Co-chair of the Dissemination, Implementation and Knowledge Transfer Workgroup within the Collaboration Engagement Domain Task Force.
In the fall of 2014, Dr. Dolor joined Vanderbilt part-time as a Consultant/Adjunct Associate Professor of Medicine within the Division of General Internal Medicine. Her role is to assist in the formation of the Meharry-Vanderbilt Clinical Research Network, a PBRN in the mid-Tennessee region. In addition, she is a co-investigator on the Mid-South Clinical Data Research Network, a PCORnet awardee, to build the partnership with the community practices for comparative effectiveness studies that will utilize the electronic health records/information system infrastructure of the CDRN.
Janet Prvu Bettger
Dr. Bettger’s research is dedicated to establishing real world evidence aimed to improve health care quality and policies that reduce the burden of disease and disability. As a health services researcher and implementation scientist, her research extends from observational studies to randomized and pragmatic trials. She was the Founding Director of Duke Roybal Center for Translational Research in the Behavioral and Social Sciences of Aging and the Founding Director of Undergraduate Initiatives for the Duke-Margolis Center for Health Policy. She has examined implementation of several integrated care models to improve the transition home from the hospital (VERITAS with virtual exercise therapy after knee replacement, COMPASS for stroke, RECOVER for stroke in rural China, and coordinated care for trauma patients in Tanzania). She also studies implementation of community-based models of care that can prevent functional decline. These include the CTSA-funded IMPAC RCT of integrating physical therapists into primary care as first line providers to address musculoskeletal pain, the VA-funded Gerofit program of structured and progressive in-person and virtual group exercise for older Veterans, MRC-funded SINEMA RCT of a village-based model supporting stroke recovery in China, and a NIDCD study comparing three primary care protocols for older adult hearing healthcare.
In addition to the evidence translation studies in China (RECOVER and SINEMA) and Tanzania, she has partnered with experts in Singapore on stroke systems research, and worked on large cluster randomized trials to improve evidence-based care in Brazil, Peru, Argentina (BRIDGE-Stroke) and China (CNSR and Golden Bridge). To address health locally, she was the faculty sponsor to launch Exercise is Medicine at Duke and Help Desk, a student volunteer community resource navigator model addressing social determinants of health.
Dr. Bettger received her BA from the University of Western Ontario, Canada and her MS from the University of Wisconsin–LaCrosse where she studied community reintegration for stroke and brain-injured patients transitioning from hospital to home. Her doctoral training in Rehabilitation Sciences, completed at Boston University, concluded with an investigation of patterns of functional recovery and factors affecting outcomes in patients transitioning home following acute rehabilitation. While working on her doctorate, she also worked in state government as the director of the Paul Coverdell National Acute Stroke Registry. Dr. Bettger completed post-doctoral training at the University of Pennsylvania with a NIH NRSA research fellowship in neurorehabilitation, a research fellowship at the NewCourtland Center for Transitions and Health, and a Switzer Fellowship funded by the National Institute on Disability and Rehabilitation Research to study the role of the environment on functional outcomes. She completed additional research training at Duke as a mentored scholar in comparative effectiveness research funded by AHRQ. As of July 2022, she is an Adjunct Associate Professor for Duke's Department of Orthopaedics and has transitioned out of her role as Co-Director of the Duke Clinical and Translational Institute (CTSA) Pilots Accelerator Core working with NCCU. She is affiliate faculty with Duke's Science and Society, Duke-Margolis Center for Health Policy, the Duke Clinical Research Institute (DCRI) and Duke Global Health Institute (DGHI), is a Senior Fellow of the Duke Center for the Study of Aging and Human Development, and is a Fellow of the American Heart Association.
Mina Ruth Silberberg
I have over thirty years of experience in health services, community health, and health policy research and evaluation. My work has focused on improving the health of low-income and otherwise underserved populations through primary care practice change, community-based programs/organizations, and addressing social drivers of health. My studies generally use mixed-methods participatory program evaluation and community-engaged research approaches. I also study, write about, and teach community engaged/participatory research and evaluation. I have a great deal of experience with mentoring trainees on research, including undergraduate students, graduate students, medical students, residents, junior faculty, and senior faculty moving into new areas of work.
Carl F. Pieper
Analytic Interests.
1) Issues in the Design of Medical Experiments: I explore the use of reliability/generalizability models in experimental design. In addition to incorporation of reliability, I study powering longitudinal trials with multiple outcomes and substantial missing data using Mixed models.
2) Issues in the Analysis of Repeated Measures Designs & Longitudinal Data: Use of Hierarchical Linear Models (HLM) or Mixed Models in modeling trajectories of multiple variables over time (e.g., physical and cognitive functioning and Blood Pressure). My current work involves methodologies in simultaneous estimation of trajectories for multiple variables within and between domains, modeling co-occuring change.
Areas of Substantive interest: (1) Experimental design and analysis in gerontology and geriatrics, and psychiatry,
(2) Multivariate repeated measures designs,
Pranab Majumder
Pranab teaches at the Fuqua and Pratt Schools at Duke University. His research area is Operations Management. He also coordinates the Experiential Learning Programs at Fuqua.
Jessica Sayles West
Jessica is a medical sociologist who specializes in research on hearing loss, aging, and health disparities over the life course. Jessica’s work has described the “spillover” effects of hearing loss on health outcomes for both individuals and those close to them, as well as sociodemographic disparities in the onset of and life expectancy with hearing loss. Her research, which leverages both population-level data and electronic health record data, has appeared in the Journals of Gerontology, Social Science & Medicine, Ear and Hearing, and other leading journals in medical sociology, hearing, and aging research.
Jessica received a B.A. from the University of Michigan in Social Anthropology (dual Sociology/Anthropology concentration) followed by an M.P.H. in Sociomedical Sciences with a certificate in Public Health Research Methods from Columbia University’s Mailman School of Public Health. She subsequently received an M.A. and Ph.D. in Sociology with a focus in Medical Sociology and Demography at Duke University. She then completed an NIA T32 Postdoctoral Fellowship at the Duke University Aging Center under the mentorship of Matthew E. Dupre, Ph.D. (Population Health Sciences) and Sherri L. Smith, Au.D., Ph.D. (Head and Neck Surgery & Communication Sciences).
Debara Lyn Tucci
The focus of current research efforts is in defining the effects of conductive hearing impairment on the development and function of the central auditory system. The ultimate goal of this research is to understand the impact of hearing loss, such as that associated with otitis media, on the development of auditory function in children. Experiments are currently being performed in which central auditory system activity is studied using the 2-deoxyglucose method following unilateral neonatal conductive hearing loss. Future experiments will examine changes in cell structure and interneuronal connections following acute and chronic conductive hearing loss in both neonatal and adult animals.
A second research program is focused on issues related to the cochlear implant. The cochlear implant is a device which allows for electrical stimulation of the auditory nerve in profoundly deaf patients. It has previously been demonstrated in animal studies as well as in human tissue histopathology that degeneration of central auditory pathways occurs following severe damage to the inner ear. It has been suggested that the introduction of electrical stimulation via a cochlear implant may prevent or reverse some of these degenerative changes. Experiments conducted previously examined this issue in the neonatally and adult deafened rat. Tissue analysis is currently undergoing completion.
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