Hearing Loss is Associated with Poorer Ratings of Patient–Physician Communication and Healthcare Quality

To the Editor: Hearing loss (HL), a chronic condition that affects nearly two-thirds of older adults in the United States,1 has been independently associated with dementia, poor health outcomes, and mortality.2 HL can interfere with patient–physician communication and thus quality of health care. The associations between HL and patient perceptions of quality of patient–physician communication and perceptions of quality of health care were investigated in a nationally representative sample of adults. Pooled data were derived from the Medical Expenditure Panel Survey Household Component (MEPS-HC), a nationally representative survey of the U.S. civilian noninstitutionalized population from 2002 to 2011.3 Participants were included if they were aged 18 and older and had visited a physician at least once in the previous year. Data were collected in computer-assisted personal interviews. HL was based on self-report and summarized as a binary variable (no hearing loss vs any hearing loss (excluding deafness)). Perception of patient–physician communication was assessed using the Consumer Assessment of Healthcare Providers and Systems (CAHPS) composite measure developed for the Agency for Healthcare Research and Quality.4 Participants indicated how often their doctor(s) explained things clearly, listened carefully, showed respect for what they had to say, and afforded them adequate time (never (1), sometimes (2), usually (3), always (4)). Responses to the four items were summed and averaged for each participant.5 The CAHPS quality-of-healthcare item asked participants to rate their care overall from 0 (worst possible) to 10 (best possible). The associations between HL and ratings of patient–physician communication and health care were analyzed using logistic regression (rating scores > vs ≤50th percentile). Potential demographic and health confounders including sex; age; race and ethnicity; education level; income; hearing aid use; physical health status (Medical Outcomes Study 12-item Short-Form Survey version 2 (SF-12) Physical Component Summary); mental health status (SF-12 Mental Component Summary); and histories of hypertension, diabetes mellitus, stroke, hypercholesterolemia, myocardial infarction, coronary heart disease, other heart disease, and smoking were adjusted for. Multiplicative interaction terms were included to determine whether age, sex, hearing aid use, or self-reported vision impairment (any vs none) modified the associations. Analyses accounted for the complex sampling design. Missing values due to nonresponses, refusals, and the survey skip pattern were excluded. Analyses were performed using Stata 12.0 (StataCorp LC, College Station, TX). The analytical cohort comprised 122,556 participants (9,747 with HL; 112,809 with normal hearing). Individuals with HL were more likely to be older, male, of lower socioeconomic status, and in poorer health (Table 1). In fully adjusted models, individuals with HL had significantly lower odds than those with normal hearing of having ratings of patient–physician communication (odds ratio (OR) = 0.91, 95% confidence interval (CI) = 0.86–0.96; P < .001) and overall health care (OR = 0.94, 95% CI = 0.89–0.99; P = .02) that were greater than the median. Sex, age, hearing aid use, and self-reported visual impairment did not significantly modify these associations (data not shown). In this nationally representative study of adults in the United States, self-reported HL was independently associated with lower ratings of patient–physician communication and overall health care. On average, individuals with HL had approximately 10% lower odds of having favorable ratings of their patient–physician communication and approximately 6% lower odds of having favorable ratings of their healthcare experiences than individuals with normal hearing. Individuals with HL may have greater difficulty understanding or engaging in discussions with their physicians, especially in the context of noisy environments or unfamiliar medical concepts and terminology. Doctors may also become frustrated or unaware of effective communication strategies when conversing with individuals with HL. These factors could affect the quality of patient–provider communication and overall rating of health care. Effective communication is necessary for patient-centered care that is respectful and responsive to individual preferences, needs, and values and facilitates knowledge transfer, shared decision-making, and patient autonomy.6 It is an important predictor of how people perceive quality of care.5 Good communication may improve health outcomes in certain situations. In a systematic review of randomized controlled trials and observational studies that occurred in a variety of healthcare settings, 16 of 21 studies showed positive correlations between patient–physician communication and outcomes such as emotional health, symptom resolution, pain control, functional status, and blood pressure and glucose control.7 Limitations of the current study are the use of self-reported assessments of HL, which may have resulted in exposure misclassification, and the possibility of residual confounding. Future research should investigate whether HL is associated with objective measures of healthcare quality and how patient–physician communication could be improved for individuals with HL. Physicians should ensure that their patients with HL fully understand healthcare discussions. This study is supported by grants from the National Institute on Deafness and Other Communication Disorders (K23DC011279), Triological Society and American College of Surgeons through a Clinician Scientist Award, and Eleanor Schwartz Charitable Foundation. Conflict of Interest: Dr. Lin serves as a consultant to Cochlear Americas and on the scientific advisory board of Pfizer and Autifony and has been a speaker for Med El and Amplifon. Author Contributions: All authors had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. Study concept and design: Mick, Lin. Acquisition of the data: Foley. Analysis and Interpretation of data: Mick, Foley, Lin. Statistical Analysis: Foley. Drafting of the manuscript: Mick, Foley. Critical revision of the manuscript for important intellectual content: Mick, Foley, Lin. Obtained funding: Lin. Study supervision: Lin. Sponsor's Role: The sponsors had no role in the design or conduct of the study; collection, analysis, or interpretation of data; or preparation, review, or approval of the manuscript.

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