MIDDLES BMJ: first published as 10.1136/bmj.299.6696.437 on 12 August 1989. Downloaded from

Provision of hearing aids: Does specialist assessment cause delay?

Carl Watson, John A Crowther

Abstract changes were implemented inevitably general practi- Objective-To identify the main delay in the tioners would have to take on greater responsibility for provision of hearing aids for people with impaired screening with hearing impairment. Before hearing and identify possible problems and short- making any radical changes to the present system the comings caused by a community based hearing aid potential problems created by these changes should dispensing service. carefully be considered. Design-Prospective cohort analysis based on This study aimed at identifying the main source of data collected from patients on the duration of delay in providing hearing aids, assessing the accuracy hearing impairment, from the referral letters in of otoscopy performed by general practitioners, and respect of the general practitioners' findings on identifying the proportion of patients with impaired otoscopy, and from the ear, nose, and throat assess- hearing who require more than simple screening and ment in the clinic with respect to the outcome of provision of hearing aids. specialist otoscopy and management of the hearing impairment. Setting-General ear, nose, and throat outpatient Subjects and methods clinic. Information was collected prospectively from 100 Patients-100 Consecutive patients aged 19-94 consecutive new patients with impaired hearing re- referred by general practitioners for the provision of ferred to the ear, nose, and throat outpatient clinic at hearing aids or for assessment and treatment of this . The patients were aged 18 or over and impaired hearing. were referred by their general practitioner either Results-Most patients with impaired hearing did specifically for the provision of a hearing aid or for not seek medical advice for at least a year. The time assessment and treatment of their condition. For the from referral by the general practitioner to the purposes ofanalysis the two groups were kept separate. provision of a hearing aid was under two months. The Royal National Institute for the Deaf has recom- General practitioners consistently recognised mended that under the new proposals patients with normality on otoscopy but failed to recognise abnor- additional symptoms-for example, otorrhoea-

mality in eight of 45 cases. Seven patients required would still warrant specialist referral; these referrals http://www.bmj.com/ further investigation to exclude serious disease and were excluded from the study. nine had conditions amenable to surgery. All patients were seen in the clinic by consultants, Conclusions-The main cause of delay in treating senior registrars, or registrars. A questionnaire was impaired hearing is failure by patients to seek help used to record the following information: (a) (from the promptly. Specialist assessment of patients with referral letter) the reason for and date of referral and impaired hearing is preferable and does not neces- the general practitioner's findings on otoscopy; (b) sarily cause delay in providing hearing aids. The (from the ) the duration of hearing impairment; (c) the specialist's findings on otoscopy; (d) the subse- provision of hearing aids should remain a hospital on 26 September 2021 by guest. Protected copyright. based service. quent management, including need for wax removal, treatment of inflammatory ear disease, further investi- gations to exlude serious underlying disease, identifica- Introduction tion ofsurgically correctable impairment, and whether There are estimated to be 3-9 million adults in the providing a hearing aid was appropriate. United Kingdom with impaired hearing which might Otoscopic findings in the clinic were compared with be helped by a hearing aid,' and with an aging those recorded in the general practitioner's referral population the potential demand will inevitably in- letter. It may be difficult to describe otoscopic findings crease. The arrangement for the provision of hearing precisely and we therefore graded these simply as aids within the NHS is almost exclusively by referral to normal or abnormal. Thus though a general practi- an ear, nose, and throat outpatient clinic. As with tioner's findings of abnormality may not have been in many hospital based services at present lengthy delays complete accordance with those made in the specialist may be encountered in certain areas. The Royal clinic, they were considered to be correct or in agree- National Institute for the Deaf has recently challenged ment provided that some abnormality was described. the need for hospital referral of all adults with hearing Simple comparisons of interobserver agreement are Hospital, impairment, and in a recent publication, Hearing misleading, as a proportion may be due to chance. G213UW Aids- The Casefor Change, it makes various proposals Hence the kappa (x) statistic was used. The details of x Carl Watson, FRCS, ENT for a complete change in the provision of hearing aids have been described in similar studies2I; in brief, registrar in both the public and private sectors. x ranges from -1 (complete disagreement), through 0 John A Crowther, FRCS, At the heart of the proposals is the creation of a new (no agreement), to 1 (complete agreement). ENT senior registrar grade oftechnician, designated a hearing aid dispenser. The dispenser would be based in health centres and Correspondence to: Mr Results Watson. larger general practices accepting referrals directly from the general practitioner and undertaking audio- The 100 consecutive new patients referred for Br MedJ7 1989;299:437-9 metry, provision ofhearing aids, and aftercare. Ifthese impaired hearing accounted for roughly one in five of

BMJ VOLUME 299 12 AUGUST 1989 437 all new patients seen during the study period. Fifty impaired hearing. According to the Office of Popula- four of the patients (mean age 71 (SD 13) years) were tion Censuses and Surveys it is the second most referred specifically for the provision of a hearing aid common disability.' Hearing impairment leads to and 46 (mean age 55 (16)) for general assessment and communication difficulties and social isolation and treatment. may eventually cause depression. These effects may be Delay in provision of hearing aid-The duration of avoided by early identification and treatment of the impaired hearing before patients sought advice varied hearing loss. We broadly agree with the aims of the BMJ: first published as 10.1136/bmj.299.6696.437 on 12 August 1989. Downloaded from from less than six months to over 10 years (table I). In Royal National Institute's proposals-that is, the early most cases the general practitioner made an immediate diagnosis and treatment of hearing impairment-but referral to the specialist clinic; in eight cases (four disagree on how this would best be achieved. patients in each group), however, there was a delay of In order to have the greatest impact on reducing over six months before referral. The mean waiting time delay in the provision of hearing aids it is essential to for patients to be seen in the ear, nose, and throat clinic identify the factor causing most delay. In this study of was three weeks for both groups. For those needing a 100 patients 79 had been aware of hearing impairment hearing aid an ear mould impression was taken during for over a year and 24 for over five years before seeking the initial visit. The delay thereafter -that is, until the treatment. The waiting time for outpatient appoint- completed mould was ready and the patient seen for ments is fortunately short in this department, and the fitting and instruction in the use of the aid-was about average time between referral by the general practi- four weeks. tioner and fitting a hearing aid is less than two months. Otoscopy-In 55 cases the referral letter made no The main delay in providing treatment therefore rested mention of the general practitioner's otoscopic with the patients themselves, and only greater public findings. Among patients referred specifically for the awareness will encourage patients to present earlier. provision of a hearing aid otoscopic findings were Undoubtedly outpatient waiting times are consider- noted in 21 letters (39%), and among patients referred ably longer in certain areas. for assessment these were noted in 24 letters (52%). A survey by the Royal National Institute for the Table II shows the agreement between the general Deaf in 1984 suggested that the average waiting time practitioners' and specialists' findings on otoscopy. for an ear, nose, and throat outpatient appointment was 16 weeks in the United Kingdom overall and 9 5 TABLE i-Duration ofhearing impairment before referral. Figures are weeks in .4 There was considerable variation numbers ofpatients in waiting times, ranging from one to 132 weeks. The Scottish Home and Health Department (Edinburgh) Duration (years) and the Department of Health (London) were con- <0 5 0-5-1 -5 -10 >10 Total tacted to obtain more recent figures. The current waiting time for an ear, nose, and throat outpatient Referral for hearing aid 3 5 31 5 10 54 appointment in Scotland varies from two to 46 weeks. Referral for assessment 6 7 24 3 6 46 It is not possible to give a median waiting time from the rotal 9 12 55 8 16 100 figures available. The Department of Health denied keeping any information on outpatient waiting times, not to obtain TABLE II-Otoscopic findings in groups referred for provision of so that it is possible similar information hearing aid andfor assessment. Figures are numbers ofpatients for England. The reasons for the considerable variation in outpatient waiting times for new referrals are Specialists' General practitioners' findings on otoscopy

complex, but include funding, staffing, facilities, http://www.bmj.com/ findings on otoscopy Normal Abnormal Total referral patterns, and fluctuations in the local catch- ment population. Group referredfor hearing aid* Normal 13 0 13 It is not clear whether delays in the provision of Abnormal 5 3 8 hearing aids are due solely to the size of outpatient waiting lists or to the shortage of audiological tech- Total 18 3 21 nicians. Central Nottinghamshire Health Authority Group referredfor assessmentt has recently reduced the delay in obtaining an aid by Normal 13 0 13 13 months by appointing an additional technician Abnormal 3 8 11 on 26 September 2021 by guest. Protected copyright. and providing funding for overtime working.5 The Total 16 8 24 shortage of technicians may limit the number of *x=0.42. tx=0 74. patients with impaired hearing who may be seen in a clinic and leads in some areas to the policy ofproducing General practitioners consistently recognised nor- a secondary waiting list for a subsequent visit during mality but failed to recognise abnormality in eight which an ear mould impression is taken by a techni- cases (17 8%). The most common abnormalities cian. This is unsatisfactory both for the patient and for missed were perforation of the tympanic membrane, the department because technicians' time is wasted in retraction of the tympanic membrane, tympano- arranging further appointments, and if the delay in sclerosis, and impacted wax. reattendance is lengthy the patient may require further Management-Thirty patients needed removal of ear removal ofwax and yet another visit. Taking ear mould wax. Of the 54 patients referred specifically for a impressions on the first visit helps to minimise delay in hearing aid and the 46 referred for general assessment, this department, and the adoption of this policy is a 46 (85%) and 23 (50%) respectively were fitted with an factor claimed for the improved service in central aid. Hearing impairment amenable to surgery was Nottinghamshire. identified in three patients referred for a hearing There are estimated to be 150 unfilled vacancies for aid and six patients referred for assessment. The audiological technicians in the NHS. The current surgically treatable causes of hearing impairment in problems of recruiting hospital technicians suggest these patients included otosclerosis, glue ear, and that difficulties would also be encountered in filling tympanic membrane perforation. vacancies for hearing aid dispensers, and any attempt to make these posts more attractive to applicants could lead to further attrition of the hospital service. This Discussion being the case, funding should be utilised to increase The Royal National Institute for the Deaf has the number of audiological technicians rather than to drawn attention to the magnitude of the problem of introduce the new grade of hearing aid dispenser.

438 BMJ VOLUME 299 12 AUGUST 1989 Hearing loss is not a diagnosis; rather it is a patients in each group the findings suggest that any symptom, and patients require careful assessment. screening which is presently being done is based The Royal National Institute for the Deaf proposes predominantly on the patient's age rather than clinical that hearing aid dispensers should perform this assessment. function. Failure to recognise and further investigate We do not seek to criticise general practitioners in asymmetric sensorineural hearing loss or unilateral this regard; many will have had little or no formal glue ear may lead to neglect of serious disease such as training in otoscopy since undergraduate days. A BMJ: first published as 10.1136/bmj.299.6696.437 on 12 August 1989. Downloaded from acoustic neuroma or postnasal carcinoma. Though the recent survey showed that roughly one sixth of voca- incidence of such diseases is low, even the small sample tional training schemes included ear, nose, and throat of 100 patients in this study included seven who attachments, and only a quarter of these included full warranted further investigation to exclude such con- time six month posts.6 For the Royal National Institute ditions. Recognising glue ear and other middle ear for the Deaf to suggest that general practitioners abnormalities, which may be amenable to surgical wishing to provide hearing aid services based in their correction, requires skill in otoscopy. Our results own practices might receive "supplementary training suggest that otoscopy performed by general practi- which could be organised during a single or two days"' tioners may miss abnormalities in a considerable is frankly naive. The suggestion that screening number of patients. As a result of inadequate assess- should be performed by the dispenser is unacceptable, ment some patients may be denied the option of and were general practitioners to delegate in this surgical treatment. manner they would almost certainly carry ultimate Comparison of the group referred specifically for the legal responsibility. provision of a hearing aid with the group referred for assessment suggests that general practitioners already perform some screening and in many cases assess their 1 Royal National Institute for the Deaf. Hearing aids-the case for change. patients' needs correctly. The group referred for a London: RNID, 1988. hearing aid contained a higher proportion of patients 2 Spitzer RL, Cohen J, Fleiss JI, Enidicott J. Qtiantification of agrecmelnt in psychiatric diagnosis. Arch Gen Psschiatrs 1967;17:83-7. who required an aid (46/54) compared with those 3 Hardcastle PF, son Haacke N, Murray JAM. Obscrver variation itt clittical referred for assessment (23/46). Similarly a greater examination of the nasal airway. Clin Osolarvngol 1984:10:3-7. proportion of patients referred for assessment had 4 Johnson J, Grover B, Martin MA. .A surves' ofNational Health Service hearilg aid services. London: Royal National Institute for the Deaf, 1984. hearing loss amenable to surgery. The kappa values for 5 Anonymous. Authority blitz cnds queue for hearing aids. Hospital D)otor interobserver agreement (table II), however, were 1989;9:(18):6. 6 Rivron RI', Clayton MI. Ear, nose, and throat teaching. Clin Otolarvngol substantially different for each group, showing much 1988;13: 133-8. poorer agreement in the group referred for hearing aids. When viewed alongside the age distribution of (Accepted 30 Mas 1989)

Lesson ofthe Week Multiple forms of epileptic attack secondary to a small chronic

subdural haematoma http://www.bmj.com/

S C Jones, J M Bamford, J Heath, N Bradey, R V Heatley

introduction of was taking chlorpropamide for maturity onset diabetes Comparatively rare Since the computed tomography (CT) manifestations of small or asymptomatic chronic subdural haematomas but there was no previous history of epilepsy or have been recognised with increasing frequency, cerebrovascular disease. He had never had an excessive epilepsy may be the on 26 September 2021 by guest. Protected copyright. presenting features of a though their detection may depend on the use of alcohol intake. Full neurological examination on subdural haematoma contrast enhancing agents.' Patients with chronic admission showed nothing abnormal, and in particular subdural haematoma commonly present with head- there was no disturbance of higher cerebral function. ache, disturbances of higher cerebral function such as Blood glucose, electrolyte, and calcium concentrations personality change and confusion, or features of raised remained normal throughout. intracranial pressure. Hemiparesis, with dysphasia if Over the next 24 hours attacks were witnessed the lesion is over the dominant hemisphere, is the most during which the patient would become vacant and his St James's University frequent focal neurological deficit. Epilepsy is tradi- head and eyes would deviate to the right. His right arm Hospital, Leeds LS9 7TF tionally thought of as a rare presenting feature.) We would then become elevated with external rotation S C Jones, MRCP, registrar in describe a patient in whom several different forms of of the shoulder followed by alternating flexion and medicine epilepsy were the only clinical manifestations of a very extension at the elbow while the wrist remained flexed J M Bamford, MRCP, senior small chronic subdural haematoma. and the extended and abducted. These registrar in neurology fingers attacks J Heath, MRCP, senior would last between five and 60 seconds and were registrar in clinical followed by a variable period of confusion. They could neurophysiology Case history occur several times an hour, often without complete N Bradey, MRCP, senior A 75 year old man was admitted after a witnessed recovery of consciousness in between. During periods registrar in neuroradiology tonic-clonic convulsion. Over the previous two weeks of full consciousness, however, no neurological deficit R V Heatley, MRCP, senior he had suffered three episodes of sudden, complete could be detected. An attack could be terminated with lecturer in medicine inability to speak, during which he remained fully intravenous diazepam, which would continue to act for conscious without any abnormal movements being about 30 minutes. He was given a loading dose of Correspondence to: Dr S C noted. Each episode lasted about five minutes. He intravenous phenytoin followed by conventional oral Jones, Pinderfields General Hospital, Wakefield was seen by his general practitioner, who diagnosed doses. WF1 4DG. transient ischaemic attacks but did not prescribe About 48 hours after admission a further change was aspirin. The patient denied headache, and neither he noted, in that he was continuously confused with a ?r.Atedj 1989;299:439-41 nor his family could recall any recent head injury. He fluctuating level of consciousness. On occasions he

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