Global return on investment and cost-effectiveness of WHO's HEAR interventions for hearing loss: a modelling study.

BACKGROUND: To address the growing prevalence of hearing loss, WHO has identified a compendium of key evidence-based ear and hearing care interventions to be included within countries' universal health coverage packages. To assess the cost-effectiveness of these interventions and their budgetary effect for countries, we aimed to analyse the investment required to scale up services from baseline to recommended levels, and the return to society for every US$1 invested in the compendium. METHODS: We did a modelling study using the proposed set of WHO interventions (summarised under the acronym HEAR: hearing screening and intervention for newborn babies and infants, pre-school and school-age children, older adults, and adults at higher risk of hearing loss; ear disease prevention and management; access to technologies such as hearing aids, cochlear implants, or hearing assistive technologies; and rehabilitation service provision), which span the life course and include screening and management of hearing loss and related ear diseases, costs and benefits for the national population cohorts of 172 countries. The return on investment was analysed for the period between 2020 and 2030 using three scenarios: a business-as-usual scenario, a progress scenario with a scale-up to 50% of recommended coverage, and an ambitious scenario with scale-up to 90% of recommended coverage. Using data for hearing loss burden from the Global Burden of Disease Study 2019, a transition model with three states (general population, diagnosed, and those who have died) was developed to model the national populations in countries. For the return-on-investment analysis, the monetary value of disability-adjusted life-years (DALYs) averted in addition to productivity gains were compared against the investment required in each scenario. FINDINGS: Scaling up ear and hearing care interventions to 90% requires an overall global investment of US$238·8 billion over 10 years. Over a 10-year period, this investment promises substantial health gains with more than 130 million DALYs averted. These gains translate to a monetary value of more than US$1·3 trillion. In addition, investment in hearing care will result in productivity benefits of more than US$2 trillion at the global level by 2030. Together, these benefits correspond to a return of nearly US$15 for every US$1 invested. INTERPRETATION: This is the first-ever global investment case for integrating ear and hearing care interventions in countries' universal health coverage services. The findings show the economic benefits of investing in this compendium and provide the basis for facilitating the increase of country's health budget for strengthening ear and hearing care services. FUNDING: None.

Chronic obstructive Eustachian tube dysfunction: CT assessment with Valsalva maneuver and ETS-7 score.

Chronic obstructive Eustachian tube dysfunction (ETD) is a common disorder of the middle ear. In recent years, two main diagnostic tools have become available: Eustachian tube score (ETS-7) and computed tomography (CT) combined with Valsalva maneuver. The aim of this study is to evaluate the outcomes of ETS-7 and CT in a group of patients affected by middle ear atelectasis with a strong suspicion of ETD. Three males and nine females, affected by middle ear atelectasis with retraction of the TM were enrolled. Each patient underwent to Eustachian tube dysfunction evaluation adopting the ETS-7 score and a temporal bone CT with Valsalva maneuver. The ears analyzed at steady state were divided into 2 groups: ETS<7 group and ETS≥ 7 group. The same division was applied for the ears analyzed after the Valsalva maneuver: ETS<7 group and ETS≥ 7 group. ETs were categorized as "well defined" (WD) and "not defined" (ND). The results of the analysis of the ETS-7 score in all 24 ears showed that 42% presented ETS ≥7, while 58% had ETS <7, indicating a diagnosis of ETD. In the ETS<7 group after Valsalva, ET was visualized in 33% of patients. In the ETS≥7 group it was WD in 29% after the Valsalva manoeuver. In both groups the comparison between the visualization of the ET before and after the Valsalva manoeuver did not present a statistical difference. No correlation emerged between ET evaluation with CT scan during Valsalva maneuver and ETS-7 score. It confirms that there is not a gold standard for the study of ET dysfunction.

Exploring perceptions, barriers, and enablers for delivery of primary ear and hearing care by community health workers: a photovoice study in Mukono District, Uganda.

BACKGROUND: Hearing loss is a prevalent but neglected disease, especially in low- or middle-income countries. The role of Community Health Workers (CHWs) to deliver primary ear and hearing care has been explored in several studies from a technical standpoint, but understanding perceptions, barriers, and enablers of such an approach from the perspective of CHWs themselves through a health equity lens has been less well documented. METHODS: This qualitative study used photovoice to explore the views and experiences of CHWs in the Seeta Nazigo Parish of Mukono District in the delivery of ear and hearing care in the community. CHWs were trained in ear and hearing care, and provided with digital cameras to capture photographs related to their work in the community over the following 3 months. Individual interviews regarding the photographs were held at the end of each month, in addition to one focus group discussion. A community workshop was convened at the end of the study to display the photos. Thematic analysis of photographs was conducted using Braune and Clarkes six-step framework. We also used the data to explore potential roles for key stakeholders in primary ear and hearing care, and how photovoice may facilitate their engagement. RESULTS: 13 CHWs participated in the study. Several themes were generated from analysis. CHWs perceived a high burden of ear and hearing disorders in their community and recognised the role they could play in tackling that burden. Potential barriers identified included a lack of equipment, training, and supervision of CHWs; logistical, financial, or psychological barriers to community participation; and the widespread use of traditional medicine. CHWs identified roles for the government and NGO bodies to enable and support delivery of ear and hearing care in the community. The community workshop was a useful method to engage key stakeholders in this topic. CONCLUSIONS: Photovoice is a powerful method to capture issues affecting CHWs. Here it was used to identify a number of perceptions, barriers and enablers to the delivery of ear and hearing care. Our results may inform future strategy in the field of ear and hearing care, and the potential use of photovoice to enact sociocultural change.

Medium-term assessment of Eustachian tube function after balloon dilation.

There is at present no consensus on the treatment of obstructive Eustachian tube dysfunction. In case of failure of well-conducted drug and pressure therapy, some authors recommend balloon dilation; the present study aimed to assess the efficacy and safety of Eustachian tube balloon dilation. MATERIALS AND METHODS: A single-center retrospective study assessed clinical and tubomanometric results of Eustachian tube balloon dilation, complications and satisfaction in a consecutive series managed between June 2012 and February 2015. Indications were based on clinical and paraclinical signs of obstructive tube dysfunction despite well-conducted medical treatment. RESULTS: Forty-five procedures were performed in 38 patients. Improvement in clinical symptoms was assessed as 88%, 80% and 80% at respectively 2 months, 6 months, and>1 year. Improved function on tubomanometry was observed in 81% of cases. The procedure was well tolerated, with a minor complications rate of only 4%. CONCLUSIONS: The present findings for efficacy, tolerance and safety were comparable to those in the literature, despite first-line failure in all patients. Eustachian tube function normalized in about one-third of cases. Despite these encouraging results, true efficacy remains to be confirmed in prospective studies with higher levels of evidence.

Providing an extended use of an otological-specific outcome instrument to derive cost-effectiveness estimates of treatment.

OBJECTIVES: Although quality-adjusted life years (QALYs) are increasingly being used by decision-makers to make comparisons of cost-effectiveness, there are no otological-specific outcome measures that fit within this QALY framework. This study had two main objectives. The first was to provide a means to derive QALYs from a condition-specific otological instrument (Cambridge Otology Quality of Life, COQOL), and the second was to assess the convergent validity, or degree of correlation, between the COQOL and SF-6D, an established QALY instrument. DESIGN: Longitudinal cohort study designed to assess the convergent validity between SF-6D and COQOL and to generate a mapping function to enable SF-6D values to be predicted from the COQOL responses. SETTING: Cambridge University Hospital, UK. PARTICIPANTS: A total of 207 patients attending a routine outpatient general otology clinic. MAIN OUTCOME MEASURES: SF-6D and the COQOL instrument completed at baseline and again 3 months later. RESULTS: Convergent validity was demonstrated with mean SF-6D values decreasing linearly with increasing severity on the COQOL instrument. Overall, the correlation between the COQOL scores and the SF-6D values was moderate and statistically significant (r = 0.490, P = <0.001). A simple mapping model based on an ordinary least squares (OLS) regression function predicted SF-6D values from the COQOL data with a reasonable degree of accuracy. Further validation using the follow-up 3-month data confirmed the prediction power of this mapping model. CONCLUSIONS: This study provides a method for estimating QALYs from condition-specific COQOL data and provides the opportunity for the cost-effectiveness of otological treatment to be measured and placed within the national QALY framework.

Systematic review of the limited evidence base for treatments of Eustachian tube dysfunction: a health technology assessment.

BACKGROUND: The Health Technology Assessment programme commissioned a wide-ranging review of treatments for adult Eustachian tube dysfunction. Treatments range from advice and observation and pharmacological treatments to surgical options. OBJECTIVE: (i) To assess the evidence for interventions for adults with a clinical diagnosis of Eustachian tube dysfunction and (ii) to identify priorities for future research. TYPE OF REVIEW: Systematic review (PROSPERO registration CRD42012003035) adhering to PRISMA guidance. SEARCH: An extensive search of 15 databases including MEDLINE, EMBASE and CENTRAL (up to October 2012). EVALUATION METHOD: Controlled and uncontrolled studies of interventions for adult Eustachian tube dysfunction were included. Because of insufficient data, the protocol was amended to also include controlled studies with mixed adult/child populations. Risk of bias was assessed. Narrative synthesis was employed due to high clinical heterogeneity. RESULTS: Interventions assessed were pharmacological treatments [two randomised controlled trials (RCTs), one controlled non-randomised trial (CCT), 159 patients]; mechanical pressure equalisation devices (one randomised controlled trial, one CCT, 48 patients); and surgery, including laser tuboplasty (seven case series, 192 patients), balloon dilatation (three case series, 103 patients), myringotomy without grommet insertion (two case series, 121 patients), transtubal steroids (one case series, 11 patients) and laser coagulation (one retrospective controlled study, 40 patients). All studies had high risk of bias except two pharmacological trials; one had low risk and one unclear risk. No evidence was found for many treatments. The single low risk of bias RCT (n = 91; 67% adults) showed no effect of nasal steroids and favoured placebo for improved middle ear function (RR 1.20, 95% CI 0.91-1.58) and symptoms (P = 0.07). Other studies showed improvements in middle ear function for mechanical devices, antihistamine/ephedrine and nasal decongestant, but they had significant methodological weaknesses including insufficient length of follow-up. None of the surgical studies were adequately controlled, and many reported high levels of co-intervention. Therefore, observed benefits for tuboplasty and balloon dilatation in symptoms, middle ear function or hearing could not be reliably attributed to the interventions assessed. There was variability in definitions of the condition. CONCLUSION: Eustachian tube dysfunction is a poorly defined condition. Due to the limited and poor-quality evidence, it is inappropriate to make conclusions on the effectiveness of any intervention; the evidence base is insufficient to guide recommendations for a trial of any particular intervention. Consensus on diagnostic criteria for Eustachian tube dysfunction is required to inform inclusion criteria of future trials.

The lifeline express--a mobile ear clinic for rural India.

The objectives of this study were to review the application and feasibility of providing screening, diagnosis, medical and surgical treatment for patients with ear discharge by setting a mobile hospital in rural India. The study was retrospective. The study involved collection of data from 1992 to 2005 from patients with ear diseases. The number of patients operated on for ear conditions and the distribution of free hearing aids were also recorded. Data regarding length of postoperative stay, complications and graft failure rates was collected from local medical centers and analyzed. Out of 304,321 patients, 4,426 were operated on for ear diseases, mostly ear perforations, grommet insertions and cholesteatoma surgeries. A total of 11,913 audiometric evaluations were done and 9,045 hearing aids were distributed. An overall success rate of 78.8% was achieved for achieving a dry ear and approximately 60% reported significant improvement in audiometric thresholds.

Impacted cerumen: composition, production, epidemiology and management.

In the UK, some 2.3 million people suffer cerumen ('ear wax') problems serious enough to warrant management, with approximately 4 million ears syringed annually. Impacted cerumen is a major cause of primary care consultation, and a common comorbidity in ENT patients, the elderly, infirm and people with mental retardation. Despite this, the physiology, clinical significance and management implications of excessive and impacted cerumen remain poorly characterized. There are no well-designed, large, placebo-controlled, double-blind studies comparing treatments, and accordingly, the evidence surrounding the management of impacted cerumen is inconsistent, allowing few conclusions. The causes and management of impacted cerumen require further investigation. Physicians are supposed to follow the edicts and principles of evidence-based medicine and clinical governance. Currently, in patients with impacted cerumen, the lack of evidence makes this impossible.

Cost-effective analysis of conventional and nurse-led clinics for common otological procedures.

The need to reduce costs while providing a first-class service has led to the expansion in the role of nurses in recent years. We present results of a comparison of the cost-effectiveness of conventional and nurse-led out-patient ear clinics. Our results indicate that cost-effective health care is a distinct competitive advantage for nurses taking up some roles conventionally performed by doctors. The difference in mean cost of out-patient visit per patient between the two groups is 75.28 pounds. This is equivalent to a reduction in cost to the hospital of more than 47,000 pounds for the 626 patients seen in a nurse-led ear clinic in a year. The nurse-led service is thus more cost-effective and presents an opportunity by freeing up otolaryngologists' time to see more complex patients and has the potential for reducing out-patient access time in the NHS.

[The value of exploratory anterior tympanotomy in differentiating causes of conductive hearing loss and assessment of their treatment results]. / Wartosc tympanotomii eksploratywnej przedniej w róznicowaniu przyczyn przewodzeniowych uszkodzen sluchu oraz ocena wyników ich leczenia.

The aim of examination was value of exploratory anterior tympanotomy in differentiation causes of conductives hearing loss and assessment of results treatment. Materials of examinations determined 34 patients aged 15-66 years, treated in 1995-2000 years, who qualified to exploratory anterior tympanotomy in aim decision of cause of conductives hearing loss. Among of examined were 14 patients with suspicion of otosclerosis (41.2%), 12 patients with unclear etiology of hypoacusis (35.3) and 8 patients with deterioration of hearing after stapedectomy (23.5%). Preoperative diagnostic embraced: a history, otolaryngologic examination, full audiologic examination and chosen cases of radiologic assessment of temporal bone by computer tomography. After perioperative decision cause of conductive hypoacousis were performed of operations of improved hearing and comprised of average hearing loss by CPT and PTA pre- and postoperative treatment. After performed of exploratory tympanotomy there vere stated following causes of conductive hypoacusis: otosclerosis (61.8%), separated of prosthesis after stapedectomy (14.7%) synechia of prosthesis with tympanic membrane (8.8%) and in singles causes of ossicular synechia in tympanic cavum (5.9%), tympanosclerosis (5.9%) and vitium of middle ear (2.9%). The best of hearing improvement after repairment operations of conductive system were obtained in cases of stapedectomy, exchange of prosthesis after stapedectomy, reconstruction of system by TORP prosthesis, however smaller improvement after operations of synechias of stapes prosthesis with surroundings and postoperation of tympanosclerosis.

Black-white differences in health care utilization among US children with frequent ear infections.

OBJECTIVE: To examine differences in patterns of and barriers to health care utilization between black and white children who have frequent ear infections (FEI). METHODS: Analysis was conducted using the 1997 and 1998 National Health Interview Survey-Sample Child Files. Data on 25 497 children under 18 years of age and 1985 who were reported by the parent/guardian to have had "3 or more ear infections during the past 12 months" were analyzed. The data were weighted and analyzed to represent all black and white children nationwide, accounting for the complex survey design. RESULTS: Of white and black children under 18 years of age in the United States, 8.0 and 6.6%, respectively, had FEI in the past year. Among those with FEI, whites and blacks exhibited significantly different patterns in the type of health insurance they had and in the usual source of care. After accounting for sociodemographic factors, health insurance, and usual source of care, there were still significant differences in health care use between whites and blacks. The affected black children had an increased risk of getting delayed care because of transportation problems (odds ratio [OR]: 2.32) and a reduced likelihood of seeing a medical specialist (OR: 0.49) and having surgery (OR: 0.39) in comparison to white children. CONCLUSION: Although black children with FEI were as likely as white children to be covered by health insurance and have a usual place of health care, they were significantly more likely to face barriers in obtaining the care, especially the more specialized care.

Health insurance status and ambulatory care for children.

BACKGROUND: Many children in the United States lack health insurance. We tested the hypothesis that these children are less likely than children with insurance to visit a physician when they have specific conditions for which care is considered to be indicated. METHODS: We examined the association between whether children were covered by health insurance and whether they received medical attention from a physician for pharyngitis, acute earache, recurrent ear infections, or asthma. Data were obtained on the subsample of 7578 children and adolescents 1 through 17 years of age who were included in the 1987 National Medical Expenditures Survey, a national probability sample of the civilian, noninstitutionalized population. RESULTS: Uninsured children were more likely than children with health insurance to receive no care from a physician for all four conditions (unadjusted odds ratios, 2.38 for pharyngitis; 2.04 for acute earache; 2.84 for recurrent ear infections; and 1.87 for asthma). Multiple logistic-regression analysis was subsequently used to control for age, sex, family size, race or ethnic group, region of the country, place of residence (rural vs. urban), and household income. After adjustment for these factors, uninsured children remained significantly more likely than insured children to go without a visit to a physician for pharyngitis (adjusted odds ratio, 1.72; 95 percent confidence interval, 1.11 to 2.68), acute earache (1.85; 95 percent confidence interval, 1.15 to 2.99), recurrent ear infections (2.12; 95 percent confidence interval, 1.28 to 3.51), and asthma (1.72; 95 percent confidence interval, 1.05 to 2.83). CONCLUSIONS: As compared with children with health insurance, children who lack health insurance are less likely to receive medical care from a physician when it seems reasonably indicated and are therefore at risk for substantial avoidable morbidity.

Audiological development in South-East Asia. Thailand health profile.

The Otological Centre:Bangkok Unit has been established since March 13, 1985 on the initiation of ISA and IFOS as one of the planned three Centres for each continent of the world. Bangkok Centre serves the Asian countries on the Global Programme on Prevention of Hearing Impairment and Deafness. It was the first of the planned three centres to be established and operative. The Centre has already run Annual Training Courses to upgrade oto-audiological knowledge of ENT doctors and personnel engaged in this field. Three courses were run with a very successful result. The epidemiological survey and services of ear diseases and hearing problems were carried out in various parts of Thailand rural areas as well as in the Bangkok metropolitan area in cooperation with the Provincial Health Offices and Provincial and District Hospitals and Bangkok Metropolitan Health Centres. Emphasis was placed on the early detection, management and preventive measures to the early diseases and hearing disorders. The Centre's mobile team is run on a voluntary basis without any financial support. The problem cases found were treated and referred to the appropriate health units, health centres or hospitals according to convenience and suitability. Some difficult cases in need of further investigation were recommended to seek specialist attention at the closest hearing centre. Essential for services at the spot is hearing aids provision free of charge or as cheap as possible, since more than 50% of congenital hearing impaired children have never before used hearing aids as this is either not affordable or not available in rural areas. Financial support is crucial for further development and running of the Centre. International help will also be needed for training of personnel both at the site of the Centre and overseas. An acoustic laboratory is essential for the future development of the Centre. The Ear Foundation (Thailand) was set up in January 1987. Some personal as well as international support in all aspects is essential for the further development as well as to cope with the maintenance costs of the Bangkok Centre. Our hope is that "Hearing for All by the Year 2000" will be true for all sectors.