20Q: Staging Hearing Loss: Closing the Gap Between Diagnosis and Action

3. Those are great points. So, what’s the biggest difference between what we do today and what a staging system would do?

Carlson: The fundamental difference is that a staging system is anchored in clinically meaningful outcomes and prognosis, not arbitrary cut-points. Current classification systems like the WHO grading scale use 15 dB HL increments that were derived from expert panel consensus, not from demonstrated differences in health risk. Labels like “slight impairment” and “mild hearing loss” may be perceived as inconsequential by patients and providers alike. There is no built-in signal that connects those descriptions to elevated risk for depression, social isolation, cognitive decline, or falls. A staging system changes that equation entirely. Like staging for chronic kidney disease, which uses estimated glomerular filtration rate to communicate not just organ function but prognosis and urgency, a hearing loss staging system ties each level to defined health risks and recommended actions.

Sydlowski: Right, plus, it really changes how we think about hearing loss in terms of overall health. It frames it as the chronic disease it is, not a “normal” consequence of aging. That’s an important mindset shift for most of the medical community and the public. Sensorineural hearing loss is permanent, progressive, and has demonstrable long-term consequences across mental health, cognitive health, safety, and quality of life. Our current language doesn’t communicate that. Staging will.

Carlson: And just to be clear, developing a staging system won’t replace the detailed audiometric descriptions specialists rely on. It’s about creating an outward-facing, patient-centric communication tool that motivates action at the frontline where most patients are first seen.

4. At recent conferences, I’ve heard people talk about establishing a “Hearing Number.” Is that the same as staging?

Carlson: It’s not the same, no, but it is an important precursor. Knowing your “hearing number” is the first step in recognizing that your hearing ability isn’t where we’d expect it to be. Staging then speaks to the impact that difference can be expected to have.

5. How does staging typically work in medicine?

Carlson: Most staging systems use objective diagnostic criteria and numerical stages, typically ranging from stage 0 through stage 4:

• Stage 0 generally indicates a person has significant risk factors but no current pathology.
• Stage 1 signals early disease with minimal functional impact.
• Stage 2 reflects moderate impairment with local complications.
• Stage 3 indicates more severe impairment with systemic involvement, and,
• Stage 4 represents complete organ failure with systemic consequences.

What’s powerful about this structure is that it doesn’t require explanation; it is intuitively understood. If someone tells you they have “Stage 1 disease,” most people understand it is early and should be monitored. If someone says “Stage 4,” nearly everyone understands that warrants urgent and significant intervention. Other systems add refinements. For example, asthma staging anchors cut-points to forced expiratory volume, chronic kidney disease uses estimated glomerular filtration rate, and heart failure uses ejection fraction. These anchors make the system clinically precise and not just intuitive.

6. So what’s an example of what staging in hearing loss might look like?

Carlson: Well, you could probably imagine that yourself because of how effective other staging systems are. Think about staging for cancer for example, and then just plug in hearing loss instead. Perhaps stage 0 indicates early, subclinical signs of hearing loss: occasional tinnitus or challenges in groups or noise without impact on speech recognition, or a history of noise exposure. Stage 4 might indicate severe auditory deprivation and reduced speech understanding that can’t be managed sufficiently by amplification. The difference between identifying the stage (0–4) and our current classification is it incorporates impact and necessary action that is more relevant, relatable, and actionable, and it never suggests a “stage” where hearing loss is “normal”.

If we think about how we’d determine the assigned stage, we just need to think about how we determine not only the degree of the hearing loss but also, what those findings might mean for outcomes and connect them. Just like for other chronic conditions, there’s a progressively more detailed investigation to understand what the patient is experiencing. For example, there is usually some kind of in-office screening that suggests further testing is warranted, a questionnaire, or a risk assessment, or other simple screening. If key indicators are present, then the provider might need to order imaging. If say, a tumor is noted on imaging, then a histologic study can be ordered to evaluate for malignancy. Based on those findings, a “stage” is assigned. With that staging comes guidance for management, ranging from watch and wait to urgent intervention. The stage also implies a severity. Not only in current degree, but in likelihood for progression or impact to the individual’s life and experience.

7. How would we define the different stages for hearing loss?

Sydlowski: We have to base the initial recommendations off what is available in the literature, and there are definitely gaps. So, there’s a multi-pronged approach needed. Initially, we can rely on widely used and well-studied measures, such as pure-tone averages and selected speech understanding tests. But we’ll need to evolve our thinking too. We intend to partner with agencies that are funding the research that is currently being developed to prioritize funding for those studies that will offer more connection to the impact of varying degrees of hearing loss and the actions that most effectively mitigate that impact, such as using cochlear implants and hearing aids. Importantly, we’ll need to keep those measures simple and scalable in order to achieve broad adoption in frontline care settings.

8. I probably should have asked: where did this idea come from?

Sydlowski: As you know, hearing loss is one of the most common chronic disease states worldwide, affecting almost 1 in 5 individuals globally, or more than 1.5 billion people. In the United States alone, 1 in 8 adults has some degree of hearing loss, and the prevalence doubles with every decade of life from the second to the seventh decade (Lin, 2011; Lin et al., 2011). Despite the enormity of this issue, approximately 29 million U.S. adults remain untreated or undertreated, often waiting years before seeking care. The consequences are profound: untreated hearing loss is associated with social isolation, depression, reduced quality of life, fall risk, and, critically, mid-life hearing loss has been identified as one of the most important potentially modifiable risk factors for later-life cognitive decline and dementia. And yet, surveys show that less than half of the public even believes hearing loss is treatable. That’s a staggering gap that demands a coordinated response.

Carlson: Right, so in 2021, a group of concerned audiologists, neurotologists, primary care physicians, professional association representatives, and public health advocates came together with an aim to remove the bureaucracy that slows us down, deeply understand the problem, and identify impactful, actionable interventions that will effectively close that gap once and for all. That’s how the Hearing Health Collaborative, or HHC, was born.

9. Why did the group decide a new staging system is the way to go? And how did you decide?

Carlson: Our mission is to leverage an interdisciplinary approach to optimize adult hearing health by identifying access barriers, implementing innovative solutions, and improving policies and care delivery in the United States. We used a structured problem-solving approach to review existing data, map current processes, and identify the gaps in our care that contribute to why people don’t manage their hearing loss (early enough, or at all). Once we defined the problem, we also set a target: to double utilization of hearing aids and cochlear implants and reduce the time to treat by half by the year 2032. Through detailed root cause analysis, we identified three countermeasures that we believe will close the majority of gap. One of those countermeasures is developing a staging system for hearing loss.

Sydlowski: To come to that conclusion, we used an approach that is well-known and well-vetted in other industries called A3 Thinking. But the tool itself isn’t what is most powerful. It’s that it offers a scientific method to dissect a problem by defining the current state, analyzing the drivers of the problem, and identifying the countermeasures that are most likely to address the key drivers most effectively. When you introduce this kind of structure and objectivity, it becomes much easier to achieve consensus and proposed interventions that are more likely to be effective. It helped us weed through the hundreds of ideas many of us have had over the years and distilled our focus to have more measurable impact.

Carlson: Sarah, we probably should mention the background of the term “A3.” It isn’t an acronym. Standard International paper sizes typically are classified by nine different sizes (A0 to A8); the larger the number, the smaller the paper. A3 (11¾ × 16½ in.) refers to the size of the sheet of paper that often is used to capture the content of the problem-solving process.

10. It sounds really different to how we’ve approached this problem before. Do you think that approach was important?

Sydlowski: I hope so! There’s a quote I really like, usually attributed to Albert Einstein, that says “We cannot solve our problems with the same thinking that created them.” It applies to our current situation. Increasing utilization of hearing devices and shortening time to treat isn’t a new problem. It’s an old problem that we have to tackle with a fresh perspective. We can’t jump to solutions based on assumptions or our own local view of the situation. We can’t have impact as disparate groups each tackling a different angle. We recognized that we need to approach a really complex problem with an objective, collaborative approach if we want to drive real, meaningful change.

Carlson: In my opinion, this is the first effort I’ve seen do that effectively, providing clear alignment on goals, actions plans, and desired outcomes. The Hearing Health Collaborative is possibly the only interdisciplinary organization that has applied a rigorous methodology to address the public health crisis of undertreated adult hearing loss, simplifying the conversation around hearing loss, emphasizing it importance to overall health, and expanding the hearing care market.

11. I definitely agree that we need people to be thinking differently about hearing loss. What do you think the problem is today?

Carlson: It’s actually pretty unbelievable how little people understand about hearing loss. We surveyed 1,250 U.S. adults between ages 50 and 80, and found that only 9% of them could correctly identify what constitutes “normal” hearing. Less than one-quarter of respondents were strongly aware of the connections between hearing loss and depression, reduced employability, fall risk, or dementia. And fewer than half believed hearing loss is even treatable, with fewer than 1 in 5 believing it is preventable (Carlson et al., 2022).

Sydlowski: Not only that, Matt, the gaps among healthcare providers are just as alarming. Among more than 400 surveyed primary care providers, only 57% were aware of a standard definition of hearing loss, only 40% believed it is treatable, and only 17% believed it is preventable (Sydlowski et al., 2022). These are the very professionals tasked with identifying and referring patients with hearing loss.

The downstream consequences are measurable: only about 10% of U.S. adults are very familiar with cochlear implants, and nearly one-third of those with hearing difficulty have never even heard of one (Marinelli et al., 2022). When patients do bring up hearing concerns to their primary care provider, fewer than one-third are referred to an otolaryngologist or audiologist (Mahboubi et al., 2018). Only about 20% of those who could benefit from a hearing aid receive one (Nassiri & Carlson, 2021), and as few as 2% to 12% of those who qualify for a cochlear implant actually receive one (Nassiri et al., 2021).

Carlson: For sure, the list of startling statistics go on and on, but they don’t surprise any of us who work with patients with hearing loss. What they tell us, though, is that we’re not speaking the language of our patients and referring providers. A staging system, grounded in the same language primary care physicians use for cancer, kidney disease, and heart failure, directly addresses the awareness and communication failures that drive these numbers.

12. Okay, you’ve sold me on why a staging system would advance our efforts to manage hearing loss. But it’s pretty overwhelming; how do we even get started?

Sydlowski: Matt and his team are going to make it happen, right, Matt?!

Carlson: Ha ha! I wish it were that easy. But yes, we do have a good plan in place. The first step will be to conduct a systematic review to guide the design of the staging system based on evidence. The only factor slowing that process down right now is funding, so the biggest focus for the HHC right now is actively working to raise the funds to allow us to do that important work.

13. Obviously, you haven’t done that review yet, but what principles do you anticipate should guide a new hearing loss staging system?

Carlson: An effective staging system will need to be one that people understand and can use. Think of the staging systems you’re familiar with, for example, for cancer, kidney disease, or heart disease. You inherently know what stage 1 vs stage 4 means. Importantly, your care team also understands not only the degree of disease you have, but what actions are necessary to take and the timeline on which to take them. The staging system we us will need to be patient-centric, prognosis-driven, simple, and intuitive. It should use familiar disease-staging language, emphasize hearing loss as a chronic disease, and encourage action by clearly conveying health risk and the need for intervention.

Sydlowski: And of course, those staging cut-points should be based on clinically meaningful outcomes rather than arbitrary audiometric thresholds alone.

14. How will evidence be used to support staging development?

Carlson: The HHC has identified key questions for systematic reviews and meta-analyses to evaluate relationships between candidate staging variables and prioritized health outcomes. This evidence base will inform clinically meaningful staging cut-points and risk profiles. Most importantly, it will focus on what will be understandable and actionable by health professionals: what indications should trigger particular actions, so that no matter where an individual is seen, they are more likely to receive the same appropriate recommendation.

15. What health risks and comorbidities should be considered in staging?

Sydlowski: The staging system must be built around the real-world consequences of hearing loss, not just decibel thresholds. Social isolation and loneliness are among the most well-documented consequences. Depression risk is significantly elevated in those with untreated hearing loss across multiple meta-analyses. Critically, mid-life hearing loss has been identified by the Lancet Commission as one of the most important potentially modifiable mid-life risk factors for later-life dementia, a finding now confirmed in prospective population-based studies including work from Matt’s team at Mayo Clinic. Fall risk, loss of independence, and reduced educational and occupational achievement are also in scope.

Carlson: Yes, all of those are fair game and will help us develop a really clear picture of the impact of hearing loss. Plus, the economic consequences are real: studies document reduced employment and income, diminished productivity, and increased care utilization. Our working group has formally prioritized these as candidate comorbidities (along with quality of life, safety, societal impact, and even mortality) with the intent to conduct systematic reviews evaluating the relationship between candidate staging variables like pure-tone average and word recognition scores and each of these outcomes. This is what will allow us to define staging cut-points that are clinically meaningful, not arbitrarily drawn.

16. What are the next steps in developing this staging system?

Sydlowski: Finding money. Seriously, this is expensive work. We need partnership across industry, associations, professionals, and the public to make this happen.

Carlson: Absolutely. It’s been a small group of us designing the framework, but bringing it to fruition is going to take all of us. Once we have funding, we’ll be completing systematic reviews, refining diagnostic labels, validating the staging system in representative patient cohorts, and aligning it with referral and treatment pathways. The system is expected to evolve over time as new evidence emerges, similar to other established disease staging frameworks. We’ll also need to determine what hearing loss factors result in different outcomes and quantify that interplay which has really never been done before.

17. That all sounds like a pretty major undertaking. Let’s say we get it right: what is the ultimate goal? What would a hearing loss staging system accomplish that makes the juice worth the pretty substantial squeeze?

Sydlowski: Let’s put this in perspective. Right now, only about 20% of those who could benefit from a hearing aid receive one. As few as 2% to 12% of those who qualify for a cochlear implant actually receive one. And our target as a Collaborative is to double utilization of both hearing aids and cochlear implants, and cut time to treatment in half, by 2032. That’s an enormous lift. But consider how this parallels other conditions where staging systems already exist.

Carlson: Right, like with chronic kidney disease, staging fundamentally changed how primary care physicians monitor and manage patients, because the stage communicates both where a patient is and what needs to happen next. That is exactly what hearing loss has lacked. A staging system built on clinically meaningful cut-points, tied to documented risk profiles for depression, cognitive decline, falls, and social isolation, and communicated in language that any physician or patient intuitively understands. That is the tool that will shift behavior at scale.

Sydlowski: Exactly; it removes the ambiguity that lets providers say “come back when it gets worse.” It replaces “mild sloping to moderate sensorineural hearing loss” (a phrase that communicates urgency to almost no one) with a shared language of disease, risk, and action. That is what makes the investment worth it.

18. Well, this all sounds great, but I imagine it’s going to take a while to be ready to use. Correct?

Sydlowski: We can all start changing the way we talk about hearing loss. Imagine how you would react if someone told you that your results fall in a “mild” range; would you be rushing out to manage it? Probably not. When someone tells you that what you’re experiencing is “typical for your age,” are you likely to be motivated to make adjustments? Not likely. We need to change our language so that instead of talking about hearing loss as an expected consequence of aging that you can learn to deal with, people start viewing it as a chronic health condition they need to take action to manage. Imagine visiting your primary care physician and hearing you have high blood pressure. Are they likely to say, “That’s common in older adults, when it starts impact your daily life, come back in”? Of course not! Similarly, we shouldn’t be using language that suggests managing hearing loss can be postponed until its effects are impacting daily communication, quality of life, and more. People can choose to do something about it or not, but it is our professional responsibility to provide them all relevant information to make an informed decision. And that includes the fact that hearing loss is a chronic health condition with consequences.

19. You mentioned earlier that this initiative is only one of several the Hearing Health Collaborative has identified. Can you tell me briefly about the others?

Carlson: Absolutely. Our A3 process led us to identify three primary countermeasures: developing a “hearing number”, developing a hearing loss staging system, and developing procedural changes to simplify and speed up the identification of hearing loss through a screening process. They are all very interconnected. First, someone needs to know whether what they are experiencing is normal or not (hearing number). And as we talked about earlier, while most people know what normal vision and normal blood pressure numbers are, they have no idea what normal hearing should be.

Sydlowski: Basically, the first step to solving a problem is to recognize there is one, in a standard objective way, so we need to create the conditions for people who don’t understand hearing loss to know when there is a “loss”. That would lead to the staging system we’ve been discussing. Once you know there’s a problem, the next natural question should be, how bad is it? What do I need to do about it? Then, the third countermeasure is around making that process as simple and straightforward as possible (screening standard).

Carlson: Which it’s not today. People generally make it into the hearing loss management system in one of three ways: ENT/audiology/hearing instrument specialists, the consumer electronics path, or through medical channels (i.e., referral by primary care providers). The last path is probably the most tenuous right now, so countermeasure three primarily focuses on standardizing a screening process and training medical professionals to use it. We aim to subsequently address simplifying treatment pathways (for both hearing aids and cochlear implants and have begun some of that early work).

20. What can audiologists do to support this work?

Sydlowski: There are lots of opportunities to get involved in big and small ways! We need individuals who want to work on the systematic reviews, we need people to speak on the work at local, state, and national meetings, we need volunteers to help engage non-audiologists in the work by introducing the concepts in this conversation. We need funding and we need partnership with industry, other professional associations, and grant funding agencies. If you have connections, please share this work and why it matters to you as an audiologist. If you’d like to get involved, please visit www.hhc.us.adulthearing.com. Together, we can have impact we’ve never achieved before. It’s an exciting time for hearing health!

References

Carlson, M. L., Nassiri, A. M., Marinelli, J. P., et al. (2022). Awareness, perceptions, and literacy surrounding hearing loss and hearing rehabilitation among the adult population in the United States. Otology & Neurotology, 43(3), e323–e330. https://doi.org/10.1097/mao.0000000000003473

Carlson, M. L., Zwolan, T. A., Bush, M. L., et al. (2025). Proposed development of a new staging system for hearing loss: Countermeasure 2 of the Hearing Health Collaborative. Otology & Neurotology, 47(2), e158–e163. https://doi.org/10.1097/MAO.0000000000004700

Lin, F. R. (2011). Hearing loss and cognition among older adults in the United States. The Journals of Gerontology: Series A, Biological Sciences and Medical Sciences, 66A(10), 1131–1136. https://doi.org/10.1093/gerona/glr115

Lin, F. R., Niparko, J. K., & Ferrucci, L. (2011). Hearing loss prevalence in the United States. Archives of Internal Medicine, 171(20), 1851–1852. https://doi.org/10.1001/archinternmed.2011.506

Mahboubi, H., Lin, H. W., & Bhattacharyya, N. (2018). Prevalence, characteristics, and treatment patterns of hearing difficulty in the United States. JAMA Otolaryngology–Head & Neck Surgery, 144(1), 65–70. https://doi.org/10.1001/jamaoto.2017.2223

Marinelli, J. P., Sydlowski, S. A., & Carlson, M. L. (2022). Cochlear implant awareness in the United States: A national survey of 15,138 adults. Seminars in Hearing, 43(4), 317–323. https://doi.org/10.1055/s-0042-1758376

Nassiri, A. M., Ricketts, T. A., & Carlson, M. L. (2021). Current estimate of hearing aid utilization in the United States. Otology & Neurotology Open, 1(1), Article e001. https://doi.org/10.1097/ono.0000000000000001

Nassiri, A. M., Sorkin, D. L., & Carlson, M. L. (2022). Current estimates of cochlear implant utilization in the United States. Otology & Neurotology, 43(5), e558–e562. https://doi.org/10.1097/MAO.0000000000003554

Sydlowski, S. A., Marinelli, J. P., Lohse, C. M., & Carlson, M. L. (2022). Hearing health perceptions and literacy among primary healthcare providers in the United States: A national cross-sectional survey. Otology & Neurotology, 43(8), 894–899. https://doi.org/10.1097/mao.0000000000003616