The Laryngoscope

© 2020 American Laryngological,

Rhinological and Otological Society Inc,
“The Triological Society” and American
Laryngological Association (ALA)

Long-term Impact of Hearing Aid Provision or Cochlear Implantation

on Hearing Handicap

Alexander S. Kim, MTM ; Joshua F. Betz, MS; Carrie L. Nieman, MD, MPH ; Matthew R. Hoyer, MD;
Jeremy Applebaum, MD; Frank R. Lin, MD, PhD; Adele M. Goman, PhD

Objectives/Hypothesis: Previous research has shown hearing handicap to be reduced following hearing aid use or
cochlear implantation in short-to-medium follow-up periods, yet the impact of interventions for hearing loss on hearing handi-
cap in the long term remains understudied. This article reports hearing handicap at 6 months, 12 months, and 5 years after
either hearing aid provision or cochlear implantation.
Study Design: Observational study.
Methods: A study of 115 participants from the Studying Multiple Outcomes after Aural Rehabilitative Treatment
(SMART) study cohort assessed self-reported hearing handicap using the Hearing Handicap Inventory for the Elderly Screening
version (HHIE-S) at baseline, 6 months, 12 months, and 5 years. Generalized estimating equations (GEE) were used to estimate
the population mean HHIE-S score over time, accounting for the correlated nature of repeated measures data, and multiple
imputation with chained equations was performed to impute missing data.
Results: Compared to baseline, mean HHIE-S scores after hearing aid provision were significantly reduced at 6 months
(mean = −7.96, 95% confidence interval [CI]: −10.40, −5.53), 12 months (mean = −6.58, 95% CI: −9.26, −3.90), and 5 years
(mean = −4.58, 95% CI: −7.87, −1.30). After cochlear implantation, mean hearing handicap scores were also significantly lower
compared to baseline at 6 months (mean = −8.18, 95% CI: −11.07, −5.30), 12 months (mean = −10.04, 95% CI: −12.92,
−7.16), and 5 years (mean = −8.97, 95% CI: −12.92, −7.16).
Conclusions: This study found short-term benefits from hearing aids and cochlear implantation on hearing handicap
were maintained over 5 years.
Key Words: Hearing loss, hearing handicap, hearing aids, cochlear implant, long-term outcomes.
Laryngoscope, 00:1–5, 2020

INTRODUCTION of hearing loss interventions on hearing handicap in the

Hearing loss affects over 38 million Americans,
which includes nearly two-thirds of adults over the age of
70 years.1 Previous research has shown the perceived dif-
ficulty in everyday situations attributable to hearing loss,
termed hearing handicap, to be reduced following hearing
aid use2–7 or cochlear implantation8–10 in short-to-
medium (<1 year) follow-up periods. However, the impact
From the Johns Hopkins University School of Medicine (A.S.K., C.L.N.,
M.R.H., J.A., F.R.L.),
Baltimore, Maryland, U.S.A.; Cochlear Center for Hearing
and Public Health (A.S.K., J.F.B., C.L.N., M.R.H., J.A., F.R.L., A.M.G.), Johns
Hopkins Bloomberg School of Public Health, Baltimore, Maryland, U.S.A.;
and the Department of Biostatistics (J.F.B.), Johns Hopkins Bloomberg
School of Public Health, Baltimore, Marland, U.S.A.
This manuscript was supported in part by grants R01AG055426:
NIH/NIA (PI: Lin), R33DC015062: NIH/NIDCD (PI: Lin), and
K23AG059900: NIH/NIA (PI: Nieman). F.R.L. is a consultant to
Boeringher-Ingelheim and Autifony Inc., and a scientific advisory board
member for Autifony Inc. F.R.L. and C.L.N. are board members of the non-
profit Access HEARS.
Editor’s Note: This Manuscript was accepted for publication on
September 29, 2020.
The authors have no other funding, financial relationships, or con-
flicts of interest to disclose.
Accepted for presentation at the Triological Society 123rd Annual
Meeting at COSM, Atlanta, Georgia, U.S.A., April 24, 2020 (meeting
canceled).
Send correspondence to Adele M. Goman, PhD, 2024 East Monu-
ment Street, Baltimore, MD 21205. E-mail: agoman1@jhmi.edu
DOI: 10.1002/lary.29175
long term remains understudied.
One of the established measures of hearing in every-
day life is the Speech, Spatial, and Qualities of Hearing
Scale, which broadly assesses the range of hearing func-
tions that are deployed in monitoring and attending to the
auditory scene, including components of direction, distance,
movement, sound quality, and sound-source segregation.11
In contrast, the Hearing Handicap Inventory for the
Elderly (HHIE) was developed to address not only the situ-
ational difficulties but also the psychosocial effects of hear-
ing loss.12 The 25-item HHIE scale has a score range of
0 (no handicap) to 100 (worse handicap), whereas a 10-item
version, the HHIE Screening (HHIE-S), has a score range
from 0 (no handicap) to 40 (worse handicap).13 Hearing
handicap scores have been shown to reduce following hear-
ing aid use for those with mild–moderate hearing loss.3–5 A
randomized controlled trial of 104 older adults with moder-
ate high-frequency hearing loss demonstrated that HHIE
scores were significantly reduced from baseline to 4 months
and were maintained over a 12-month period.3 Significant
reductions in hearing handicap have also been shown in
more recent observational studies using newer technol-
ogy.4,5 For instance, Vuorialho et al. administered the
HHIE-S to 98 first-time hearing aid users with moderate
hearing loss, and HHIE scores reduced from 28.7 (out of a
possible 40) at baseline to 12.7 6 months later.5 Benefits
have also been shown with cochlear implantation for

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1
individuals with severe–profound hearing loss in small
observational studies.8,10 Vermeire et al. found hearing
handicap was significantly reduced at 4 months after
cochlear implantation among a group of 29 profoundly
deafened adults.10 Amoodi et al. similarly found reduced
hearing handicap among a group of 27 adults, with the
mean HHIE score reducing from 68 out of 100 before
implantation to 35 out of 100 1 year after implantation.8
Although common clinical interventions, little is
known regarding whether short-to-medium reductions in
hearing handicap from hearing aid use or cochlear
implantation are sustained in the long term. One study
found that reductions in hearing handicap with hearing
aid provision were maintained after 5 years, whereas
non–hearing aid users experienced worsening hearing
handicap after 5 and 11 years, consistent with the pro-
gression of age-related hearing loss.14 Another study
observed reduced hearing handicap at 1 year following
hearing aid provision that was sustained at 2 years, but
substantial attrition occurred, with just 36% of partici-
pants completing the HHIE at the 2-year time point.6
Currently, there are no known long-term studies reported
for hearing handicap after cochlear implantation. The
present study recontacted participants from a prospective
cohort receiving hearing aids or cochlear implants to
assess their respective intervention’s short-to-medium
and long-term impact on hearing handicap. Based on pre-
vious research, we hypothesized that hearing handicap
would be reduced in the short-term and would be
maintained over the medium and long term.
MATERIALS AND METHODS
Participants
One hundred fifty-six patients from the Johns Hopkins
Department of Otolaryngology were consented to the Studying
Multiple Outcomes after Aural Rehabilitation Treatment
(SMART) study.15 The focus of the study was to evaluate the
impact of hearing treatment on a broad range of functional
domains in older adults. All participants were oral–aural com-
municators, English speaking, ≥50 years old, and were receiving
a cochlear implant or hearing aid for the first time (or had less
than 1 hour a day prior hearing aid use). Full details of study
recruitment and design of the SMART study is described else-
where.15 A follow-up study initiated in 2017 gathered long-term
outcomes at approximately 5 years after baseline. The analytic
sample (N = 115) consisted of individuals who had completed a
baseline session, received treatment, and completed at least one
follow-up session either at 6 months, 12 months, or 5 years.
Hearing Handicap Inventory for the Elderly
Screening Version
The HHIE-S is a validated 10-item questionnaire assessing
the perceived emotional and situational impact of hearing loss
among older adults.13,16,17 For each question, participants
respond “yes” (four points), “no” (zero points), or “sometimes”
(two points). Scores range from zero to 40, and higher scores indi-
cate greater handicap. A referral to an audiologist or hearing
specialist is recommended for scores greater than nine9, as
scores from 10 to 24 reflect a mild-to-moderate handicap, and
26 to 40 represent severe handicap.13 Participants were
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2
instructed not to skip a question if they avoid a situation because
of a hearing problem. In addition, participants were instructed
to respond with the way they hear when using the hearing aid
or cochlear implant.
Other Variables
Self-reported demographic (age, sex, race/ethnicity, educa-
tion) and health history data (hypertension, diabetes, and
smoking), and pure-tone audiometric hearing thresholds were
gathered during the baseline session.
Procedure
Baseline evaluations of hearing handicap took place either
before or within 1 to 2 weeks of receiving a hearing aid or under-
going cochlear implantation, and in-person follow-up evaluations
took place at 6 and 12 months following intervention.15 For the
5-year assessment of hearing handicap, participants completed
the HHIE-S either on paper or electronically. From the 156 partici-
pants consented to the SMART study, one did not receive treat-
ment, 22 had not consented to be contacted about future follow-up
studies, and Johns Hopkins medical records indicated that four
participants were known to be deceased. As such, 129 participants
who had received either cochlear implantation or hearing aids
were contacted for the 5-year follow-up via email or mail according
to preferred contact methods indicated during the baseline assess-
ment; contact details were updated using Johns Hopkins records
as needed. At 1-week, participants who had provided an email
address and who had not yet responded were sent an email
reminder. Mailed reminders were sent at 2 weeks to all partici-
pants who had not yet responded. Telephone reminders were
made at 4 weeks to all participants who had not responded. Mean
duration since baseline for the 5-year follow-up was 4.8 years
(standard deviation = 0.7). The Johns Hopkins Medicine Institu-
tional Review Board reviewed and approved the study.
Analyses
Generalized estimating equations (GEEs) were used to esti-
mate the population mean HHIE-S score over time, accounting for
the correlated nature of repeated measures data. Responses were
assumed to be approximately normally distributed after factoring
in demographic (age, sex, race/ethnicity, education) and health fac-
tors (hypertension, diabetes, smoking), with an independence work-
ing correlation structure. GEEs provide consistent estimates of the
population average even when the working correlation structure is
misspecified. GEE estimates are only valid under the assumption
that data are missing completely at random. Therefore, multiple
imputation with chained equations was performed to impute miss-
ing data. A total of 50 imputed datasets were created, each having
20 iterations of the imputation process to achieve convergence. No
adjustment was made to confidence intervals (CIs) to account for
multiple comparisons. All analyses were performed in R version
3.4.1 (R Foundation for Statistical Computing, Vienna, Austria).
RESULTS
Demographic Data
Table I shows baseline summary demographic and
health data for the two groups of participants. The two
groups were similar in age, race/ethnicity, and health his-
tory, though baseline HHIE scores were significantly lower
in the hearing aid group. The hearing aid group reported
Kim et al.: Five-Year Aural Rehab for Hearing Handicap
 TABLE I.
Summary Self-Reported Baseline Demographic and Health Information, and Objective Hearing Thresholds for the Cochlear Implant and
Hearing Aid Groups.
Cochlear Implant, N = 51 Hearing Aid, N = 64 Total, N = 115 P Value

Age, yr [IQR] 69 [64.2–78.5] 71 [63.5–75.8] 69.6 [63.6–77.2] .931

Female 21 (41.2%) 26 (40.6%) 47 (40.9%) 1.000
Race: White 46 (90.2%) 58 (90.6%) 104 (90.4%) 1.000
Education
High school or less 12 (23.5%) 4 (6.2%) 16 (13.9%) .012
College/associates 22 (43.1%) 26 (40.6%) 48 (41.7%)
Postgraduate 16 (31.4%) 33 (51.6%) 49 (42.6%)
Missing data 1 (2%) 1 (1.6%) 2 (1.7%)
Smoking status
Current/former smoker 30 (58.8%) 26 (40.6%) 56 (48.7%) .087
Nonsmoker 20 (39.2%) 36 (56.2%) 56 (48.7%)
Missing data 1 (2%) 2 (3.1%) 3 (2.6%)
History of hypertension
Hypertension 27 (52.9%) 35 (54.7%) 62 (53.9%) 1.000
Missing data 2 (3.9%) 1 (1.6%) 3 (2.6%)
History of diabetes
Diabetes 7 (13.7%) 17 (26.6%) 24 (20.9%) .163
Missing data 2 (3.9%) 1 (1.6%) 3 (2.6%)
Baseline HHIE scores (SD) 27.7 (8.9) 18.7 (9.8) 22.9 (10.4) <.001
PTA [IQR]* 69.4 [64.4–81.6] 36.2 [27.5–42.8] 46.9 [35.0–65.3] <.001

Parentheses indicate percent unless otherwise stated.

*
PTA indicates the better-ear four-frequency (0.5, 1, 2, 4 kHz) PTA threshold (decibels hearing level).
HHIE = Hearing Handicap Inventory for the Elderly, IQR = interquartile range; PTA = pure-tone average; SD = standard deviation.

higher levels of education than the cochlear implant group.
An analysis of associations between baseline HHIE scores
and demographic factors was performed for potential
covariates but was not significant for any variable.
Missing Data
Among the 115 participants, 83.5% of participants
(n = 96) completed the baseline session and at least two
follow-up assessments. Of the participants, 40.9% (56.9% of
the cochlear implant group and 28.1% of the hearing aid
group) completed all study assessments (baseline, 6 months,
12 months, and 5 years). At 6 months, 12 months, and
5 years, hearing aid group response rates were 94%, 58%,
and 42%, respectively, whereas the cochlear implant group
response rates were 94%, 80%, and 61%.
Hearing Aid Usage
Table II displays the hearing aid usage patterns as
reported at 6 months, 12 months, and 5 years. Though
usage >10 hours increased from 40.6% at 6 months to
62.7% at 5 years, there was a high degree of missingness
at 12 months (42.2%) and 5 years (27.5%).
Hearing Handicap
Figure 1 plots the mean HHIE-S score differences
from baseline at 6 months, 12 months, and 5 years by
group as calculated from multiple imputation. Partici-
pants with missing data were compared against those
with data from all four study assessments, and no signifi-
cant differences were found except when comparing
cochlear implants and hearing aids, as a higher percent-
age of participants in the cochlear implant group com-
pleted all three follow-ups compared to the hearing aid
group. For the cochlear implant group, participants were
measured on average to have a severe handicap that
reduced to a mild to moderate handicap at all follow-up
periods. The mean HHIE-S score decreased from a base-
line of 28.30 (95% CI: 22.84, 33.76) to 20.11 (95% CI:
14.62, 25.60) at 6 months (mean difference = −8.18, 95%
CI: −11.07, −5.30) and to 18.26 (95% CI: 12.73, 23.78) at
12 months (mean difference = −10.04, 95% CI: −12.92,
−7.16), and to 19.33 (95% CI: 13.56, 25.11) at 5 years
(mean difference = −8.97, 95% CI: −12.92, −7.16). For
the hearing aid group, participants were measured on
average to have a mild-to-moderate handicap, which was
maintained at all follow-up periods. HHIE-S scores
decreased from a baseline of 19.24 (95% CI: 12.85, 25.64)
to 11.28 (95% CI: 4.83, 17.73) at 6 months (mean difference
= −7.96, 95% CI: −10.40, −5.53), and to 12.66 (95% CI:
6.00, 19.33) at 12 months (mean difference = −6.58, 95%
CI: −9.26, −3.90), and to 14.66 (95% CI: 7.99, 21.32) at
5 years (mean difference = −4.58, 95% CI: −7.87, −1.30).
Though wider CIs were observed at 5 years, differences in
HHIE scores were significant and negative at all time
points in both groups.

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 TABLE II.
Hearing Aid Usage Patterns.
Hearing Aid Usage Per Day
Follow-up <1 Hour 1–5 Hours
6 months 5 (7.8%) 13 (20.3%)
12 months 1 (1.6%) 9 (14.1%)
5 years 1 (2%) 1 (2%)
Fig. 1. Mean Hearing Handicap Inventory for the Elderly (HHIE)-
Screening score differences from baseline for hearing aid (white)
and cochlear implant (gray) groups at 6 months, 12 months and
5 years. Error bars show 95% confidence intervals.
DISCUSSION
Hearing aids and cochlear implants are mainstays in
the clinical management of hearing loss, though rela-
tively little is known regarding the long-term impact of
these interventions on hearing handicap. We found that
hearing aids and cochlear implants were associated with
sustained improvements in hearing handicap up to
5 years postintervention. Among participants undergoing
cochlear implantation, perceived hearing handicap was
significantly reduced at 6 months and 12 months. This
observation is consistent with previous smaller-sampled
observational studies looking at short-term outcomes.8,10
The present study additionally observed that the benefit
following cochlear implantation was maintained after
5 years. For hearing aid users, reductions in HHIE-S
scores were also maintained at 5-year follow-up compared
to baseline, though their reductions were less pronounced
compared to those receiving cochlear implantation. How-
ever, we do not know whether these reductions are clini-
cally meaningful from the perspective of the participants.
Previous research has found significant benefits in hear-
ing handicap following hearing aid use in the short
term.2–7 Potential reasons for differences in the strength
of findings between studies include differences in analytic
approach and sample characteristics. Both Chang et al.
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6–10 Hours >10 Hours Missing
17 (26.6%) 26 (40.6%) 3 (4.7%)
12 (18.8%) 15 (23.4%) 27 (42.2%)
3 (5.9%) 32 (62.7%) 14 (27.5%)
and Vuorialho et al. observed significant reductions in
hearing handicap among samples with greater degrees of
hearing loss (mean four-frequency pure tone aver-
age = 70.7 dB and 48 dB HL, respectively, versus 36.2 dB
HL in the present study) and poorer hearing handicap
scores at baseline.4,5 For instance, whereas 6-month
scores observed in the current study were similar to those
observed by a similarly aged cohort at 4 months after
hearing aid provision, the participants in the current
study reported substantially less handicap at baseline
(18.99 compared to 31.1 reported by Chang et al. and
28.7 reported by Vuorialho et al.).4,5 Therefore, as the
participants in the current study were experiencing less
handicap at baseline, they had less room for reduction
following hearing aid use compared to other studies.
Though the data in this article present novel find-
ings in the long-term follow-up for hearing handicap
research, notable limitations of this study include the
lack of an untreated cohort, qualitative satisfaction data,
and complete hearing aid usage patterns over time. Thus,
this observational study cannot comment on the contribu-
tion of normal aging on the trends observed, including
benefit from hearing aids and cochlear implantation rela-
tive to a population without these interventions. Addi-
tional data regarding hearing aid usage patterns may
elucidate whether compliance was a factor in the possible
attenuation of the benefits seen by the 5th year of these
respective participants. A more robust cohort with more
frequent measurements between the 1st and 5th year
since intervention may further strengthen the trend
seen in this article, though our group was limited by the
feasibility of conducting such a trial.
This study also experienced a high degree of missing
data, with 59% of participants having missing data for at
least one follow-up visit, though this is consistent with pre-
vious longitudinal research with clinical populations.6 Com-
pared to participants who received hearing aids, a higher
percentage of participants in the cochlear implant group
completed all three follow-ups. This may be due to partici-
pants in the cochlear implant group having more routine
clinical appointments separate from our study in the first
year following cochlear implantation. To account for the
high degree of missingness, we utilized multiple imputa-
tion to reduce potential bias in the study. This study bal-
anced the demands of a more resource-intensive study
design to address the long-term impact of hearing loss on
hearing handicap, and future studies will require rigorous
study designs to further strengthen the present findings.
Kim et al.: Five-Year Aural Rehab for Hearing Handicap
CONCLUSION
This study presents short-term benefits of cochlear
implantation and hearing aid provision on hearing handi-
cap that were maintained over 5 years. Though random-
ized control trial designs are ideal to establish the impact
of interventions, this study is one of the first to explore
the long-term association of interventions for hearing loss
with hearing handicap.
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