Optimizing Elderly Hearing Loss Care in Hong Kong A Cost-Effectiveness and Satisfactory Analysis of a Pilot Collaborative Model Between Otorhinolaryngologists and Family Medicine Specialists

Age-related hearing loss is common and can affect communication, daily activities, social participation, emotional wellbeing, and quality of life. Older adults with hearing loss may experience delays in accessing assessment and rehabilitation because demand for ENT specialist outpatient services is exceedingly high. A collaborative care pathway based in Family Medicine may allow suitable patients to receive earlier hearing assessment and rehabilitation while maintaining clear routes for referral to ENT when clinically indicated.

This prospective, parallel-cohort observational study will evaluate a new FM elderly hearing clinic at Tseung Kwan O South Family Medicine Clinic. The clinic is delivered by Family Medicine doctors with support from ENT specialist nurses and audiology services. It will be compared with the established ENT elderly hearing clinic at ENT Specialist Outpatient Clinic at Tseung Kwan O Hospital. Allocation will follow usual clinical referral, triage, and service pathways; participants will not be randomized.

Consecutive eligible patients aged 65 years or above with bilateral progressive hearing loss, earwax impaction, or a referral need for hearing aids will be invited to participate. Patients with urgent or complex otologic presentations requiring specialist care, including sudden sensorineural hearing loss, acute ear infection or otorrhoea, tympanic-membrane perforation, or suspected cholesteatoma or other serious middle-ear disease, will be excluded. Patients must be able to provide informed consent, either independently or with sufficient caregiver support to complete study questionnaires.

Approximately 500 participants will be recruited over about 12 months: approximately 100 in the FM cohort and 400 in the ENT cohort. Participants will undergo hearing assessment, including pure-tone audiometry or an equivalent assessment, and will receive care according to their assigned usual-care pathway. In the FM pathway, clinicians will assess hearing loss, provide counselling, arrange audiologic testing, facilitate hearing-aid fitting where indicated, and refer patients to ENT according to predefined escalation criteria. In the ENT pathway, participants will receive assessment and treatment through established specialist clinic and audiology protocols.

Baseline data will include demographic and clinical information, comorbidities, presenting symptoms, otologic findings, and hearing-test results. Participants will complete the traditional Chinese versions of Speech, Spatial and Qualities of Hearing Scale-12 (SSQ-12), the Older People's Quality of Life Brief questionnaire (OPQOL-Brief), the 15-item Geriatric Depression Scale (GDS-15), and a structured patient-satisfaction questionnaire. These measures will be repeated after hearing-aid fitting, where applicable, to assess changes in hearing-related function, quality of life, mood, experience of care, hearing-aid use, and adherence. Participants with a GDS-15 score of 8 or higher will be provided with information regarding mood disturbance and referred to Family Medicine for further assessment and management of possible depression.

The study will compare time from first presentation with hearing loss to first hearing assessment and, where indicated, to hearing-aid prescription. It will also compare patient-reported outcomes, satisfaction, hearing-aid compliance, clinic consultation time, and the proportion of FM-pathway patients subsequently referred to ENT. Researchers will assess changes in the volume and pattern of ENT referrals for elderly hearing loss after implementation of the FM clinic. Analyses will include an overall comparison between the FM and ENT cohorts, as well as a secondary matched comparison between the FM cohort and a similar-sized ENT subgroup with comparable age, baseline characteristics, and hearing-loss severity.

The cost-effectiveness analysis will consider the number of clinic visits before discharge, proportion of patients that require referral to ENT specialist outpatient clinic. The study is intended to assess whether this collaborative model can provide safe, satisfactory, and timely hearing rehabilitation for older adults while reducing avoidable demand on specialist ENT outpatient services.

Inclusion criteria

• Aged 65 years or above.
• Attending the Family Medicine elderly hearing clinic at Tseung Kwan O South Family Medicine Clinic or the ENT elderly hearing clinic at Specialist Outpatient Clinic at Tseung Kwan O Hospital.
• Bilateral progressive hearing loss for more than 1 month without acute ear infection; or earwax impaction affecting hearing; or referred for hearing-aid assessment, prescription, fitting, or follow-up.
• Able to provide written informed consent independently, or with caregiver support sufficient to facilitate completion of study questionnaires.
• Adequate language proficiency, including Cantonese where applicable, to complete the validated study questionnaires.

Exclusion criteria

• Sudden sensorineural hearing loss.
• Acute otitis, otorrhoea, or other acute ear infection requiring urgent assessment.
• Tympanic-membrane perforation.
• Suspected cholesteatoma or other serious middle-ear disease.
• Other red-flag otologic presentations requiring urgent ENT specialist evaluation.
• Severe cognitive impairment that, in the clinician's judgement, prevents meaningful informed consent or completion of study questionnaires.