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
KQ indicates key question; USPSTF, US Preventive Services Task Force.
eTable 1. Screening Tests Used in Primary Care to Detect Hearing Loss in Adults
List of Excluded Studies
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Feltner C, Wallace IF, Kistler CE, Coker-Schwimmer M, Jonas DE. Screening for Hearing Loss in Older Adults: Updated Evidence Report and Systematic Review for the US Preventive Services Task Force. JAMA. 2021;325(12):1202–1215. doi:10.1001/jama.2020.24855
Hearing loss is common in older adults and associated with adverse health and social outcomes.
To update the evidence review on screening for hearing loss in adults 50 years or older to inform the US Preventive Services Task Force.
MEDLINE, Cochrane Library, EMBASE, and trial registries through January 17, 2020; references; and experts; literature surveillance through October 8, 2020.
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.
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.
Detailed methods are available in the full evidence report.10 Figure 1 shows the analytic framework and key questions (KQs) that guided the review.
PubMed/MEDLINE, the Cochrane Library, EMBASE, and ClinicalTrials.gov were searched for English-language articles from 2010 through January 17, 2020 (eMethods in the Supplement). 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 (eMethods in the Supplement). 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 age-related 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 KQs1 through 3, eligible screening tests included those used, available, or feasible for use in primary care settings (eTable 1 in the Supplement).
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.
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 (eMethods in the Supplement).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 Supplement.
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.
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 (eTable 18 in the Supplement).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).
There was 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 measure of 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 (eTable 19 in the Supplement).
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 US25,26,38,41,46,47,50-52,54-56,58,59,61-64; 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 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
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.
Key Question 4A. What is the efficacy of interventions for screen-detected 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 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.
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?
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 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 false-positive 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.
Corresponding Author: Cynthia Feltner, MD, MPH, Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, 725 Martin Luther King Jr Blvd, CB#7295, Chapel Hill, NC 27599 (email@example.com).
Accepted for Publication: November 30, 2020.
Author Contributions: Dr Feltner had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.
Concept and design: All authors.
Acquisition, analysis, or interpretation of data: All authors.
Drafting of the manuscript: All authors.
Critical revision of the manuscript for important intellectual content: All authors.
Statistical analysis: Feltner, Wallace, Kistler.
Obtained funding: Feltner, Jonas.
Administrative, technical, or material support: Feltner, Coker-Schwimmer, Jonas.
Supervision: Feltner, Jonas.
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 Contributions: We gratefully acknowledge the following individuals for their contributions to this project, including AHRQ staff (Justin Mills, MD, and Tracy Wolff, MD, MPH) and RTI International–University of North Carolina Evidence-based Practice Center (EPC) staff (Carol Woodell, BSPH; Lynn Whitener, DrPH, MSLS; Sharon Barrell, MA; and Loraine Monroe), who received compensation for their role in this project. The USPSTF members, expert consultants, peer reviewers, and federal partner reviewers did not receive financial compensation for their contributions.
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.
Editorial Disclaimer: This evidence report is presented as a document in support of the accompanying USPSTF Recommendation Statement. It did not undergo additional peer review after submission to JAMA.