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National Guideline Centre (UK). Hearing loss in adults: assessment and management. London: National Institute for Health and Care Excellence (NICE); 2018 Jun. (NICE Guideline, No. 98.)
17.1. Introduction
Many people use hearing aids as part of the management of their hearing and communication needs. Hearing aids are usually fitted in a clinic setting by an audiologist who should also advise on the use and management of the device, as well as aspects of communication specific to the individual. Hearing aids should be programmed and functionality set to meet individual needs and capabilities.
Traditionally, after the hearing aid fitting there is a follow-up appointment. This follow-up enables: the individual to share their experience with the audiologist and for adjustments to be made, for the audiologist to provide further advice and support including onward referral to other agencies as required, for the audiologist to observe the correct fitting and handling of the device and for patient-reported outcome and experience measures to be obtained.
A follow-up appointment as part of the hearing aid fitting pathway is included within current recommended practice documents; for example, within the adult service model specification outlined within NHS England’s ‘Commissioning Services for People with Hearing Loss: A framework for clinical commissioning groups’.86 Additional recommendations for good practice appear in the Welsh and Scottish quality standards for adult hearing rehabilitation.90
Despite this guidance, current provision of a follow-up appointment is variable across the UK with some services offering no follow-up appointment and no opportunity to re-access the service following the initial hearing aid fitting. Where a follow-up appointment is offered, these are sometimes face-to-face in clinic and sometimes over the telephone. It is also unclear as to the optimal timing for follow-up and if further long-term monitoring is of value.
The current guidance documents also indicate that people should be offered an appointment to reassess their hearing and communication needs 3 years following their previous assessment. However, this invitation for review currently varies depending on location and service provider and service users may be unaware that reassessment is an option. Exceptions may include groups of people who are considered suitable for reassessment for a specific reason, for example, people with dual sensory impairment or people with learning disabilities.
This chapter aims to explore the benefits of providing follow-up to those people with hearing aids and for the ongoing monitoring of people with identified hearing and communication needs who may or may not have hearing aids.
It was thought that most relevant papers would be likely to include both the ‘when’ and the ‘how’ aspects of follow-up and that the ensuing recommendations would reflect that. Therefore, this chapter includes 2 clinical questions for which a combined search strategy was used to identify relevant papers.
17.2. Review question 1: What is the most clinically and cost-effective method of delivery of monitoring and follow-up of people with hearing-related communication needs (including those with hearing aids)?
Table 96
PICO characteristics of review question 1.
17.3. Review question 2: When should people with hearing-related communication needs (including those with hearing aids) be monitored and followed up?
For full details see review protocols in appendix C.
Table 97
PICO characteristics of review question 2.
17.3.1. Clinical evidence
No clinical evidence was identified comparing different methods of follow-up and monitoring or different frequencies. See study selection flow chart in appendix E and the excluded studies list in appendix L.
17.3.2. Economic evidence
No relevant health economic studies were identified for either review question.
See also the health economic study selection flow chart in appendix F.
17.3.3. Evidence statements
Clinical
- No relevant clinical evidence was found.
Economic
- No relevant economic evaluations were identified.
17.3.4. Recommendations and link to evidence
| Recommendations |
|
| Research recommendation |
|
| Relative values of different outcomes | The following critical outcomes were included in this review: hearing-specific health-related quality of life including HHIE, QDS and Auditory Disability Preference – Visual Analog Scale (ADPI-VAS)., health-related quality of life including HUI-3, EQ-5D, Glasgow Benefit Inventory (GBI) and WHODAS., listening ability including APHAB, SSQ and GHABP, speech recognition in noise test, usage of hearing aids (including data logging and self-report if applicable). Outcomes reporting social functioning or employment were considered important outcomes. |
| Quality of the clinical evidence | No evidence was identified for inclusion in this review. |
| Trade-off between clinical benefits and harms | The committee made consensus recommendations based on its clinical knowledge and expertise. Method of delivery of follow-up Current recommended practice is to offer a follow-up appointment 6 to 12 weeks after fitting a hearing device and the committee considered it very important that people have this in order to assess how they are adapting to the hearing device and to resolve any difficulties or problems early. Not providing this service can result in people giving up using their hearing aids and may consequently have a negative impact on their quality of life over time as their ability to communicate and participate in everyday situations declines. The committee agreed that face-to-face follow-up appointments have traditionally been used, however either face-to-face or telephone appointments are currently permitted. The committee noted that for people who have been fitted with hearing aids a face-to-face appointment is preferable in order to check the fitting of the device and make any necessary adjustments (see section 18.2.4, interventions to support the use of hearing aids), and a telephone appointment would not be as helpful. The committee further noted that ability to use the telephone is one of the issues that needs to be addressed by this appointment, precisely because many hearing aid users struggle with this, and so a substantial proportion of hearing aid users would be unable to use a telephone well at the time of the appointment. The committee discussed the difficulties some people may have in attending audiology services in person for hearing assessments, fitting of hearing aids, demonstrating other listening devices and ongoing management. The committee acknowledged the inequalities in accessing audiology services for some populations, such as older people, those who live in residential care homes or those with learning disabilities. The committee noted a flexible approach in the delivery of hearing services is desirable to ensure such populations are not disadvantaged. The committee discussed provision of follow-up appointments for people who opt to have other interventions such as assistive listening devices or other auditory support strategies rather than a hearing aid. However, it would not be possible to indicate a time frame when this should occur because this would be dependent on the intervention chosen and how long the user would need to use it for before a useful assessment could be made. However the committee agreed that a follow-up appointment should be discussed with the person and offered for a time when an evaluation could be made. This could be arranged over the phone or face-to-face at the clinic dependent on what was appropriate. Some people may decline all interventions, in which case it was agreed by the committee that information on how to access audiology services again at a future point should be provided to the person in order that they can obtain further advice or reassessment when required. Frequency of monitoring The committee discussed the absence of any evidence on the frequency of monitoring. Currently there is no national automatic system to recall people for ongoing monitoring. Some local areas and some providers have their own systems that automatically recall people, most often every 3 years, but in some cases every 5 years. In other areas it is up to the individual to self-refer when they think they need their hearing reassessed or require assistance with their hearing device. Although the recommended practice provided by the NHS England model adult service specifications85,86 is that hearing needs should be reviewed 3 years after fitting a hearing device, and this fits in with the current funding model for some providers, the committee noted that there is variation in practice across the country. The committee is aware of a pilot study recalling people after 3 years that found that 100% needed minor interventions (such as repairs or advice) and 39% needed a major intervention (such as new hearing aids).49 This study had no control group and did not compare with other recall frequencies, so it is not possible to determine the optimum recall frequency. This is however an important question. The committee agreed that as no evidence was identified a research recommendation should be made to establish the clinical and cost effectiveness of monitoring and follow-up, and to understand how and when they might best be used in clinical practice. In the meantime, the committee was unable to recommend any particular frequency of monitoring. However, noting that automatic recall is already recommended by NHS England and is in place in some areas, and the risk that people not recalled may not receive any ongoing care after 12 weeks, the committee recommended that all providers consider implementing a recall system, with the frequency of recall being carefully considered at a local level. The committee agreed that this was particularly important for those who were unlikely to request a review such as those with mild cognitive impairment, dementia, learning difficulties and the elderly. The committee agreed that it is important that all patients are aware of how to re-access audiology services when needed, and that health professional’s update and maintain patient records to facilitate follow-up and ongoing monitoring of patients and to improve information sharing between health professionals. Additional support Some people have significant problems coming to terms with their hearing problems. These people may benefit from working alongside a hearing therapist or a psychologist to adjust to hearing loss, develop communication skills and manage the psychosocial challenges of hearing loss. |
| Trade-off between net clinical effects and costs | No health economic evaluations were identified specifically comparing methods of delivery of follow-up or different timings of follow-up. However, the committee noted that the economic evaluation identified for the review of interventions to support the use of hearing aids (section 18.2.2) addressed the cost effectiveness of implementing a single follow-up appointment after 6 months and suggested that this intervention was effective. The original economic modelling conducted for this guideline (see appendix N) assumed that a follow-up appointment would be included 6–12 weeks following hearing aid fitting, and the cost of that appointment (conducted by an audiologist) was included in the modelling, which found the whole pathway, including hearing assessment, hearing aid fitting and follow-up appointment, to be cost effective. As follow-up appointments are expected to increase the benefits gained by hearing aid use, by increasing the proportion of the time hearing aids are used successfully, such appointments are not just cost effective on their own, but are integral to making the whole process of hearing aid fitting and use cost effective, and so excluding this aspect of the pathway would damage the effectiveness and cost effectiveness of the pathway as a whole. A follow-up appointment 6–12 weeks after initial hearing aid fitting is current best practice, and is recommended in the NHS England commissioning framework.86 This recommendation therefore requires no more activity than is already expected, however, the committee noted that at present not all providers are offering follow-up appointments. Therefore it is likely that an increase in planned early follow-up appointments will be required, which is expected to increase upfront costs. However, the committee noted that this would reduce the number of later unplanned follow-up audiology aftercare and GP appointments booked by the hearing aid users, which would lead to some savings. The committee also noted the clinical benefits of increasing the number of people able to use their hearing aids effectively, thereby avoiding a waste of money on hearing aids that are not used, or used suboptimally. The committee noted the qualitative evidence from the information, support and advice review (see chapter 12) about the importance of follow-up. The committee is aware that some providers currently favour telephone appointments. This is generally because in current practice they are typically briefer than in-person appointments, and because in some cases they are delegated to less highly trained (and therefore less expensive) staff members. The committee has made recommendations in the chapter on interventions to support the use of hearing aids (section 18.2.4) on the tasks that should be included in any follow-up appointment. These must be the same whatever the method of delivery. Telephone consultations are currently seen as quicker because they tend to be less thorough than in-person appointments, and so take less time. However, when the full list of tasks necessary to establish that a hearing aid is working properly are conducted, the method of communication does not affect the length of the appointment (indeed, for someone struggling to use a telephone due to their hearing difficulties, that method might well take longer than an appointment in person). Regarding who conducts the follow-up appointment, the committee was clear that this must be someone suitably trained with expertise in operating and explaining the working of hearing aids, though not necessarily an audiologist. Whichever method of communication is used to conduct a follow-up appointment, the staff conducting the appointment should be equivalent. The committee agreed that using more junior staff to speak to people on the telephone, and conducting only a brief check-up that does not cover all aspects of follow-up as recommended in this guideline are completely unacceptable. As a means of saying money they are likely to be counterproductive in the long run, as inadequate follow-up checks will increase the proportion of hearing aid users unable to use their hearing aids to maximum benefit, or to use them at all, therefore wasting the costs of the hearing aids themselves and the previous assessment and fitting appointments. When appointments of the same length and thoroughness, using equivalent members of staff are compared, the means of communication does not affect the cost of the appointment, as this is dependent on the length of time the healthcare professional spends conducting the appointment. Face-to-face appointments have benefits over telephone consultations in that the clinician can physically modify the hearing aids and communication between the patient and clinician is easier. Therefore, there is no economic reason not to favour face-to-face appointments over telephone appointments. Some electronic communication methods, such as video links, offer many of the same benefits of face-to-face appointments, as both participants can see each other, although physical adjustment of the hearing aid settings is not possible. The committee is therefore confident that conducting a face-to-face follow-up appointment 6–12 weeks after hearing aid fitting is either cost saving or cost effective at a cost-effectiveness threshold of £20,000 per QALY gained. However, the committee noted that a proportion of patients do themselves express a preference for telephone communication. These may be experienced hearing aid users who are being fitted with hearing aids for a second or subsequent time, already understand most of the hearing aids’ settings well and are able to hear effectively over the telephone. The committee noted stakeholder comments that face-to-face only strategies are thought to have higher non-attendance rates, which would be a matter for concern. Therefore the committee agreed that hearing aid users should be able to choose telephone or other methods of contact (if available) as their personal preference. However, the committee was clear that face-to-face is the preferred option and so should be offered to all patients as the first choice. A decision to have a telephone appointment should only be made by the hearing aid user not the provider. The hearing aid user must never be offered a telephone appointment as their only option. Given that current practice varies across the country between face-to-face appointments, telephone appointments and no follow-up appointments at all, implementing this recommendation for all providers would be expected to increase total upfront costs. However, as noted there may be savings from a reduction in later additional audiology aftercare or GP appointments from people presenting with problems with using their hearing aids. People who have chosen management strategies other than hearing aids would also be expected to benefit from a follow-up appointment, for similar reasons to hearing aid users. A short amount of time spent ensuring that an individual is following the optimum communication strategies, or can use their assistive listening device effectively, could lead to much greater success for the individual, and could reduce future unplanned appointments or other unnecessary use of resources due to problems accessing healthcare. Therefore the committee expects that a follow-up appointment for people in this group would also be cost effective or cost saving. However, given a lack of evidence or current standard practice, and the diversity of options in this category, the committee chose not to define a time period for the follow-up appointment, believing that this would be best chosen at the point that the management strategy is started. Regarding the routine recall of people for periodic reassessment of their hearing, and consideration for new hearing aids, the committee noted that the original economic modelling conducted for this guideline used a base case of reassessment every 3 years (see appendix N). The whole pathway of hearing aid use, including regular reassessment, was found to be highly cost effective compared with not using hearing aids. Sensitivity analyses considered the difference made if this period was reduced to 2 years or extended to 10 years. This correspondingly increased and decreased the ICERs for the pathway, although all values were below £7,000 per QALY gained. However, given a lack of information, the modelling was not able to consider the differential effectiveness of hearing aids dependent on their age or the length of time since they were last checked. The model can therefore not be used to determine what the best frequency of reassessment would be, but it suggests that whatever frequency is appropriate on clinical grounds as optimising the effectiveness of hearing aid use is likely to be cost effective. The committee therefore recommended that providers should consider adopting a system of automatic recall to ensure that their patients receive some regular monitoring, but was not able to recommend a particular frequency. The committee also made a research recommendation, to gather further information that would be useful in updating these recommendations in future, and in particular in determining the most cost effective frequency of monitoring, and what that monitoring should include. |
| Other considerations | The committee is aware that there are emerging technologies such as self-fitting and remote fitting hearing aids and tele-audiology which are suitable for some individuals with non-complex hearing loss. However, no evidence to support making a recommendation on their use was found. The committee consider that it is important that GPs and other health professionals recognise the need for continuing audiological monitoring and care for individuals with hearing loss, whether or not they are using amplification, and refer back into local audiological services if indicated. |
- Introduction
- Review question 1: What is the most clinically and cost-effective method of delivery of monitoring and follow-up of people with hearing-related communication needs (including those with hearing aids)?
- Review question 2: When should people with hearing-related communication needs (including those with hearing aids) be monitored and followed up?
- Monitoring and follow-up - Hearing loss in adultsMonitoring and follow-up - Hearing loss in adults
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