Barker Fiona, Mackenzie Emma, Elliott Lynette, Jones Simon, de Lusignan Simon
Department of Healthcare Management and Policy, University of Surrey, Guildford, UK.
Cochrane Database Syst Rev. 2014 Jul 12(7):CD010342. doi: 10.1002/14651858.CD010342.pub2.
Acquired adult-onset hearing loss is a common long-term condition for which the most common intervention is hearing aid fitting. However, up to 40% of people fitted with a hearing aid either fail to use it or may not gain optimal benefit from it.
To assess the long-term effectiveness of interventions to promote the use of hearing aids in adults with acquired hearing loss fitted with at least one hearing aid.
We searched the Cochrane ENT Disorders Group Trials Register; CENTRAL; PubMed; EMBASE; CINAHL; Web of Science; Cambridge Scientific Abstracts; ICTRP and additional sources for published and unpublished trials. The date of the search was 6 November 2013.
We included randomised controlled trials (RCTs) of interventions designed to improve or promote hearing aid use in adults with acquired hearing loss compared with usual care or another intervention. We excluded interventions that compared hearing aid technology. We classified interventions according to the 'chronic care model' (CCM). The primary outcomes were hearing aid use (measured as adherence or daily hours of use) and adverse effects (inappropriate advice or clinical practice, or patient complaints). Secondary patient-reported outcomes included quality of life, hearing handicap, hearing aid benefit and communication. Outcomes were measured over the short (</= 12 weeks), medium (> 12 to < 52 weeks) and long term (one year plus).
We used the standard methodological procedures expected by The Cochrane Collaboration.
We included 32 studies involving a total of 2072 participants. The risk of bias across the included studies was variable. We judged the GRADE quality of evidence to be very low or low for the primary outcomes where data were available.The majority of participants were over 65 years of age with mild to moderate adult-onset hearing loss. There was a mix of new and experienced hearing aid users. Six of the studies (1018 participants) were conducted in a military veteran population. Six of the studies (287 participants) assessed long-term outcomes.All 32 studies tested interventions that could be classified as self management support (ways to help someone to manage their hearing loss and hearing aid(s) better by giving information, practice and experience at listening/communicating or by asking people to practise tasks at home) and/or delivery system design interventions (just changing how the service was delivered) according to the CCM. Self management support interventions We found no studies that investigated the effect of these interventions on adherence, adverse effects or hearing aid benefit. Two studies reported daily hours of hearing aid use but we were unable to combine these in a meta-analysis. There was no evidence of a statistically significant effect on quality of life over the medium term. Self management support reduced short- to medium-term hearing handicap (two studies, 87 participants; mean difference (MD) -12.80, 95% confidence interval (CI) -23.11 to -2.48 (0 to 100 scale)) and increased the use of verbal communication strategies in the short to medium term (one study, 52 participants; MD 0.72, 95% CI 0.21 to 1.23 (0 to 5 scale)). The clinical significance of these statistical findings is uncertain but it is likely that the outcomes were clinically significant for some, but not all, participants. Our confidence in the quality of this evidence was very low. No self management support studies reported long-term outcomes. Delivery system design interventions These interventions did not significantly affect adherence or daily hours of hearing aid use in the short to medium term, or adverse effects in the long term. We found no studies that investigated the effect of these interventions on quality of life. There was no evidence of a statistically or clinically significant effect on hearing handicap, hearing aid benefit or the use of verbal communication strategies in the short to medium term. Our confidence in the quality of this evidence was low or very low. Long-term outcome measurement was rare. Combined self management support/delivery system design interventions We found no studies that investigated the effect of complex interventions combining components of self management support and delivery system design on adherence or adverse effects. There was no evidence of a statistically or clinically significant effect on daily hours of hearing aid use over the long term, or the short to medium term. Similarly, there was no evidence of an effect on quality of life over the long term, or short to medium term. These combined interventions reduced hearing handicap in the short to medium term (13 studies, 485 participants, standardised mean difference (SMD) -0.27, 95% CI -0.49 to -0.06). This represents a small-moderate effect size but there is no evidence of a statistically significant effect over the long term. There was evidence of a statistically, but not clinically, significant effect on long-term hearing aid benefit (two studies, 69 participants, MD 0.30, 95% CI 0.02 to 0.58 (1 to 5 scale)), but no evidence of effect over the short to medium term. There was evidence of a statistically, but not clinically, significant effect on the use of verbal communication strategies in the short term (four studies, 223 participants, MD 0.45, 95% CI 0.15 to 0.74 (0 to 5 scale)), but not the long term. Our confidence in the quality of this evidence was low or very low.We found no studies that assessed the effect of other CCM interventions (decision support, the clinical information system, community resources or health system changes).
AUTHORS' CONCLUSIONS: There is some low to very low quality evidence to support the use of self management support and complex interventions combining self management support and delivery system design in adult auditory rehabilitation. However, effect sizes are small and the range of interventions that have been tested is relatively limited. Priorities for future research should be assessment of long-term outcome a year or more after the intervention, development of a core outcome set for adult auditory rehabilitation and development of study designs and outcome measures that are powered to detect incremental effects of rehabilitative healthcare system changes over and above the provision of a hearing aid.
获得性成人听力损失是一种常见的长期病症，最常见的干预措施是佩戴助听器。然而，高达40%佩戴助听器的人要么不使用，要么无法从中获得最佳益处。
评估干预措施对促进佩戴至少一只助听器的获得性听力损失成人使用助听器的长期效果。
我们检索了Cochrane耳鼻喉疾病组试验注册库、CENTRAL、PubMed、EMBASE、CINAHL、Web of Science、剑桥科学文摘数据库、ICTRP以及其他已发表和未发表试验的来源。检索日期为2013年11月6日。
我们纳入了旨在改善或促进获得性听力损失成人使用助听器的干预措施的随机对照试验（RCT），并与常规护理或其他干预措施进行比较。我们排除了比较助听器技术的干预措施。我们根据“慢性病护理模式”（CCM）对干预措施进行分类。主要结局是助听器使用情况（以依从性或每日使用时长衡量）和不良反应（不适当的建议或临床实践，或患者投诉）。次要的患者报告结局包括生活质量、听力障碍、助听器益处和沟通情况。结局在短期（≤12周）、中期（>12周至<52周）和长期（一年及以上）进行测量。
我们采用了Cochrane协作网期望的标准方法程序。
我们纳入了32项研究，共涉及2072名参与者。纳入研究的偏倚风险各不相同。对于有数据的主要结局，我们判断GRADE证据质量为极低或低。大多数参与者年龄超过65岁，患有轻度至中度成人获得性听力损失。有新用户和有经验的助听器用户。其中6项研究（1018名参与者）在退伍军人人群中进行。6项研究（287名参与者）评估了长期结局。所有32项研究均测试了根据CCM可归类为自我管理支持（通过提供信息、练习和倾听/沟通经验或要求人们在家中练习任务来帮助某人更好地管理其听力损失和助听器的方法）和/或服务提供系统设计干预（只是改变服务的提供方式）的干预措施。自我管理支持干预措施我们未发现研究这些干预措施对依从性、不良反应或助听器益处影响的研究。两项研究报告了助听器的每日使用时长，但我们无法将其合并进行荟萃分析。没有证据表明在中期对生活质量有统计学显著影响。自我管理支持在短期至中期降低了听力障碍（两项研究，87名参与者；平均差值（MD）-12.80，95%置信区间（CI）-23.11至-2.48（0至100量表）），并在短期至中期增加了言语沟通策略的使用（一项研究，52名参与者；MD 0.72，95%CI 0.21至1.23（0至5量表））。这些统计结果的临床意义尚不确定，但可能对部分而非全部参与者具有临床意义。我们对该证据质量的信心非常低。没有自我管理支持研究报告长期结局。服务提供系统设计干预措施这些干预措施在短期至中期对依从性或助听器每日使用时长没有显著影响，在长期对不良反应也没有显著影响。我们未发现研究这些干预措施对生活质量影响的研究。没有证据表明在短期至中期对听力障碍、助听器益处或言语沟通策略的使用有统计学或临床显著影响。我们对该证据质量的信心低或非常低。长期结局测量很少见。自我管理支持/服务提供系统设计联合干预措施我们未发现研究将自我管理支持和服务提供系统设计的组成部分相结合的复杂干预措施对依从性或不良反应影响的研究。没有证据表明在长期或短期至中期对助听器每日使用时长有统计学或临床显著影响。同样，没有证据表明在长期或短期至中期对生活质量有影响。这些联合干预措施在短期至中期降低了听力障碍（13项研究，485名参与者，标准化平均差值（SMD）-0.27, 95%CI -0.49至-0.06）。这代表了小到中等的效应量，但没有证据表明在长期有统计学显著影响。有证据表明对长期助听器益处有统计学但非临床显著影响（两项研究，69名参与者，MD 0.30，95%CI 0.02至0.58（1至5量表）），但在短期至中期没有影响证据。有证据表明在短期对言语沟通策略的使用有统计学但非临床显著影响（四项研究，223名参与者，MD 0.45，95%CI 0.15至0.74（0至5量表）），但在长期没有影响证据。我们对该证据质量的信心低或非常低。我们未发现评估其他CCM干预措施（决策支持、临床信息系统、社区资源或卫生系统变革）效果的研究。
有一些低到极低质量的证据支持在成人听觉康复中使用自我管理支持以及将自我管理支持和服务提供系统设计相结合的复杂干预措施。然而，效应量较小，且已测试的干预措施范围相对有限。未来研究的重点应是评估干预后一年或更长时间的长期结局，制定成人听觉康复的核心结局集，以及开发有足够效力检测康复医疗系统变革相较于单纯提供助听器所产生的增量效应的研究设计和结局测量方法。
