Documentation of hearing difficulty by providers amidst cognitive concerns: A study of the Medicare Annual Wellness Visit

Abstract

The ability to adequately hear is instrumental to effective care.¹ For those with dementia, unidentified or unmanaged hearing loss may exacerbate neuropsychiatric symptoms, social isolation, cognitive decline, and dementia care challenges.²

The electronic medical record (EMR) presents an opportunity to evaluate how clinicians' approach, discuss, or record health conditions or concerns within the context of a medical visit.³ Few studies have characterized clinical documentation following expressed hearing concerns.⁴ The Medicare Annual Wellness Visit (AWV), which includes collection of both hearing and cognition concerns through a required health risk assessment, may facilitate detection and management of new concerns.⁵

We sought to characterize how clinicians approach and document hearing concerns identified at an AWV for patients with and without dementia or cognitive concerns.

This study uses EMR data for Medicare beneficiaries with an AWV at a large academic health system (2017–2022) as previously published.⁶ Patients were included if they indicated hearing concerns for the first time at the AWV (n = 2596 patients). A 20% random sample of AWV encounters and associated clinical notes (n = 474 clinical notes) were coded for documentation of (1) elaboration on hearing concerns, (2) acknowledging a known hearing loss or hearing aid use, and (3) referral for hearing health care. Patient demographic characteristics, portal use, and chronic conditions were captured for the corresponding AWV.⁷ We recorded presence of a concurrent dementia diagnosis via an algorithm incorporating EMR problem list or diagnosis code.⁷ Indications of cognitive (memory or decision-making) concerns were captured from health risk assessment responses.

We included 2596 older adults with a Medicare AWV and reported hearing concerns (Table 1), 169 (6.5%) of whom had existing dementia diagnosis. The mean age was 78.8 years (SD 7.7), most were female (56.5%), White (74.5%), and active portal users (79.1%). Only 20% had a prior diagnosis of hearing loss in the EMR. Those with diagnosed dementia were older (mean 83.4 years vs 78.5 years, p < 0.001) and more likely to have concurrent cognitive concerns (92.3% vs 36.0%; p < 0.001). No differences by sex, race, marital status, prior hearing diagnosis or patient portal use were observed by dementia status.

Among the 474 patients randomly sampled for AWV clinical note review, 189 (39.8%) had a dementia diagnosis or cognitive concerns concurrent with hearing concerns (Table S1). Clinicians were less likely to elaborate on hearing concerns in the clinical note among those with diagnosed dementia or cognitive concerns compared to those without (30.2% vs 44.4%), especially when no hearing loss diagnosis was present (41.5% no dementia vs 28.0% dementia). Among those without EMR hearing loss diagnosis, documented acknowledgement of hearing loss were more common for those without than with diagnosed dementia (46.2% vs 26.0%, respectively).

In adjusted logistic regression models (Table S2), clinicians were half as likely (OR: 0.50; 95% CI: 0.34, 0.77) to elaborate on hearing concerns in note documentation for older adults with a dementia diagnosis or cognitive concerns compared to those without. Additionally, older adults with a dementia diagnosis or cognitive concerns (vs without) were 45% less likely (OR: 0.55; 95% CI: 0.37, 0.83) to have clinicians acknowledge a known hearing loss or hearing aid use.

We found that clinicians were 50% less likely to elaborate on or acknowledge hearing difficulty in their AWV clinical note for patients with diagnosed dementia or cognitive concerns, even for those with diagnosed hearing loss. Overall, we observed missed opportunities to attend to hearing and few referrals to audiology. Limited attention to hearing concerns may impede hearing loss awareness and management, patient communication, or lead to missed opportunities to address a contributor to dementia-related neuropsychiatric symptoms.^{8, 9} Gaps in patient understanding during visits may be misidentified as cognitive impairment without consideration of hearing loss, while the complex care needs of dementia may limit clinician ability to attend to hearing loss.² Building innovations to improve workflows within existing systems, like the patient portal, may assist providers to promote higher quality care and deliver provider hearing education without imposing additional burdens (Figure 1).^{2, 3, 10}

While this study represents findings from a single health system and may not represent processes and care patterns of other centers, our study identifies potential missed opportunities to address patient-identified health concerns. Findings present potential areas of investigation for quality improvement projects to support those with dementia and hearing loss and additional educational opportunities for effective communication and hearing care navigation.

Study concept and design: Danielle S. Powell, Jennifer L. Wolff, M. J. Wu, Nicholas S. Reed, Stephanie Nothelle, and Esther S. Oh. Acquisition of data: Kelly Gleason, M. J. Wu, Jennifer L. Wolff, and Danielle S. Powell. Analysis and interpretation: Danielle S. Powell, M. J. Wu, and Jamie M. Smith. Manuscript preparation: Danielle S. Powell and Jennifer L. Wolff. Manuscript review: Jamie M. Smith, M. J. Wu, Kelly Gleason, Stephanie Nothelle, Nicholas S. Reed, Danielle Peereboom, Esther S. Oh, and Danielle Peereboom.

The authors declare no conflicts of interest.

The sponsor had no role in data collection, analysis, or manuscript preparation.

This work was supported by the National Institute on Aging grant R35AG072310 supports the data used and many authors. Additional Grant/Award Numbers: K01AG054693, K23AG065443 to S.N., R01AG076525, R01AG057667, R01AG057725, P30AG021334, P30AG073104 to E.S.O., T32AG066576 to J.M.S., and Alzheimer's Association 23AARF-1030303 to D.S.P.