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Figure.
Flowchart of the Systematic Review
Flowchart of the Systematic Review
Table 1.  
Included Publications by Country
Included Publications by Country
Table 2.  
Increases in Direct Medical Expendituresa and Indirect Costsb Associated With Hearing Impairment
Increases in Direct Medical Expendituresa and Indirect Costsb Associated With Hearing Impairment
Table 3.  
Disability Impact of Hearing Impairment
Disability Impact of Hearing Impairment
Table 4.  
Disability Payouts for Occupational Noise-Induced Hearing Loss
Disability Payouts for Occupational Noise-Induced Hearing Loss
1.
Lin  FR, Niparko  JK, Ferrucci  L.  Hearing loss prevalence in the United States.  Arch Intern Med. 2011;171(20):1851-1852. doi:10.1001/archinternmed.2011.506PubMedGoogle ScholarCrossref
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Goman  AM, Lin  FR.  Prevalence of hearing loss by severity in the United States.  Am J Public Health. 2016;106(10):1820-1822. doi:10.2105/AJPH.2016.303299PubMedGoogle ScholarCrossref
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Chien  W, Lin  FR.  Prevalence of hearing aid use among older adults in the United States.  Arch Intern Med. 2012;172(3):292-293. doi:10.1097/IPC.0b013e31822e9bba.IPubMedGoogle ScholarCrossref
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Lin  FR, Ferrucci  L.  Hearing loss and falls among older adults in the United States.  Arch Intern Med. 2012;172(4):369-371. doi:10.1001/archinternmed.2011.728PubMedGoogle ScholarCrossref
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Genther  DJ, Betz  J, Pratt  S,  et al; Health ABC Study.  Association of hearing impairment and mortality in older adults.  J Gerontol A Biol Sci Med Sci. 2015;70(1):85-90. doi:10.1093/gerona/glu094PubMedGoogle ScholarCrossref
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Lin  FR, Yaffe  K, Xia  J,  et al; Health ABC Study Group.  Hearing loss and cognitive decline in older adults.  JAMA Intern Med. 2013;173(4):293-299. doi:10.1001/jamainternmed.2013.1868PubMedGoogle ScholarCrossref
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Moher  D, Liberati  A, Tetzlaff  J, Altman  DG; PRISMA Group.  Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement.  BMJ. 2009;339(21):b2535.PubMedGoogle ScholarCrossref
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14.
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Murray  CJL, Atkinson  C, Bhalla  K,  et al; U.S. Burden of Disease Collaborators.  The state of US health, 1990-2010: burden of diseases, injuries, and risk factors.  JAMA. 2013;310(6):591-608.PubMedGoogle ScholarCrossref
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Jung  D, Bhattacharyya  N.  Association of hearing loss with decreased employment and income among adults in the United States.  Ann Otol Rhinol Laryngol. 2012;121(12):771-775.PubMedGoogle ScholarCrossref
17.
Kochkin  S.  The efficacy of hearing aids in achieving compensation equity in the workplace.  Hear J. 2010;63(10):19-28.Google ScholarCrossref
18.
Stucky  SR, Wolf  KE, Kuo  T.  The economic effect of age-related hearing loss: national, state, and local estimates, 2002 and 2030.  J Am Geriatr Soc. 2010;58(3):618-619. doi:10.1111/j.1532-5415.2010.02746.xPubMedGoogle ScholarCrossref
19.
Mohr  PE, Feldman  JJ, Dunbar  JL,  et al.  The societal costs of severe to profound hearing loss in the United States.  Int J Technol Assess Health Care. 2000;16(4):1120-1135.PubMedGoogle ScholarCrossref
20.
Tufts  JB, Weathersby  PK, Rodriguez  FA.  Modeling the United States government’s economic cost of noise-induced hearing loss for a military population.  Scand J Work Environ Health. 2010;36(3):242-249. doi:10.5271/sjweh.2911PubMedGoogle ScholarCrossref
21.
Jones  DD.  Relative earnings of deaf and hard-of-hearing individuals.  J Deaf Stud Deaf Educ. 2004;9(4):459-461. doi:10.1093/deafed/enh047PubMedGoogle ScholarCrossref
22.
Houtenville  AJ.  A comparison of the economic status of working-age persons with visual impairments and those of other groups.  J Vis Impair Blind. 2003;97(3):133-148.Google Scholar
23.
Daniell  WE, Fulton-Kehoe  D, Smith-Weller  T, Franklin  GM.  Occupational hearing loss in Washington state, 1984-1991: II, morbidity and associated costs.  Am J Ind Med. 1998;33(6):529-536.PubMedGoogle ScholarCrossref
24.
Harris  JP, Anderson  JP, Novak  R.  An outcomes study of cochlear implants in deaf patients: audiologic, economic, and quality-of-life changes.  Arch Otolaryngol Head Neck Surg. 1995;121(4):398-404.PubMedGoogle ScholarCrossref
25.
Ruben  RJ.  Redefining the survival of the fittest: communication disorders in the 21st century.  Laryngoscope. 2000;110(2, pt 1):241-245. doi:10.1097/00005537-200002010-00010PubMedGoogle ScholarCrossref
26.
Ginnold  R. Occupational Hearing Loss: Workers Compensation under State & Federal Programs; 1979. https://books.google.com/books/about/Occupational_Hearing_Loss.html?id=ChpSAAAAMAAJ. Accessed March 16, 2016.
27.
Prince  MJ, Wu  F, Guo  Y,  et al.  The burden of disease in older people and implications for health policy and practice.  Lancet. 2015;385(9967):549-562.PubMedGoogle ScholarCrossref
28.
Access Economics. Listen Hear!: The economic impact and cost of hearing loss in Australia. Australian Policy Online. https://audiology.asn.au/public/1/files/Publications/ListenHearFinal.pdf. Published February 2006. Accessed July 27, 2015.
29.
Mathers  CD, Vos  ET, Stevenson  CE, Begg  SJ.  The burden of disease and injury in Australia.  Bull World Health Organ. 2001;79(11):1076-1084.PubMedGoogle Scholar
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Mathers  C, Vos  T, Stevenson  C.  The Burden of Disease and Injury in Australia. Canberra, Australia: Australian Institute of Health and Welfare; 1999.
31.
Alleyne  BC, Dufresne  RM, Kanji  N, Reesal  MR.  Costs of workers’ compensation claims for hearing loss.  J Occup Med. 1989;31(2):134-138.PubMedGoogle Scholar
32.
Alleyne  BC.  Hearing loss: can knowing what it costs society help reduce its occurrence?  Can J Public Health. 1989;80(6):463-464.PubMedGoogle Scholar
33.
Chen  H, Wang  H, Crimmins  EM, Chen  G, Huang  C, Zheng  X.  The contributions of diseases to disability burden among the elderly population in China.  J Aging Health. 2014;26(2):261-282. doi:10.1177/0898264313514442PubMedGoogle ScholarCrossref
34.
Nachtegaal  J, Heymans  MW, van Tulder  MW, Goverts  ST, Festen  JM, Kramer  SE.  Comparing health care use and related costs between groups with and without hearing impairment.  Int J Audiol. 2010;49(12):881-890. doi:10.3109/14992027.2010.507603PubMedGoogle ScholarCrossref
35.
Thorne  PR, Ameratunga  SN, Stewart  J,  et al.  Epidemiology of noise-induced hearing loss in New Zealand.  N Z Med J. 2008;121(1280):33-44.PubMedGoogle Scholar
36.
Catalá-López  F, Gènova-Maleras  R, Ridao  M,  et al.  Burden of disease assessment with summary measures of population health for the region of Valencia, Spain: a population-based study.  Med Clin (Barc). 2013;140(8):343-350.PubMedGoogle ScholarCrossref
37.
Gènova-Maleras  R, Álvarez-Martín  E, Morant-Ginestar  C, Fernández de Larrea-Baz  N, Catalá-López  F.  Measuring the burden of disease and injury in Spain using disability-adjusted life years: an updated and policy-oriented overview.  Public Health. 2012;126(12):1024-1031.PubMedGoogle ScholarCrossref
38.
Dobie  RA.  The burdens of age-related and occupational noise-induced hearing loss in the United States.  Ear Hear. 2008;29(4):565-577. doi:10.1097/AUD.0b013e31817349ecPubMedGoogle ScholarCrossref
39.
Nelson  DI, Nelson  RY, Concha-Barrientos  M, Fingerhut  M.  The global burden of occupational noise-induced hearing loss.  Am J Ind Med. 2005;48(6):446-458. doi:10.1002/ajim.20223PubMedGoogle ScholarCrossref
40.
Centers for Medicare & Medicaid Services. National Health Expenditures 2014 Highlights; 2015. https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/NationalHealthExpendData/Downloads/highlights.pdf. Accessed January 29, 2016.
41.
Daniel  E.  Noise and hearing loss: a review.  J Sch Health. 2007;77(5):225-231.PubMedGoogle ScholarCrossref
42.
Helzner  EP, Cauley  JA, Pratt  SR,  et al.  Race and sex differences in age-related hearing loss: the Health, Aging and Body Composition Study.  J Am Geriatr Soc. 2005;53(12):2119-2127. doi:10.1111/j.1532-5415.2005.00525.xPubMedGoogle ScholarCrossref
43.
Brant  LJ, Gordon-Salant  S, Pearson  JD,  et al.  Risk factors related to age-associated hearing loss in the speech frequencies.  J Am Acad Audiol. 1996;7(3):152-160.PubMedGoogle Scholar
44.
Cruickshanks  KJ, Nondahl  DM, Dalton  DS,  et al.  Smoking, central adiposity, and poor glycemic control increase risk of hearing impairment.  J Am Geriatr Soc. 2015;63(5):918-924. doi:10.1111/jgs.13401PubMedGoogle ScholarCrossref
45.
Cruickshanks  KJ, Klein  R, Klein  BEK, Wiley  TL, Nondahl  DM, Tweed  TS.  Cigarette smoking and hearing loss: the epidemiology of hearing loss study.  JAMA. 1998;279(21):1715-1719. doi:10.1001/jama.279.21.1715PubMedGoogle ScholarCrossref
46.
Bogoch  II, House  RA, Kudla  I.  Perceptions about hearing protection and noise-induced hearing loss of attendees of rock concerts.  Can J Public Health. 2005;96(1):69-72.PubMedGoogle Scholar
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Widén  SEO, Erlandsson  SI.  The influence of socio-economic status on adolescent attitude to social noise and hearing protection.  Noise Health. 2004;7(25):59-70.PubMedGoogle Scholar
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Chen  JM, Amoodi  H, Mittmann  N.  Cost-utility analysis of bilateral cochlear implantation in adults: a health economic assessment from the perspective of a publicly funded program.  Laryngoscope. 2014;124(6):1452-1458. doi:10.1002/lary.24537PubMedGoogle ScholarCrossref
50.
Cheng  AK, Niparko  JK.  Cost-utility of the cochlear implant in adults: a meta-analysis.  Arch Otolaryngol Head Neck Surg. 1999;125(11):1214-1218.PubMedGoogle ScholarCrossref
51.
Kuthubutheen  J, Mittmann  N, Amoodi  H, Qian  W, Chen  JM.  The effect of different utility measures on the cost-effectiveness of bilateral cochlear implantation.  Laryngoscope. 2015;125(2):442-447.PubMedGoogle ScholarCrossref
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Gorodetskaya  I, Zenios  S, McCulloch  CE,  et al.  Health-related quality of life and estimates of utility in chronic kidney disease.  Kidney Int. 2005;68(6):2801-2808. doi:10.1111/j.1523-1755.2005.00752.xPubMedGoogle ScholarCrossref
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Helvik  AS, Krokstad  S, Tambs  K.  Hearing loss and risk of early retirement: the HUNT study.  Eur J Public Health. 2013;23(4):617-622. doi:10.1093/eurpub/cks118PubMedGoogle ScholarCrossref
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Pierre  PV, Fridberger  A, Wikman  A, Alexanderson  K.  Self-reported hearing difficulties, main income sources, and socio-economic status; a cross-sectional population-based study in Sweden.  BMC Public Health. 2012;12:874. doi:10.1186/1471-2458-12-874PubMedGoogle ScholarCrossref
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Review
October 2017

The Economic Impact of Adult Hearing Loss: A Systematic Review

Author Affiliations
  • 1Department of Otolaryngology–Head & Neck Surgery, Johns Hopkins School of Medicine, Baltimore, Maryland
  • 2Center on Aging and Health, Johns Hopkins Medical Institutions, Baltimore, Maryland
  • 3The Boston Consulting Group, New York City, New York
  • 4Department of Gastroenterology, Johns Hopkins School of Medicine, Baltimore, Maryland
  • 5Centers for Medicare & Medicaid Services, Baltimore, Maryland
  • 6Johns Hopkins Welch Medical Library, Baltimore, Maryland
  • 7Johns Hopkins Carey School of Business, Baltimore, Maryland
JAMA Otolaryngol Head Neck Surg. 2017;143(10):1040-1048. doi:10.1001/jamaoto.2017.1243
Key Points

Question  What is the economic impact of hearing impairment?

Findings  In this systematic review, direct medical expenditures and indirect costs associated with hearing impairment were assessed. In the United States, estimates of the economic cost of lost productivity varied from $1.8 to $194 billion, and direct medical costs ranged from $3.3 to $12.8 billion.

Meaning  Hearing loss is associated with billions of dollars of excess costs in the United States, but significant variance is seen between studies. A rigorous, comprehensive estimate of the economic impact of hearing loss is needed to help guide policy decisions around the management of hearing loss in adults.

Abstract

Importance  Hearing impairment (HI) is highly prevalent in older adults and has been associated with adverse health outcomes. However, the overall economic impact of HI is not well described.

Objective  The goal of this review was to summarize available data on all relevant costs associated with HI among adults.

Evidence Review  A literature search of PubMed, Embase, the Cochrane Library, CINAHL, and Scopus was conducted in August 2015. For this systematic review, data extraction and quality assessment were performed by 2 independent reviewers. Eligibility criteria for included studies were presence of quantitative estimation of economic impact or loss of productivity of patients with HI, full-text English-language access, and publication in an academic, peer-reviewed journal or government report prior to August 2015. This review follows the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) statement. A meta-analysis was not performed owing to the studies’ heterogeneity in outcomes measures, methodology, and study country.

Findings  The initial literature search yielded 4595 total references. After 2043 duplicates were removed, 2552 publications underwent title and abstract review, yielding 59 articles for full-text review. After full-text review, 25 articles were included. Of the included articles, 8 incorporated measures of disability; 5 included direct estimates of medical expenditures; 8 included other cost estimates; and 7 were related to noise-induced or work-related HI. Estimates of the economic cost of lost productivity varied widely, from $1.8 to $194 billion in the United States. Excess medical costs resulting from HI ranged from $3.3 to $12.8 billion in the United States.

Conclusions and Relevance  Hearing loss is associated with billions of dollars of excess costs in the United States, but significant variance is seen between studies. A rigorous, comprehensive estimate of the economic impact of hearing loss is needed to help guide policy decisions around the management of hearing loss in adults.

Introduction

Hearing impairment (HI) has attracted increasing attention as a public health concern. Hearing impairment is highly prevalent in older adults, affecting nearly two-thirds of the US population aged 70 years or older,1,2 but fewer than 20% of adults with hearing loss obtain any form of treatment.3 Importantly, HI has been linked to a number of negative health outcomes including falls, depression, cognitive decline, dementia, and increased hospitalizations. Consequently, top-down efforts in the United States at the Institute of Medicine and with the White House, the President’s Council of Advisors on Science and Technology, are now addressing hearing loss as a key public health issue.4-8

However, the true economic impact of HI in adults remains poorly studied. This project aimed to summarize the available evidence of the costs of adult hearing loss, including direct medical costs and indirect costs such as lost productivity, disability, and disability claims both in the United States and globally.

Methods

This systematic review follows guidelines suggested by the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) statement.9 An informationist developed and conducted the search strategy after input and feedback from the research team. The literature search was applied to PubMed, Embase, the Cochrane Library, CINAHL, and Scopus, and was conducted on August 12, 2015. Controlled vocabulary, such as Medical Subject Headings and Emtree terms, were used in combination with keywords for the concepts of hearing loss, cost of illness, and outcomes. The concept for hearing loss included terms such as hearing loss, persons with hearing impairments, auditory defects, presbycusis, hearing dysfunction, auditory threshold, and other similar terms. The concept for cost of illness included search terms such as economics, cost, expenditure, utility theory, and other similar terms to account for economics, burden of disease, and utility theory. In an effort to capture relevant outcomes, the outcomes concept included words and phrases such as quality-adjusted life-years (QALYs), quality of life, disability evaluation, life tables, employment, retirement, income, and morbidity, among others. To exclude articles where pediatrics was the main focus, terms such as pediatrics, children, and neonates were excluded from the titles only. The search strategy can be found in the eAppendix in the Supplement. The searches were limited to the English language only. The research team then performed a title and abstract review of the search results for eligibility. All articles meeting the inclusion criteria were retrieved, and the full text was reviewed.

Inclusion criteria during the title and abstract review included evidence of estimation of overall economic impact of hearing loss. Exclusion criteria included articles dealing with pediatric patients, defined as those younger than 18 years, and non–English-language articles. Inclusion criteria during full-text review included presence of quantitative estimation of economic impact or loss of productivity of patients with hearing loss, full-text access, and publication in an academic, peer-reviewed journal or government report. Exclusion criteria during full-text review included articles calculating impact based on pediatric or congenital hearing loss, association publications, cost-effectiveness or cost-utility studies comparing screening or intervention programs, quality-of-life studies, and studies focused solely on tinnitus.

Two reviewers performed data extraction independently, using predetermined data fields for extraction, and rated the study quality using the Evers checklist,10 excluding items 2 and 13, which were not applicable because they relate to cost-effectiveness studies. The 2 reviewers independently created an Evers score for each article by counting the number of Evers checklist criteria met by that article. The Evers scores were averaged between the 2 reviewers; the maximum total score was 17. A third researcher combined the extracted data and resolved discrepancies with reviewers until consensus was obtained. Currency was converted into US dollars using exchange rates from the year in which the study cost estimation occurred.11 Cost data were then inflated to first-half 2015 US dollars using a medical consumer price index (CPI) calculator for medical costs and general CPI calculator for all other costs.12 All costs are presented in first-half 2015 US dollars. As methodology and outcome measures varied widely across studies, no meta-analysis was performed.

Data were split into categories based on cost estimate: disability estimates included DALYs and years lived with disease (YLDs), direct medical costs, and other costs including loss of income. Noise-induced hearing loss is presented separately because much of the literature on noise-induced hearing loss involves disability claims and insurance payouts.

The disability claim total for HI paid by the US Department of Veterans Affairs was not explicitly stated in the report but was estimated from information found in the report.13 First, the disability claim payout for all audiologic disability was calculated for each level of disability by multiplying the number of audiologic disability recipients at a given disability level by the average yearly payment for that disability level. These total payouts for each disability level were then summed to produce the overall disability payout for all audiologic disability. This total was then multiplied by the proportion of audiologic disability attributed to HI (41.48%) to obtain an estimate for the total disability payment for HI.

Results

The initial literature search yielded 4595 total references. After 2043 duplicates were removed, 2552 publications underwent title and abstract review, yielding 59 articles for full-text review (Figure). Two sources were added through reference review and expert recommendation. After full-text review, 25 articles met the inclusion criteria (Table 1). Of the included articles, 5 measured direct estimates of medical expenditures (Table 2); 8 included other cost estimates (Table 2); 8 incorporated measures of disability (Table 3); and 7 related to noise-induced or work-related hearing loss (Table 4). Some studies included estimates in more than 1 of these categories. All included studies are summarized in Table 1. The majority of studies (n = 14) were from the United States. The remainder included 3 from Australia, 3 from Europe, 2 from Canada, 1 from New Zealand, 1 from China, and 1 from multiple countries. Averaged modified Evers checklist quality scores ranged from 8.0 to 15.5 out of a maximum score of 17. Hearing loss was defined in different ways across studies.

The total annual cost of HI in Australia was estimated to be $10.9 billion ($3056 per person with hearing loss).28 A recent and similarly comprehensive overall estimate of total cost in the United States is lacking, but Mohr et al19 estimated the overall lifetime cost of for individual with severe HI to range from $69 451 per person with onset in the retired elderly (aged ≥65 years) to $673 339 per person with onset in early adulthood (aged 18-44 years).

Medical Expenditures

Of the 5 studies that measured direct medical costs, adult HI was associated with high medical expenditures in all studies (Table 2). A study using Medical Expenditure Panel Survey data from 2000 to 2010 estimated annual excess medical expenditures in adults with hearing loss aged 65 years or over to be $3.3 billion.14 Per person, this total equates to $420 in excess medical expenditures in a given year. A 2010 study from the Netherlands found excess medical expenditures of $700 per person in a 7-month study period, including primary and secondary care as well as occupational health.34 Some studies found an even higher cost of hearing loss: a 2010 California study of older adults found $2012 in medical costs for the first year of hearing treatment, including audiometric testing and treatment with bilateral hearing aids, corresponding to $12.8 billion nationally.18 Another US study looked at lifetime medical costs for HI by age group.19 In hearing loss onset at age 65 or older, lifetime medical expenditures related to hearing loss were $33 794 per person, compared with $79 343 per person with a hearing loss onset at younger ages (18-44 years). Annual total medical expenditures for HI in Australia were estimated at $706 million.28

Other Cost Estimates

Other economic estimates measured a variety of outcomes including lost income, lost productivity, caregiver costs, and cost of well-being (Table 2). Loss of income ranged from no difference to $15 528 annually depending on sex and severity of hearing loss.16,17,22 Income increases of $1552 to $5424 yearly were observed for individuals with severe to profound HI after cochlear implantation,24 and estimated at up to $22 000 with hearing aids in individuals with severe HI.17 Lost productivity was estimated at $1.8 billion to $194 billion ($15 528 per person) annually in the United States and $6.2 billion in Australia.17,18,28

Disability Burden

Disability burden was most commonly expressed in DALYs, a common metric used to indicate the impact of disease or disability by calculating the number of years of healthy life lost due to poor health or disability (Table 3). Australian studies have estimated DALYs from HI to be 95 000 yearly or a total burden of disease of 48 million DALYs.28,29 The US estimates include lifetime burden of disease of 559 200 YLDs.15 The global burden of disease of hearing loss has been estimated at 7.5 million DALYs, or 1.3% of all global disease burden.27

Noise-Induced Hearing Loss

Much of the research on the economic impact of noise-induced hearing loss involved the cost of disability claims to the government or workers’ compensation (Table 4). In a 2013 US Department of Veterans Affairs report, hearing loss was the second most common disability, accounting for 5.3% of all disability claims, and second only to tinnitus.13 From this report we estimated from available data that $4.38 billion was paid out for all audiologic complaints, and $1.8 billion of that total was paid for hearing impairment. A review of 6539 nonfederal workers’ compensation claims over 8 years in Washington state indicated total disability payments of $45.6 million.23 Another study predicted levels of hearing loss with different levels of noise exposure possibly encountered in the US Navy and predicted future lifetime costs of $16 289 per sailor.20

Discussion

To our knowledge, this is the first comprehensive systematic review to assess the economic impact of adult hearing loss. The available literature is limited, and it is difficult to draw summary conclusions. The cost of hearing loss in the United States appears to be in the billions of dollars with medical expenditures, indirect costs, and disability payments as major contributors, but no single study has provided a comprehensive estimate of the costs of adult hearing loss.

A report prepared by Access Economics28 assessing the costs of hearing loss in Australia conducted the most comprehensive estimation of any study, with direct medical costs, productivity losses, support service costs, device costs, caregiver costs, welfare costs, conversion of burden of disease into monetary estimates, and impact on tax revenue taken into account. However, no such similar study exists in the United States—with most studies including only 1 or 2 measures of cost. At the surface, per-person costs for Australians with HI appear to be lower than US costs—$3056 per person with HI in Australia28 vs a US range from $69 451 per person with onset in the retired elderly population (aged ≥65 years) to $673 339 per person with onset in early adulthood (aged 18-44 years).19 However, the Australian study included any HI, while Mohr et al19 included only severe-to-profound HI. The inclusion of lower degrees of HI severity likely increases total estimated cost while decreasing per-person cost estimates.

Estimated excess medical expenditures per person with HI were $700 in the Netherlands34 vs $420 in the United States.14 Average cost data and specific utilization data were not presented in Foley et al,14 making direct comparison difficult. Methodologically, the Netherlands study (Nachtegaal et al34) included all adults with HI aged 18 years or older, while Foley et al14 focused only on adults aged 65 years or older. In addition, the Netherlands study used an objective, home-based hearing screening while the US study used subjective measures to define HI and specifically excluded deafness. Therefore, at least part of the greater Netherlands excess medical expenditures may be explained by inclusion of more severe HI as well as younger adults.19

The reasons for excess medical expenditures among individuals with HI may be related to increased falls,4 hospitalizations,6 cognitive decline,8 and depression5 associated with hearing loss in addition to the cost of hearing loss care such as audiologic examinations and hearing aids. Excess medical costs for patients with hearing loss are estimated at $3.3 to $12.8 billion in the United States alone.14,18 The methodology of these studies was somewhat different. In Foley et al,14 the Medical Expenditure Panel Survey was used along with self-reported hearing loss to determine overall excess medical expenditures in individuals aged 65 years or older with HI, while in Stucky et al,18 the California Medicaid database was used to determine the cost of the first year of hearing health care treatment in adults 65 years or older with HI (audiologic testing, hearing aids), and then this cost was extrapolated nationally using a model with prevalence data. The study by Foley et al14 likely captures a more accurate assessment of the true excess cost of HI to the medical system, while Stucky et al18 estimate the cost of medical treatment if all patients with HI sought treatment.

Indirect costs are more difficult to estimate. Many of the studies identified in this systematic review examined income differences among those with HI vs the normal-hearing population. Lost productivity may be estimated by income disparities and differences in employment rates. Estimates of the economic cost of lost productivity varied widely, from $1.8 to $194 billion.17,18 This disparity is again likely owing to methodological differences. In Stucky et al,18 income data from the National Health Interview Survey (NHIS) for individuals with severe to profound HI were combined with population prevalence data to produce a national estimate of $1.8 billion annually in lost income. In Kochkin et al,17 self-reported data on income and hearing status were used to calculate income by degree of hearing loss (including all levels of impairment), and these findings were then combined with previously available data on prevalence of unaided HI to calculate a national estimate of lost income owing to HI of $194 billion. The Kochkin et al17 estimate is likely higher because it includes mild hearing loss, and therefore a larger cohort (24.9 million compared with 6.4 adults with HI), and also because the survey used in Kochkin et al17 calculated a larger income disparity than did NHIS. Hearing aids may mitigate income loss up to $22 000 per year in profound HI according to another model described in Kochkin et al.17

Noise-induced hearing loss is expensive, costing the US Department of Veterans Affairs billions of dollars and costing the private sector millions of dollars as well. Occupational noise exposure accounts for approximately 10% of overall HI in the United States, and typically occurs with noise exposures of 95 dB or greater without ear protection.38 Globally, occupational noise exposure is responsible for 16% of disabling HI, but up to 21% in China and Southeast Asia.39 As US government health care spending continues to grow,40 increased attention to preventive medicine is warranted. Beyond the widely accepted modifiable risk factors for HI including the use of ototoxic medications and noise exposure,41 other targets for hearing loss prevention are more controversial.42-45 Certainly, protection against recreational noise exposure is underutilized,46,47 but better workplace hearing safety measures may also be a cost-effective future intervention.

Hearing loss represents 1.3% of the global burden of disease27 and 559 000 DALYs in the United States in 2010.15 This is a similar level of DALYs as that for stroke (629 000 DALYs), bipolar affective disorder (578 000 DALYs), dysthymia (546 000 DALYs), and sickle cell disease (372 000 DALYs). Hearing loss represents a higher burden of disease than vision loss (375 000 DALYs), but this difference is not statistically significant.15

Another measure of disability is the Health Utility Index (HUI), used commonly in cost-effectiveness studies.48 An HUI score of 0 is equivalent to being dead, and a score of 1 indicates perfect health. The reported HUI scores for cochlear implant candidates with severe bilateral HI ranges from 0.49 to 0.54, similar to HUI scores of stroke survivors or patients with end-stage renal disease undergoing dialysis, and improves to approximately 0.80 after cochlear implantation, a similar HUI score to patients with brain tumors or hepatitis.49-52 Despite this large impact on health utility, many of the identified studies included in this review failed to take into account the psychosocial aspects (eg, social isolation) of HI, leading to an underestimation of the true impact of HI.19

Multiple studies have also demonstrated the impact of hearing loss on employment without estimating economic impact. Hearing loss has been linked to earlier retirement,53 a 2.1 times greater odds of poverty,54 and an increased use of sickness or disability benefits.55

Limitations

There are several limitations to this review. Several of the included studies used self-reported hearing loss and some did not detail how HI was defined. Self-reported hearing loss may not correlate well with objective hearing loss.56-58 In many of the included studies hearing loss was defined as a binary variable with no degradation by severity; thus, the influence of hearing loss severity on costs could not be fully addressed. However, among the few studies that did assess the economic burden of hearing loss by severity, it was observed that more severe forms of HI were associated with lower income. Wide differences in methodology make direct comparisons between countries and study populations difficult and prevent the combination of data into meaningful meta-analysis. In addition, many studies list aggregate national costs and do not express costs per person with hearing loss, further obscuring study comparisons.

Although hearing loss appears to have a high cost, and some studies have suggested that hearing aids or cochlear implantation may mitigate some of the income loss, more research is needed to fully understand the health and economic effects of hearing treatments before recommendations can be made on the economic impact of hearing interventions. In addition, a comprehensive economic estimate including the cost of the increased risk of falls, cognitive decline, hospitalizations, depression, and other negative health effects would provide a clearer view of the costs of hearing loss and may help to establish hearing loss prevention and treatment as more important public health targets. The failure to include negative downstream effects of hearing loss likely has led to an underestimation of the negative economic impact of HI.

Conclusions

Hearing loss has a negative economic impact in the United States, with an estimated effect in the billions of dollars, and expense estimates are on a similar order of magnitude around the globe. A comprehensive estimate of the economic impact of hearing loss in the United States is needed to understand its importance as a public health priority and to estimate the net benefit of future large-scale national hearing loss interventions.

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Article Information

Accepted for Publication: May 24, 2017.

Corresponding Author: Adele M. Goman, PhD, Center on Aging & Health, Johns Hopkins Medical Institutions, 2024 E Monument St, Ste 2-700, Baltimore, MD 21205 (agoman1@jhmi.edu).

Published Online: August 10, 2017. doi:10.1001/jamaoto.2017.1243

Author Contributions: Dr Huddle had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Huddle, Kernizan, Price, Frick, Lin.

Acquisition, analysis, or interpretation of data: Huddle, Goman, Kernizan, Foley, Price.

Drafting of the manuscript: Huddle, Kernizan, Price.

Critical revision of the manuscript for important intellectual content: Goman, Foley, Frick, Lin.

Statistical analysis: Huddle, Kernizan.

Administrative, technical, or material support: Goman, Kernizan, Price.

Supervision: Lin.

Conflict of Interest Disclosures: All authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Drs Lin and Goman report being consultants to Cochlear. Dr Lin serves on the advisory board of Hearing Loss Association of America and has received a research grant from Cochlear. No other disclosures were reported.

Funding/Support: This work was supported by the Eleanor Schwartz Charitable Foundation (Dr Lin). Dr Lin is also supported by National Institutes of Health grants K23DC01179, R34AG046548, R01HL096812, and R21DC015062.

Role of the Funder/Sponsor: The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

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