Hearing Rehabilitation in Veterans With Severe Hearing Loss: Challenges and Opportunities

Objectives: There is increased recognition of the importance of hearing ability in social connectedness and healthy aging. Hearing loss is common among Veterans, and hearing rehabilitation is prioritized within the Veterans Administration (VA). Despite the attention to hearing care in the VA, limited data on cochlear implant (CI) utilization raises concern about whether this transformative and accessible treatment is reaching Veterans who could be helped with communication to improve their quality of life. The overall hypothesis is that Veterans with severe hearing loss, despite having unique rehabilitative needs, are not consistently treated as a distinct population. In this article, we identify patterns associated with specific management strategies for Veterans with severe hearing loss and describe the utilization of CIs in the VA as an evidence-based strategy when hearing aids provide limited benefit. Design: We investigated rehabilitation strategies used for Veterans with severe hearing loss. We defined a population-based cohort of 213,285 United States Veterans with newly diagnosed bilateral severe or worse hearing loss from January 1, 2006, to December 31, 2023. Severe hearing loss was defined as having a 4-frequency pure tone average (0.5, 1, 2, and 4 kHz) ≥70 dB HL in both ears. Speech perception abilities were also collected. We related hearing rehabilitation treatment of Veterans to factors hypothesized to impact care, including audiologic results, sociodemographic characteristics, comorbidities, and geography. Main outcomes included the receipt of CI and the cumulative incidence of CI. We used a competing risks framework to determine the factors associated with CI receipt. Results: Of the 213,285 Veterans with bilateral severe or poorer hearing loss (mean age [SD], 80.3 [9.7]), 202,949 (95.2%) were fit with hearing aids, 5335 (2.5%) had a CI procedure, and 5001 (2.3%) had no evidence of receiving hearing rehabilitation. The 5- and 10-yr cumulative incidence (95% confidence interval) of receipt of CI was 1.9% (1.8 to 2.0%) and 2.9% (2.8 to 3.0%), respectively (death treated as a competing risk). In competing risks regression, age, race and ethnicity, VA priority group, word recognition score (WRS), hearing loss severity, the year hearing loss was first identified, and a greater number of comorbidities were all significantly associated with the receipt of CI. Patient age, word recognition score, and hearing loss severity were found to be the most important predictors of CI receipt based on concordance loss. Conclusions: Most Veterans with severe hearing loss and poor speech understanding, who are likely to be audiologic candidates for CIs, are treated with hearing aids, whereas relatively few receive CIs. The treatment approach may be driven by several different factors specific to the Veteran, site of care, and VA policies. A multifaceted strategy and care delivery may be required to improve evidence-based care for those with severe hearing loss.