The Medicare annual wellness visit: An opportunity to improve health system identification of hearing loss?

BACKGROUND: Hearing loss is prevalent and consequential but under-diagnosed and managed. The Medicare Annual Wellness Visit (AWV) health risk assessment elicits patient-reported hearing concerns but whether such information affects documentation, diagnosis, or referral is unknown. METHODS: We use 5 years of electronic medical record (EMR) data (2017-2022) for a sample of 13,776 older primary care patients. We identify the first (index) AWV indication of hearing concerns and existing and subsequent hearing loss EMR diagnoses (visit diagnoses or problem list diagnoses) and audiology referrals. For a 20% random sample of AWV notes (n = 474) we compared hearing loss EMR diagnoses to documentation of (1) hearing concerns, (2) hearing loss/aid use, and (3) referrals for hearing care. RESULTS: Of 3845 (27.9%) older adults who identified hearing concerns (mean age 79.1 years, 57% female, 75% white) 24% had an existing hearing diagnosis recorded. Among 474 patients with AWV clinical notes reviewed, 90 (19%) had an existing hearing loss diagnosis. Clinicians were more likely to document hearing concerns or hearing loss/aid use for those with (vs. without) an existing EMR diagnosis (50.6% vs. 35.9%, p = 0.01; 68.9% vs. 37.5%, p < 0.001, respectively). EMR diagnoses of hearing loss were recorded for no more than 40% of those with indicated hearing concerns. Among those without prior diagnosis 38 (9.9%) received a hearing care referral within 1 month. Subgroup analysis suggest greater likelihood of documenting hearing concerns for patients age 80+ (OR:1.51, 95% confidence interval [CI]: 1.03, 2.19) and decreased likelihood of documenting known hearing loss among patients with more chronic conditions (OR: 0.49, 95% CI: 0.27, 0.9), with no differences observed by race. CONCLUSION: Documentation of hearing loss in EMR and AWV clinical notes is limited among older adults with subjective hearing concerns. Systematic support and incorporation of hearing into EMR and clinical notes may increase hearing loss visibility by care teams.

Care partners and consumer health information technology: A framework to guide systems-level initiatives in support of digital health equity.

Introduction: Consumer-oriented health information technologies (CHIT) such as the patient portal have a growing role in care delivery redesign initiatives such as the Learning Health System. Care partners commonly navigate CHIT demands alongside persons with complex health and social needs, but their role is not well specified. Methods: We assemble evidence and concepts from the literature describing interpersonal communication, relational coordination theory, and systems-thinking to develop an integrative framework describing the care partner's role in applied CHIT innovations. Our framework describes pathways through which systematic engagement of the care partner affects longitudinal work processes and multi-level outcomes relevant to Learning Health Systems. Results: Our framework is grounded in relational coordination, an emerging theory for understanding the dynamics of coordinating work that emphasizes role-based relationships and communication, and the Systems Engineering Initiative for Patient Safety (SEIPS) model. Cross-cutting work systems geared toward explicit and purposeful support of the care partner role through CHIT may advance work processes by promoting frequent, timely, accurate, problem-solving communication, reinforced by shared goals, shared knowledge, and mutual respect between patients, care partners, and care team. We further contend that systematic engagement of the care partner in longitudinal work processes exerts beneficial effects on care delivery experiences and efficiencies at both individual and organizational levels. We discuss the utility of our framework through the lens of an illustrative case study involving patient portal-mediated pre-visit agenda setting. Conclusions: Our framework can be used to guide applied embedded CHIT interventions that support the care partner role and bring value to Learning Health Systems through advancing digital health equity, improving user experiences, and driving efficiencies through improved coordination within complex work systems.

The Annual Wellness Visit Health Risk Assessment: Potential of Patient Portal-Based Completion and Patient-Oriented Education and Support.

Background and Objectives: Patient portals are secure online platforms that allow patients to perform electronic health management tasks and engage in bidirectional information exchange with their care team. Some health systems administer Medicare Annual Wellness Visit (AWV) health risk assessments through the patient portal. Scalable opportunities from portal-based administration of risk assessments are not well understood. Our objective is 2-fold-to understand who receives vs misses an AWV and health risk assessment and explore who might be missed with portal-based administration. Research Design and Methods: This is an observational study of electronic medical record and patient portal data (10/03/2021-10/02/2022) for 12 756 primary care patients 66+ years from a large academic health system. Results: Two-thirds (n = 8420) of older primary care patients incurred an AWV; 81.0% of whom were active portal users. Older adults who were active portal users were more likely to incur AWV than those who were not, though portal use was high in both groups (81.0% with AWV vs 76.8% without; p < .001). Frequently affirmative health risk assessment categories included falls/balance concerns (44.2%), lack of a documented advanced directive (42.3%), sedentary behaviors (39.9%), and incontinence (35.1%). Mean number of portal messages over the 12-month observation period varied from 7.2 among older adults affirmative responses to concerns about safety at home to 13.8 for older adults who reported difficulty completing activities of daily living. Portal messaging varied more than 2-fold across affirmative health risk categories and were marginally higher with greater number affirmative (mean = 13.8 messages/year no risks; 19.6 messages/year 10+ risks). Discussion and Implications: Most older adults were active portal users-a group more likely to have incurred a billed AWV. Efforts to integrate AWV risk assessments in the patient portal may streamline administration and scalability for dissemination of tailored electronically mediated preventive care but must attend to equity issues.

Caregiving Time of Unpaid Family Caregivers Assisting Older Adults With Hearing Difficulty.

Objectives: We aimed to investigate the association of older adults' hearing difficulty status with caregiving time. Methods: We used data from two linked surveys of Medicare beneficiaries and family caregivers. Hearing difficulty was defined by hearing aid use and hearing capacity in functional settings. Weighted multivariable linear regression examined the association between hearing difficulty and caregiving time. Stratified analyses were conducted to investigate the moderation effects of caregiving networks and care recipient's dementia status. Results: Among 3003 caregivers, those who assisted older adults with hearing difficulty were observed to spend greater time providing care (ß = 1.18, 95% Confidence Interval [CI]: 1.04, 1.32). Stronger associations in magnitude were observed among caregivers without caregiving networks (ß = 1.35, 95% CI: 1.13, 1.56) and assisting older adults without dementia (ß = 1.22; 95% CI = 1.06, 1.37). Discussion: Hearing difficulty may contribute to greater caregiving time and remains a potential target for caregiver support programs.

Patient portal interventions: a scoping review of functionality, automation used, and therapeutic elements of patient portal interventions.

Objectives: We sought to understand the objectives, targeted populations, therapeutic elements, and delivery characteristics of patient portal interventions. Materials and Methods: Following Arksey and O-Malley's methodological framework, we conducted a scoping review of manuscripts published through June 2022 by hand and systematically searching PubMed, PSYCHInfo, Embase, and Web of Science. The search yielded 5403 manuscripts; 248 were selected for full-text review; 81 met the eligibility criteria for examining outcomes of a patient portal intervention. Results: The 81 articles described: trials involving comparison groups (n = 37; 45.7%), quality improvement initiatives (n = 15; 18.5%), pilot studies (n = 7; 8.6%), and single-arm studies (n = 22; 27.2%). Studies were conducted in primary care (n = 33, 40.7%), specialty outpatient (n = 24, 29.6%), or inpatient settings (n = 4, 4.9%)-or they were deployed system wide (n = 9, 11.1%). Interventions targeted specific health conditions (n = 35, 43.2%), promoted preventive services (n = 19, 23.5%), or addressed communication (n = 19, 23.4%); few specifically sought to improve the patient experience (n = 3, 3.7%). About half of the studies (n = 40, 49.4%) relied on human involvement, and about half involved personalized (vs exclusively standardized) elements (n = 42, 51.8%). Interventions commonly collected patient-reported information (n = 36, 44.4%), provided education (n = 35, 43.2%), or deployed preventive service reminders (n = 14, 17.3%). Discussion: This scoping review finds that most patient portal interventions have delivered education or facilitated collection of patient-reported information. Few interventions have involved pragmatic designs or been deployed system wide. Conclusion: The patient portal is an important tool in real-world efforts to more effectively support patients, but interventions to date rely largely on evidence from consented participants rather than pragmatically implemented systems-level initiatives.

Dementia and Hearing Aid Use and Cessation: A National Study.

PURPOSE: The current standard for management of hearing loss in the United States involves the use of a hearing aid. Anecdotal evidence suggests that the use of a hearing aid may be less effective in the context of dementia, though national data on use and cessation are not described. METHOD: This longitudinal analysis of the National Health and Aging Trends Study followed participants who self-reported hearing aid use to estimate risk of hearing aid cessation over 9 years. We examine whether hearing aid cessation differs by dementia status using generalized estimating equations logistic regression accounting for loss to follow-up. Supplemental analyses were undertaken to examine the contribution of caregiving and environmental factors on hearing aid cessation. RESULTS: Of 1,310 older adults who reported hearing loss (25% 80-84 years, 51% women, 74% White), 22% with dementia and 57% baseline hearing aid use. Dementia increased likelihood of ceasing hearing aid use during the first year after adoption (OR = 2.07, 95% CI [1.33, 3.23], p interaction = .11). In later years, older adults with either a previous or recent diagnosis of dementia had a 95% higher odds of hearing aid cessation (OR = 1.95, 95% CI [1.31, 2.90]), a decrease in odds with respect to the first year after adoption, when compared to participants without dementia, after adjusting for demographic, health, and economic factors. Economic and social factors that may influence care demands (more caregivers, income-to-poverty ratio, and additional insurance) increased likelihood for cessation for those with dementia. CONCLUSIONS: Older adults with (vs. without) dementia are more likely to cease hearing aid use over time, most notably during the first year after adoption. Strategies to support hearing ability, such as self-management or care partner education, may improve communication for those living with co-occurring hearing loss and dementia.

Use of the patient portal among older adults with diagnosed dementia and their care partners.

INTRODUCTION: Care partners are at the forefront of dementia care, yet little is known about patient portal use in the context of dementia diagnosis. METHODS: We conducted an observational cohort study of date/time-stamped patient portal use for a 5-year period (October 3, 2017-October 2, 2022) at an academic health system. The cohort consisted of 3170 patients ages 65+ with diagnosed dementia with 2+ visits within 24 months. Message authorship was determined by manual review of 970 threads involving 3065 messages for 279 patients. RESULTS: Most (71.20%) older adults with diagnosed dementia were registered portal users but far fewer (10.41%) had a registered care partner with shared access. Care partners authored most (612/970, 63.09%) message threads, overwhelmingly using patient identity credentials (271/279, 97.13%). DISCUSSION: The patient portal is used by persons with dementia and their care partners. Organizational efforts that facilitate shared access may benefit the support of persons with dementia and their care partners. Highlights Patient portal registration and use has been increasing among persons with diagnosed dementia. Two thirds of secure messages from portal accounts of patients with diagnosed dementia were identified as being authored by care partners, primarily using patient login credentials. Care partners who accessed the patient portal using their own identity credentials through shared access demonstrate similar levels of activity to patients without dementia. Organizational initiatives should recognize and support the needs of persons with dementia and their care partners by encouraging awareness, registration, and use of proper identity credentials, including shared, or proxy, portal access.

Patient Portal Use Among Older Adults With Dementia Diagnosis.

This cohort study assesses the level of engagement with an electronic health management system among patients with recently diagnosed dementia and their caregivers.

Catalyzing dementia care through the learning health system and consumer health information technology.

To advance care for persons with Alzheimer's disease and related dementias (ADRD), real-world health system effectiveness research must actively engage those affected to understand what works, for whom, in what setting, and for how long-an agenda central to learning health system (LHS) principles. This perspective discusses how emerging payment models, quality improvement initiatives, and population health strategies present opportunities to embed best practice principles of ADRD care within the LHS. We discuss how stakeholder engagement in an ADRD LHS when embedding, adapting, and refining prototypes can ensure that products are viable when implemented. Finally, we highlight the promise of consumer-oriented health information technologies in supporting persons living with ADRD and their care partners and delivering embedded ADRD interventions at scale. We aim to stimulate progress toward sustainable infrastructure paired with person- and family-facing innovations that catalyze broader transformation of ADRD care.

The role of care partners in medical visits of older adults with hearing loss and dementia: A national study.

BACKGROUND: Dementia and hearing loss (HL) are conditions, which restrict communication ability and amplify the difficulty of implementing effective care coordination and communication with medical providers. We examined how the presence of HL and dementia influence communication with medical providers, and the role of involved care partners during medical visits. METHODS: Drawing on responses from 7070 community-dwelling older adults who participated in the 2015 National Health and Aging Trends Study, we used logistic regression to quantify care partner accompaniment to medical visits and the role care partners assume during visits by older adult hearing and dementia status. RESULTS: Nearly 4 in 10 older adults with dementia also reported HL. Eighty-two percent of older adults with both HL and dementia were accompanied to medical visits by a care partner. Those with HL and dementia were six times more likely to be accompanied by a care partner to medical visits than those with neither condition (OR: 6.04; 95% CI:4.06, 8.99). Care partners of older adults with both (vs neither) HL and dementia were more actively engaged in: (1) facilitating understanding between the older adult and doctor (OR: 4.55, 95% CI:2.68, 7.71); (2) asking or telling the doctor information (OR: 6.13, 95% CI:3.44, 10.9); and (3) reminding the older adult of their questions (OR: 2.52, 95% CI: 1.66, 3.83). CONCLUSIONS: Care partners have an active role during medical visits of older adults with HL and dementia. Efforts to support care partner engagement and teach advocacy skills may close gaps in care quality for the subgroup of older adults who are living with HL and dementia.

Associations of audiometric hearing and speech-in-noise performance with cognitive decline among older adults: The Baltimore Longitudinal Study of Aging (BLSA).

Background: Established associations between hearing loss and cognitive decline were primarily defined by pure-tone audiometry, which reflects peripheral hearing ability. Speech-in-noise performance, which reflects central hearing ability, is more limited in prior literature. We examined the longitudinal associations of audiometric hearing and speech-in-noise performance with cognitive decline. Methods: We studied 702 participants aged ≥60 years in the Baltimore Longitudinal Study of Aging 2012-2019. Global and domain-specific (language, memory, attention, executive function, visuospatial ability) cognitive performance were assessed by the cognitive assessment battery. Hearing thresholds at 0.5, 1, 2, and 4 kilohertz obtained from pure-tone audiometry were averaged to calculate better-ear pure-tone average (PTA) and participants were categorized as having hearing loss (>25 decibels hearing level [dB HL]) or normal hearing (≤25 dB HL). Speech-in-noise performance was assessed by the Quick Speech-in-Noise (QuickSIN) test, and participants were categorized as having below-median (worse) or above-median performance. Linear mixed effects models with random intercepts and slopes were used to assess baseline cognitive performance and cognitive decline by hearing status. Models adjusted for demographic, lifestyle and disease factors. Results: Participants with audiometric hearing loss showed similar baseline cognitive performance but faster decline in global cognitive function, language, executive function, and attention. Participants with below-median QuickSIN score showed worse baseline cognitive performance in all domains and faster decline in global cognitive function, language, memory, executive function and attention. Conclusions: Audiometric hearing might be targeted to delay cognitive decline. Speech-in-noise performance might be a novel marker and might be more sensitive to memory decline.

Associations of dual sensory impairment with long-term depressive and anxiety symptoms in the United States.

OBJECTIVE: We explored the associations of dual sensory impairment (DSI) with long-term depressive and anxiety symptoms as well as low perceived social support (LPSS) as a modifier of these associations. METHODS: Multinomial logistic regression models were used to examine the associations of DSI and single sensory impairment (hearing [pure-tone average > 25 dB] and vision [impaired visual acuity and/or contrast sensitivity]) with long-term depressive symptom (≥8 on the 10-item Center for Epidemiologic Studies-Depression Scale) and anxiety symptom (present on the Hopkins Symptom Checklist) latent classes from group-based trajectory models (rare/never; mild/moderate increasing; chronically high) among 2102 Health, Aging and Body Composition Study participants (mean age:74.0 ± 2.8 years; 51.9 % female) over 10 years. Models were adjusted by demographic characteristics and cardiovascular risk factors, and LPSS. An additional model evaluated the two-way interaction between DSI and LPSS. RESULTS: DSI was associated with increased risk of being chronically depressed (Risk Ratio, RR = 1.99, 95 % Confidence Interval, CI: 1.25, 3.17), not mild/moderate increasingly depressed (RR = 1.25, 95 % CI: 0.91, 1.71). DSI had increased risk of being mild/moderate increasingly anxious (RR = 1.60, 95 % CI: 1.16, 2.19) and chronically anxious (RR = 1.86, 95 % CI: 1.05, 3.27) groups, as compared to no impairments. Hearing impairment was associated with being mild/moderate increasingly anxious (RR = 1.34, 95 % CI: 1.01, 1.79). No other associations were found for single sensory impairments. LPSS did not modify associations. LIMITATIONS: Sensory measures were time-fixed, and LPSS, depression and anxiety measures were self-reported. CONCLUSIONS: Future research is warranted to determine if DSI therapies may lessen long-term chronically high depressive and anxiety symptoms.

Assessment of hearing and vision impairment in cohort studies collecting cognitive data in older adults.

INTRODUCTION: There are no standard practices for considering sensory impairment in studies measuring cognitive function among older adults. Exclusion of participants with impairments may inaccurately estimate the prevalence of cognitive impairment and dementia. METHODS: We surveyed prospective cohort studies measuring cognitive function in older adults, determined the proportion that excluded participants based on sensory impairment and the proportion that assessed each type of sensory impairment, and described the methods of sensory assessment. RESULTS: Investigators/staff from 85 (of 192 cohorts) responded; 6 (7%) excluded participants with severe impairment; 80 (94%) measured hearing and/or vision impairment, while 5 (6%) measured neither. Thirty-two (38%) cohorts assessed hearing objectively and 45 (53%) assessed vision objectively. DISCUSSION: Findings indicate variation in methods used to assess sensory impairment, with potential implications for resource allocation. To ensure equitable inclusion of study participants, consensus is needed on best practices standardized protocols for assessment and accommodations of sensory impairment.

Examining the Combined Estimated Effects of Hearing Loss and Depressive Symptoms on Risk of Cognitive Decline and Incident Dementia.

OBJECTIVES: Late-life depression is a comorbidity that may co-occur in older adults with hearing loss-each has prevalent and independent modifiable risk factors for dementia. METHODS: Using data from 1,820 Health, Aging and Body Composition study participants (74 ± 2.8 years, 38% Black race), we compared the hearing loss-dementia/cognitive decline relationship between those with normal hearing/mild hearing loss and those with moderate or greater hearing loss. Using linear mixed-effects and Cox proportional hazard models, we investigated if the associations between hearing loss and cognitive decline or dementia (Modified Mini-Mental State [3MS] Examination and Digit Symbol Substitution Test [DSST]) differed by the presence or absence of depressive symptoms. Depressive symptoms were defined as Center for Epidemiologic Study-Depression scale 10 ≥10 at one or more visits from Years 1-5. Algorithmic incident dementia was defined using medication use, hospitalizations, and cognitive test scores. Audiometric hearing loss was measured at Year 5 and categorized as normal/mild versus moderate or greater hearing loss. RESULTS: Having both hearing loss and depressive symptoms (vs. having neither) was associated with faster rates of decline in 3MS Examination (ß = -0.30; 95% confidence interval [CI]: -0.78, -0.19) and DSST (ß = -0.35; 95% CI: -0.67, -0.03) over 10 years of follow-up. Having both hearing loss and depressive symptoms (vs. neither) was associated with increased risk (hazard ratio [HR]: 2.91; 95% CI: 1.59, 5.33 vs. HR: 1.54; 95% CI: 1.10, 2.15 hearing loss only and HR: 2.35; 95% CI: 1.56, 3.53 depressive symptoms only) of incident dementia in multivariable-adjusted Cox proportional hazards models. DISCUSSION: Comorbid conditions among hearing-impaired older adults should be considered and may aid in dementia prevention and management strategies.

Hearing loss and risk of depressive symptoms in older adults in the Health ABC study.

Objective: Hearing loss (HL) is highly prevalent among older adults and may lead to increased risk of depressive symptoms. In both cross-sectional and longitudinal analysis, we quantified the association between HL and depressive symptoms, incorporating the variable nature of depressive symptoms and characterizing by race and gender. Methods: Data were from the Health, Aging, and Body Composition study. Depressive symptoms were measured using the Center for Epidemiologic Study Depression Scale short form (CES-D 10), defined as CES-D 10 score ≥10 or treatment for depression. Hearing was defined via four-frequency pure-tone average (PTA) decibel hearing level (dB HL), categorized as normal hearing (PTA ≤25 dB HL), mild HL (PTA26-40 dB HL), and ≥moderate HL (PTA > 40 dB HL). Associations at baseline were quantified using logistic regression, incident depressive symptoms using Cox proportional hazard models, and change in depressive symptoms over time using growth mixture models and multinomial logistic regression. Results: Among 2,089 older adults (1,082 women, 793 Black; mean age 74.0 SD: 2.8), moderate or greater HL was associated with greater odds of concurrent [Odds Ratio (OR):2.45, 95% CI:1.33, 4.51] and incident depressive symptoms [Hazard Ratio (HR):1.26, 95% CI:1.00, 1.58]. Three depressive symptom trajectory patterns were identified from growth mixture models: low, moderate increasing, and borderline high depressive symptom levels. Those with moderate or greater HL were more likely to be in the borderline high depressive-symptom trajectory class than the low trajectory class [Relative Risk Ratio (RRR):1.16, 95% CI:1.01, 1.32]. Conclusions: HL was associated with greater depressive symptoms. Although findings were not statistically significantly different by gender and race, estimates were generally stronger for women and Black participants. Investigation of psychosocial factors and amelioration by hearing aid use could have significant benefit for older adults' quality of life.

The Relationship of APOE ε4, Race, and Sex on the Age of Onset and Risk of Dementia.

Objective: To investigate whether APOE ε4 genotype-an established risk factor for dementia-is associated with earlier age at diagnosis in addition to increased risk overall and in secondary analysis by race and sex. Methods: We followed up 13,782 dementia-free individuals (n = 10,137 White, n = 3,645 Black, baseline age 60-66 years) in the Atherosclerosis Risk in Communities study for up to 30 years. Dementia was operationalized using standardized algorithms incorporating longitudinal cognitive change, proxy report, and hospital or death certificate dementia codes. We used a mixture of generalized gamma distributions to simultaneously estimate time to dementia, time to dementia-free death, and the proportion of individuals with dementia, by APOE ε4 status (≥1 vs. no alleles). Results: Median age of dementia onset among APOE ε4 carriers was 81.7 (Blacks) and 83.3 years (Whites) compared with 82.6 (Blacks) and 85.7 years (Whites) in non-APOE ε4 carriers (p > 0.05 Blacks; p < 0.01 Whites). Age of dementia diagnosis did not differ by sex in ε4 carriers, but among non-carriers, average age was earlier in males than females regardless of race. APOE ε4 carriers had on average a higher proportion of diagnoses; results did not differ by race or sex. Conclusions: APOE ε4 carrier status is associated with earlier age of dementia diagnosis with differences across race and sex. These findings clarify the causal role of APOE in dementia etiology, which could help better identify at-risk subgroups and may help facilitate better research trial recruitment and design.

Do Hearing Aids Prevent Falls? Commentary on Study From the National Health and Nutrition Examination Survey.

PURPOSE: This letter serves to underscore the importance of understanding the relationship between hearing loss treatment and falls and to provide additional clarity and commentary on the interpretation of the results by Riska et al. (2021). With the salience of falls for older adults, clear interpretation of results in context is necessary to understand the evidence available and need for future studies.