1. 1 Can self-report measures reliably predict audiometric measures in Hong Kong older adults? 9 Oct 2005 Kevin Yuen 12, Michael Tong 12, Alex Lee 12, Peter Tang 1, Andrew van Hasselt 12 1 Institute of Human Communicative Research, Division of Otorhinolaryngology, Dept of Surgery, The Chinese University of Hong Kong & 2 Hear Talk Foundation

2. 2 Objectives To compare the prevalence of hearing problem estimated from self- reports and pure-tone audiometryTo compare the prevalence of hearing problem estimated from self- reports and pure-tone audiometry To investigate the performance of self-reports: (1) a single question, (2) HHIE-S in identifying individuals with hearing loss, against the standards from pure-tone audiometryTo investigate the performance of self-reports: (1) a single question, (2) HHIE-S in identifying individuals with hearing loss, against the standards from pure-tone audiometry

3. 3 Hearing Handicap Inventory for the Elderly – Screening (HHIE-S) (Ventry & Weinstein, 1983) Self-administered 10-item questionnaireSelf-administered 10-item questionnaire Aim at detecting emotional and social problems associated with impaired hearingAim at detecting emotional and social problems associated with impaired hearing Subjects respond to questions about circumstances related to hearing by stating whether the situations presents a problemSubjects respond to questions about circumstances related to hearing by stating whether the situations presents a problem –“no” (score 0) –“sometimes” (score 2) –“yes” (score 4) Total HHIE-S score range from 0 to 40Total HHIE-S score range from 0 to 40

4. 4 HHIE-S questions (English version) Does a hearing problem cause you to feel embarrassed when you meet new people?Does a hearing problem cause you to feel embarrassed when you meet new people? Does a hearing problem cause you to feel frustrated when talking to members of your family?Does a hearing problem cause you to feel frustrated when talking to members of your family? Do you have difficulty hearing when someone speaks in a whisper?Do you have difficulty hearing when someone speaks in a whisper? Do you feel handicapped by a hearing problem?Do you feel handicapped by a hearing problem? Does a hearing problem cause you difficulty when visiting friends, relatives, or neighbors?Does a hearing problem cause you difficulty when visiting friends, relatives, or neighbors? Does a hearing problem cause you to attend religious services less often than you would like?Does a hearing problem cause you to attend religious services less often than you would like? Does a hearing problem cause you to have arguments with family members?Does a hearing problem cause you to have arguments with family members? Does a hearing problem cause you to have difficulty when listening to TV or radio?Does a hearing problem cause you to have difficulty when listening to TV or radio? Do you feel that any difficulty with your hearing limits/hampers your personal or social life?Do you feel that any difficulty with your hearing limits/hampers your personal or social life? Does a hearing problem cause you difficulty when in a restaurant with relatives or friends?Does a hearing problem cause you difficulty when in a restaurant with relatives or friends?

5. 5 HHIE-S questions (Chinese translation version) 在遇見新相識的人時，聽力問題有否讓你感到尷尬？ 在遇見新相識的人時，聽力問題有否讓你感到尷尬？ 在和家人交談時，聽力問題有否讓你感到受挫折？ 在和家人交談時，聽力問題有否讓你感到受挫折？ 當別人喁喁細語時，你有否感到聆聽困難？ 當別人喁喁細語時，你有否感到聆聽困難？ 聽力問題有否令你感到殘缺？ 聽力問題有否令你感到殘缺？ 聽力問題有否令你在探望朋友, 家人或鄰居時感到困難？ 聽力問題有否令你在探望朋友, 家人或鄰居時感到困難？ 聽力問題有否令你參加宗教或其他活動較你希望能參加的 為少？ 聽力問題有否令你參加宗教或其他活動較你希望能參加的 為少？ 聽力問題有否引至你和家人或朋友吵架？ 聽力問題有否引至你和家人或朋友吵架？ 聽力問題有否令你聆聽電視或收音機時感到困難？ 聽力問題有否令你聆聽電視或收音機時感到困難？ 你認為任何的聽力問題有否影響你的個人或社交生活？ 你認為任何的聽力問題有否影響你的個人或社交生活？ 和家人或朋友在餐廳時，聽力問題有否令你感到困難？ 和家人或朋友在餐廳時，聽力問題有否令你感到困難？

6. 6 Question 8 Does a hearing problem cause you to have difficulty when listening to TV or radio? 聽力問題有否令你聆聽電視或收音機時感到困難？ AnswerScore “yes” ” 有 ” 4 “sometimes” “ 間中有 ” 2 “no” “ 沒有 ” 0

7. 7 Single Question Do you think you have a problem with your hearing? 你覺得你的聽力有問題 嗎？

8. 8 Subjects 1016 subjects participated in the “Ear and Hearing Assessment Project for the Elderly” (June to Oct 2004)1016 subjects participated in the “Ear and Hearing Assessment Project for the Elderly” (June to Oct 2004) Data from 911 subjects were analyzed in this studyData from 911 subjects were analyzed in this study –99 subjects excluded (reported signs of dementia) –6 subjects excluded (incomplete data) Gender distributionGender distribution –Male (n=369; 40.5%); female (n=542; 59.5%)

9. 9 Age and gender distribution

10. 10 Definition of hearing loss vs hearing handicap Hearing loss by Pure Tone AudiometryHearing loss by Pure Tone Audiometry –pure tone average (PTA) of 500,1k, 2k & 4kHz of the better ear –Hearing loss defined at 4 cut-off points PTA ≥ 25dBHLPTA ≥ 25dBHL PTA ≥ 40dBHLPTA ≥ 40dBHL PTA ≥ 55dBHLPTA ≥ 55dBHL PTA ≥ 70dBHLPTA ≥ 70dBHL Hearing handicap by HHIE-S and Single QuestionHearing handicap by HHIE-S and Single Question –HHIE-S > 8, >10, >12 & >16 –Single Question -> Answered “yes”

11. 11 Comparison of prevalence rates Definition of hearing lossDefinition of hearing loss –PTA >25dBHL (0.5 – 4kHz) of the better ear Age range N Prevalence rate Framingham Cohort (1978-79)57-89229347% (1983-85) 63-95166242% Wisconsin Cohort (1993-95)48-92375332% Blue Mountains Cohort (1997-99) 55-100201530% Hong Kong Cohort (2004) 60-92911 82% (for all, N=911) 71% (the group answered “no” from the Single Question, n=336)

12. 12 Odds ratios for the presence of hearing loss at different PTA cut-off levels Odds ratio PTA ≥ N=911Factor25dBHL40dBHL55dBHL70dBHL Age60-651.01.01.01.0 group66-701.41.52.52.3 (years)71-752.7***2.5***3.8**5.9 75-808.3***6.5***8.5***7.0 > 80 17.6***9.8***13.5***18.3*** SexF1.01.01.01.0 M1.5*1.5**1.7*2.4* * p < 0.05, ** p < 0.01, *** p < 0.0005.

13. 13 Prevalence of hearing loss (measured) vs hearing handicap (estimation) Estimated prevalence -> Single question > HHIE >8 Prevalence from HHIE >8 (estimation) similar to PTA ≥ 40 (measured) Hearing handicap Hearing loss 82 38 34 13 4 63

14. 14 Comparison of measured (audiometry) vs estimated prevalence McNemar Test p <.001 for all comparisons * except for PTA >=40 vs HHIE >8 p =.04 *

15. 15 Screening performance characteristics YesNo Yes True Pos False Neg No False Pos True Neg Hearing problem from HHIE-S / Single Question ? Hearing problem from audiometry ? Sensitivity = TP / ( TP + FN ) Specificity = TN / ( TN + FP ) Positive predictive value (PPV) = TP / (TP + FP ) Negative predictive value (NPV) = TN / ( TN + FN ) Positive likelihood ratio (PLR) = sensitivity/ (1-specificity) Negative likelihood ratio (NLR) = (1-sensitivity)/ specificity

16. 16 HHIE-S vs Single Question Definition of hearing handicap Definition of hearing loss PTA 0.5-4kHz, better ear Sensitivity(%)Specificity(%)Accuracy(%)PPV(%)NPV(%)PLR(%)NLR(%) HHIE-S > 8 ≥40dBHL52776758722.20.6 HHIE-S > 16 ≥40dBHL34916969693.70.7 Single Question ≥40dBHL83496250821.60.4 HHIE-S > 8 ≥55dBHL72727228942.50.4 HHIE-S > 16 ≥55dBHL55878339934.20.5 Single Question ≥55dBHL92414819971.60.2 HHIE-S better in ruling IN the presence of hearing loss (FP) Single Question better in ruling OUT the presence of hearing loss (FN)

17. 17 HHIE-S vs Single Question HHIE-S better in ruling in the presence of hearing loss, with better –PPV and PLR Single Question better in ruling out the presence of hearing loss, with better –NPV and NLR

18. 18 Receiving-operating characteristic curves of different PTA cut-off levels with HHIE-S score Area under curve (AUC) = Discriminating power of an HHIE-S score at each PTA cut-off levels. Probability that a random person with measured hearing loss (audiometry) has a higher HHIE-S score than a random person without the hearing loss Area under curve 0.83 0.78 0.69 0.67 HHIE-S cutoff increase HHIE >8 HHIE >16 Perfect accuracy AUC = 1 Chance AUC = 0.5

19. 19 HHIE-S > 8 vs HHIE-S > 16 Definition of hearing handicap Definition of hearing loss PTA 0.5-4kHz, better ear Sensitivity(%)Specificity(%)Accuracy(%)PPV(%)NPV(%)PLR(%)NLR(%) HHIE > 8 ≥40dBHL52776758722.20.6 HHIE> 16 ≥40dBHL34916969693.70.7 HHIE > 8 ≥55dBHL72727228942.50.4 HHIE> 16 ≥55dBHL55878339934.20.5

20. 20 Revised HHIE-S cut-off score HHIE-S > 16 vs HHIE-S > 8HHIE-S > 16 vs HHIE-S > 8 –Better specificity, accuracy, (PPV) and PLR –Worse (sensitivity) –Similar NPV, NLR according to the comparisons between 95% confidence intervals For PTA cut-off levels ≥ 40 & ≥ 55 dBHL

21. 21 Combined “HHIE-S - Single Question” screening tool HHIE-SFPFP SQPPFF Combined PF HHIE-SPPFFSQPFPF CombinedPF P – Pass F – Fail SUPER POWER SCREENER ?! raise sensitivity lower FN raise FP

22. 22 HHIE-S – Single Question SUPER POWER SCREENING TOOL ?!

23. 23

24. 24 Conclusion 1 The prevalence of hearing handicap (HHIE-S >8) is comparable with the prevalence of hearing loss (PTA ≥ 40dBHL)

25. 25 Conclusion 2 The prevalence of hearing handicap increases with age. The prevalence of hearing handicap is higher in male than in female.

26. 26 Conclusion 3 HHIE-S better in ruling IN the presence of hearing lossHHIE-S better in ruling IN the presence of hearing loss Single Question better in ruling OUT the presence of hearing lossSingle Question better in ruling OUT the presence of hearing loss HHIE-S >16 has a better screening characteristics profile than HHIE-S >8 for screening PTA level ≥ 40 and ≥ 55 dBHLHHIE-S >16 has a better screening characteristics profile than HHIE-S >8 for screening PTA level ≥ 40 and ≥ 55 dBHL

27. 27 Conclusion 4 For older adults reported with hearing handicap (HHIE > 16), the probability with PTA ≥ 40dBHL is 69%with hearing handicap (HHIE > 16), the probability with PTA ≥ 40dBHL is 69% (Positive predicative value). without hearing handicap (HHIE ≤ 16), the probability with PTA < 40dBHL is 69%without hearing handicap (HHIE ≤ 16), the probability with PTA < 40dBHL is 69% (Negative predicative value). Overall accuracy = 69 ％

28. 28

29. 29 Kevin Yuen Division of Otorhinolaryngology, Department of Surgery The Chinese University of Hong Kong kevinyuen@surgery.cuhk.edu.hk

30. 30 Screening performance characteristics YesNo YesTruePos False Neg NoFalsePos True Neg Hearing problem from HHIE-S / Single Question ? Hearing problem from audiometry ? Sensitivity = TP / ( TP + FN ) Specificity = TN / ( TN + FP ) Positive predictive value (PPV) = TP / (TP + FP ) Negative predictive value (NPV) = TN / ( TN + FN ) Positive likelihood ratio (PLR) = sensitivity/ (1-specificity) Negative likelihood ratio (NLR) = (1-sensitivity)/ specificity

31. 31 Receiving-operating characteristic curves of different PTA cut-off levels with HHIE-S score Area under curve (AUC) = Discriminating power of an HHIE-S score at each PTA cut-off levels. Probability that a random person with measured hearing loss (audiometry) has a higher HHIE-S score than a random person without the hearing loss Area under curve 0.83 0.78 0.69 0.67 HHIE-S cutoff increase HHIE >8 HHIE >16

32. 32 Prevalence of HHIE-S >8 with age and gender Prevalence of hearing handicap increases with age Pearson Chi square = 14.2, p <.01 Linear-by-linear association = 6.3, p <.001 higher in Male than in Female Pearson Chi square = 5.2, p <.05

33. 33 Prevalence of HHIE >8 with degree of hearing loss Prevalence of hearing handicap increases with hearing loss Pearson Chi square = 116.8, p <.001 Linear-by-linear association = 111.1, p <.001

34. 34 Measured (audiometry) vs estimated prevalence – by gender

35. 35 Screening performance characteristics of HHIE-S and Single Question MeasureSubgroupGroupMeaning Sensitivityreported with problem fail audiometry All fail audiometry Prob with true hearing loss identified by the report Specificityreported without problem pass audiometry All pass audiometryProb without true hearing loss correctly identified by the question Positive predictive value reported with problem fail audiometry All reported with problem Prob of report to identify disorder Negative predictive value reported without problem pass audiometry All reported without problem Prob of report to identify normality

36. 36 Sensitivity and specificity Sensitivity – –increase with PTA cut-off – –Single question better than HHIE-S Specificity – –decrease with PTA cut-off – –HHIE-S better than Single question

37. 37 Positive and negative predictive values (PPV & NPV) PPV – –decrease with PTA cut-off NPV – –increase with PTA cut-off

38. 38 Positive and negative likelihood ratios (PLR & NLR) PLR – –Increase slightly with PTA cut-off – –Increase with HHIE-S cut-off NLR – –decrease with PTA cut-off – –Increase slightly with HHIE-S cut-off

39. 39 Accuracy