Economic Burden of Hearing Loss inMiddle‐Aged and Older Adults in China

Abstract

Our study aimed to estimate the economic burden of hearing loss. Using data from the China Health and Retirement Longitudinal Study (CHARLS), hearing loss attributed fraction based on the rate of hearing loss was derived. Then, we calculated the direct and indirect economic burden of hearing loss. The base year for the monetary amounts shown was 2015. For middle-aged and older people aged 45+ in China, the economic burden of hearing loss in 2011, 2013, and 2015 was US$6.13 billion, US$7.39 billion, and US$8.50 billion, respectively. The direct economic burden of hearing loss accounted for 46.99%–50.24%, the indirect economic burden of premature death accounted for 49.41%–52.70%, and the indirect economic burden of productivity loss accounted for the least proportion of 0.31%–0.35%. Immediate measures such as hearing loss prevention, hearing screening, and hearing aid wearing should be taken, so as to reduce the economic burden of hearing loss.

Keywords

hearing loss economic burden epidemiological attribution method China

What this paper adds

• Our study is the first to estimate the direct and indirect economic burden attributed to hearing loss in China.

• The epidemiological attribution method was used to obtain a more refined estimate and provide scientific evidence for the exact economic burden of hearing loss.

Applications of study findings

• It is urgent to measure the economic burden of diseases attributed to hearing loss, so as to provide evidence in favor of potential economic savings or cost-effective interventions.

• Our study can provide valuable reference for the government to formulate effective hearing prevention, screening, and intervention measures to reduce the prevalence of hearing loss.

Introduction

Hearing loss imposes enormous economic burden on individuals, families, and the society, including direct economic burden, indirect economic burden of premature death and productivity loss. First, hearing loss itself can lead to certain costs of screening, treatment, nursing, and purchasing assistive devices such as hearing aids. Second, hearing loss can be associated with a number of negative outcomes, including falls (Lin & Ferrucci, 2012), chronic diseases (Kramer et al., 2002), depressive symptoms (Mener et al., 2013), cognitive decline (Lin et al., 2013), and thus increasing healthcare costs of hearing-related diseases (Genther et al., 2013). Third, hearing loss can be also associated with higher risk of premature death (Engdahl et al., 2019), so the life expectancy of people with hearing loss may be shorter than that of the general population (Vos et al., 2017). In addition, hearing loss may interfere people’s labor force participation and the rates of employment are lower for people with hearing loss (Garramiola-Bilbao & Rodriguez-Alvarez, 2016). Hearing loss will also contribute to productivity losses of family members and friends who provide support to people with impaired hearing (World Health Organization, 2017).

Most studies estimating economic burden of hearing loss were from developed countries. The World Health Organization (WHO) estimated that unaddressed hearing loss cost US$750 billion annually (World Health Organization, 2020a). In Europe it was up to 213 billion euros per year (Shield, 2006). A report in Australia estimated direct and indirect economic burden of hearing loss, such as the direct medical burden, productivity loss, nursing costs, equipment costs (Opitz & Zbaracki, 2006). Results showed that the economic burden of hearing loss was US$1.175 billion in 2005 and the annual burden for each hearing-impaired patient was US$3314 (Economics, 2006). A systematic review in the United States showed that the additional medical costs associated with hearing loss ranged from US$3.3 billion to US$12.8 billion (Huddle et al., 2017). Among the total economic burden of hearing loss, direct medical burden accounted for 5.74% (Opitz & Zbaracki, 2006) to 24.44% (Daniell et al., 1998); direct non-medical expenses account for the smallest proportion, ranging from 3.83% (Mohr et al., 2000) to 10.14% (Opitz & Zbaracki, 2006); productivity loss accounted for 83.82% (Mohr et al., 2000) to 84.14% (Opitz & Zbaracki, 2006).

Data, methods, and sample used in these studies were quite different. To be exact, Foley et al. (2014) used the Medical Expenditure Panel Survey to measure the excess medical expenditure of hearing-impaired patients aged 65 or above. Stucky et al. (2010) used the Health Insurance Database from California to determine the costs of hearing treatment (such as hearing test, hearing aids) in the first year for those aged 65+ year old with hearing loss, assuming that all hearing-impaired patients sought treatments, and then extrapolated the costs nationwide using an prevalence data model. In 2002, the cost of treating hearing loss for Americans aged 65 and older for the first year was approximately US$1292 per person, representing a national loss of US$8.2 billion, and it will increase to US$51.4 billion by 2030 (Stucky et al., 2010). The total lifetime cost for patients with severe hearing loss in the US was US$1,179,831 per person, of which the direct medical cost was US$145,707 (12.35%), and the direct non-medical cost was US$45,208 (3.83%) (Mohr et al., 2000).

Estimates of the economic burden of productivity loss varied widely. In the United States, it ranged from US$1.8 billion to US$194 billion (Kochkin, 2010; Stucky et al., 2010). Among the total lifetime costs for patients with severe hearing loss in the US, the lost productivity was US$988,916, accounting for 83.82% (Mohr et al., 2000). Stucky et al. combined income data with the hearing data from the U.S. National Health Interview Survey (NHIS), and found a national income loss of US$1.8 billion per year, among which the productivity loss caused by hearing loss for the elderly aged 65 and above was about US$1.4 billion; By 2030, the cost will increase to US$9 billion (Stucky et al., 2010). Kochkin et al. calculated income loss at different levels of hearing loss, and concluded that total income loss due to hearing loss was US$194 billion (Kochkin, 2010). Kochkin et al.’s estimate for the burden of hearing loss was higher because it included mild hearing loss and the sample size was larger.

China has a large number of people with hearing loss in the world, but there are few studies on the economic burden of hearing loss (Xiangyang et al., 2016). According to the Second China National Sample Survey on Disability in 2006, there were 27.8 million disabled people with hearing loss in China, accounting for 2.2% of the total population, and the prevalence rate ranked second among all kinds of disabilities. Meanwhile, with the aging of China’s population, the prevalence of hearing loss is increasing rapidly. But specific estimates of the economic burden of hearing loss are lacked. Only one study exploring the burden of disability in China compared the average income of households with or without hearing loss. It was found that in 2006, the annual cost for rural people with severe hearing loss was US$289; for rural people with mild hearing loss was US$139; for urban people with severe hearing loss was US$449; for urban people with mild hearing loss was US$7 (Loyalka et al., 2014).

Considering the prevalence and severity of hearing loss, and that there is no specific study to quantify the economic burden of hearing loss in China, it is urgent to measure the economic burden of diseases attributed to hearing loss, so as to provide evidence in favor of potential economic savings or cost-effective interventions. Our study aims to provide precise estimates for the economic burden of diseases attributed to hearing loss in China in 2011, 2013, and 2015 by the epidemiological attribution method from a societal perspective. The research results will help to increase the government’s impetus to prevent and treat hearing loss.

Methods

Data and Sample

Data on hearing loss, hearing-related diseases, healthcare utilization and costs, as well as productivity loss $(P L)$ were derived from the China Health and Retirement Longitudinal Survey (CHARLS). CHARLS is a long-term tracking project for all respondents, which combines detailed socioeconomic data with high-quality health data of individuals and aims to collect a set of high-quality micro databases representing families and individuals aged 45 and above in China (Zhao et al., 2014). CHARLS adopts the Probability Proportional to Size (PPS) sampling to stratify urban/rural areas and GDP. The baseline survey was conducted in 2011 and follow-up surveys were in 2013 and 2015, with the rate of follow-up reaching 88% and 87%, respectively (China Health and Retirement Longitudinal Study, 2019). Our study used panel data of CHARLS 2011, 2013, and 2015, including a nationally representative sample of 17,508 middle-aged and older people aged 45 and above.

The number of population and per capita income by sex, residency (urban/rural areas), and age groups came from the China Statistical Yearbooks. The employment rates by sex, residency (urban/rural areas), and age groups came from the China Population and Employment Statistics Yearbooks. Potential years of life lost $(Y L L)$ measures were taken by sex and age groups from the Global burden of disease (Institute for Health Metrics and Evaluation, U. o, W, 2022). The life expectancy by sex and age groups was derived from the WHO Life Expectancy Table (World Health Organization, 2020b). To reconcile different stratifications, for example, we have merged the indicators in urban/rural areas together when calculating the present value of forgone lifetime earnings $(P V F L E)$ and costs of premature deaths $(C P D)$ , as $P V F L E$ , and $C P D$ both involves life expectancy only stratified by sex and age groups.

Hearing Loss and Related Diseases

According to previous literature, specific diseases associated with hearing loss are depressive symptoms (Amieva et al., 2018; Li et al., 2014; Wu, 2021), mental disability (Amieva et al., 2018; Lin et al., 2011; Moorman et al., 2021; Williams et al., 2020), hypertension (Chen & Ding, 1999; Mondelli & Lopes, 2009; Przewoźny et al., 2015), hyperlipidemia (Chang et al., 2007; Doosti et al., 2016; Kojima et al., 2001), stroke (Bamiou, 2015; Gopinath et al., 2009), heart diseases (Gan et al., 2016; Gates et al., 1993), and diabetes (Kakarlapudi et al., 2003; Tay et al., 1995; Wackym & Linthicum, 1986).

(1) Hearing loss: Respondents were asked, “Do you have a hearing problem?”, and they subjectively answered “yes” or “no.”

(2) Depressive symptoms: The Chinese version of the 10-item Center for Epidemiological Studies Depression Scale (CES-D-10) was used to detect depressive symptoms (Andresen et al., 1994). Respondents rated the frequency of each emotion in the past week on a 4-point scale, ranging from 0 (“none”) to 3 (“most of the time”) (Andresen et al., 1994). Those with a score of ≥10 on a CES-D-10 score of 0–30 were judged to be at risk for having depressive symptoms (Tomita & Burns, 2013).

(3) Mental disability: Respondents were asked if they had brain damage or mental retardation, such as bipolar disorder, schizophrenia, anxiety disorders, obsessive-compulsive disorder, post-traumatic stress disorder (PTSD), and personality disorders, and they subjectively answered “yes” or “no.” Mental disability status was reported by respondents themselves if they were able to answer the question, and by a proxy, for example, caregivers if they could not. Also, responding by proxy applies to all questions in CHARLS for those with mental disabilities who could not respond by themselves, except for a few questions that had to be self-assessed by respondents.

(4) Hypertension, hyperlipidemia, stroke, heart disease, diabetes: Respondents were asked whether they had hypertension, hyperlipidemia, stroke, heart diseases (such as myocardial infarction, coronary heart disease, angina pectoris, congestive heart failure), diabetes or high blood (including abnormal glucose tolerance and elevated fasting glucose levels) diagnosed by doctors. Respondents subjectively answered “yes” or “no.”

Economic Burden of Diseases

Self-reported healthcare utilization and its related costs were used to calculate direct economic burden attributed to hearing loss. Healthcare utilization included number of outpatient visits per month, number of hospitalizations per year, and number of days per hospital stay. Healthcare costs included outpatient and inpatient cost specific to the health conditions, outpatient transportation costs, inpatient transportation, and accommodation costs. Indirect economic burden included premature death and productivity loss attributed to hearing loss. We computed every single measure by disease/sex/residency/age. All monetary amounts were adjusted for inflation to 2015 dollars using the health care component of the Consumer Price Index (CPI) provided by the National Bureau of Statistics (Huang et al., 2021).

Statistical Analysis

The economic burden attributed to hearing loss was measured using the epidemiological attribution method.

(1) Hearing loss attributed fraction $(H L A F)$

The epidemiological $H L A F$ for hearing loss is calculated by diseases types, residency, sex, and age groups. $H L A F$ is expressed by the following formula (Yang et al., 2010)

H L A F_{i r s a} = \frac{(P N_{r s a} + P H_{r s a} \times R R_{i}) - 1}{P N_{r s a} + P H_{r s a} \times R R_{i}}

(1)

Where

P N

is the proportion of people with no hearing loss;

P H

is the proportion of people with hearing loss;

R R

is the relative risk of hearing-impaired people compared with non-hearing-impaired people (we calculated odd ratio

(O R)

in correlation studies of CHARLS to approximate

R R

under the rare disease assumption (Schmidt & Kohlmann, 2008)). Detailed calculating methods and its results can be found in the Supplementary Material 1 and Supplementary Table 1);

i

represents the type of diseases;

r

indicates residency;

s

represents sex;

a

represents age groups (45–64 years and 65+ years). Besides, we have elaborated how the current equation for

H L A F

was derived and cited the sources we referred to in Supplementary Material 2.

(2) Direct Economic Burden of Diseases $(D E B D)$

$D E B D$ includes inpatient and outpatient medical expenditures, as well as the associated transportation, nutrition, and nursing costs attributed to hearing loss. $D E B D$ for each subgroup by disease type, residency, sex, and age is calculated as follows

D E B D_{i r s a} = [(P H_{i r s a} \times Q H_{i r s a} + P V_{i r s a} \times Q V_{i r s a}) + (P H N_{i r s a} \times Q H_{i r s a} + P V N_{i r s a} \times Q V_{i r s a})] \times P O P_{r s a} \times H L A F_{i r s a}

(2)

Where

P H

is the medical cost per hospital stay;

P V

is the medical cost per outpatient visit;

P H N

is the average cost of transportation, nutrition, and nursing expenses per hospital stay;

P V N

is the average transportation cost per outpatient visit;

Q H

is the average number of hospitalizations per person per year;

Q V

is the average number of outpatient visits per person per year;

P O P

is the incidence in the year;

i

represents the type of diseases;

r

represents residency;

s

represents sex;

a

represents age (divided into two age groups: 45–64 years and 65 years and over).

(3) Indirect Economic Burden of Diseases $(I E B D)$

$I E B D$ includes productivity loss $(P L)$ during hospitalization and costs of premature deaths $(C P D)$ attributed to hearing loss. The $P L$ during hospitalization is calculated as follows

P L_{i r s a} = I D A Y_{i r s a} \times Y_{r s a} \times E_{r s a} \times P O P_{i r s a} \times H L A F_{i r s a}

(3)

I D A Y

is the average number of days per employee spent in hospital per year due to treating the hearing-related disease

i

;

Y

is the average daily income calculated based on per capita annual household income;

E

is the percentage of the total population that is currently working;

P O P

is the incidence in the year.

The calculation of $C P D$ due to hearing loss is divided into three steps. First, the potential years of life lost $(Y L L)$ is derived from the Global burden of disease (Detailed results can be found in the Supplementary Table 2); Then the present value of forgone lifetime earnings $(P V F L E)$ measured by the human capital method is calculated, using per capita income and a 3% discount rate to discount the future loss $d$ , and the economic growth rate $p$ is represented by 8% growth rate; Finally, $C P D$ is calculated by multiplying $P Y L L$ , $P V F L E$ , and $H A F$ . The specific formula is as follows

P V F L E_{s m} = \frac{\sum {}^{n}{[Y_{s} (m) E_{s} (m)]} \times {(1 + p)}^{L E}}{{(1 + d)}^{L E}}

(4)

C P D_{i s m} = Y L L_{i s m} \times P V F L E_{s m} \times H L A F_{i s m}

(5)

Where

Y_{s} (m)

is the average income of people by sex and age groups;

E_{s} (m)

is the employment rate by sex and age groups;

L E

is life expectancy;

m

is the age groups of death, measured by every 5 years;

i

represents the type of diseases;

r

represents residency;

s

represents sex;

a

represents age groups (45–64 years and 65 years and over).

$I E B D$ is calculated as follows

I E B D = P L + C P D

(6)

(4) Total Economic Burden of Diseases $(T E B D)$

$T E B D$ is the sum of DEBD and IEBD, and the formula is as follows

T E B D = D E B D + I E B D

(7)

Results

Hearing Loss Attributed Fraction

Table 1 shows the prevalence of hearing loss among Chinese people aged 45 and above in CHARLS from 2011 to 2015. In 2011, the prevalence of hearing loss in the middle-aged population was lower than that in older population. There were significant differences in the prevalence of hearing loss between rural and urban population (p < 0.001), but no difference in sex (p = 0.688; p = 0.294). Samples from 2013 and 2015 showed similar trends.

Table 1.

Prevalence of hearing loss among people aged 45 and above in China from 2011 to 2015 (%).

	Urban	Rural	p value	Male	Female	p value
Year 2011
45–59 years old	3.21	5.63	<0.001	4.79	4.61	0.688
60+ years old	11.82	16.39	<0.001	15.11	14.20	0.294
Year 2013
45–59 years old	2.79	3.93	0.005	3.46	3.50	0.927
60+ years old	8.93	10.74	0.011	10.75	9.27	0.035
Year 2015
45–59 years old	3.86	5.17	0.010	4.39	4.91	0.298
60+ years old	7.69	11.48	<0.001	9.66	10.31	0.345

Supplementary Table 1 presents ORs among people aged 45 and above in China from CHARLS 2011 to 2015. Depressive symptoms, mental disability, hypertension, stroke, heart diseases, and diabetes all had consistent ORs >1 in 2011, 2013, and 2015, indicating that exposure to hearing loss associated with higher odds of having these diseases.

Further, we calculated the HLAF among people aged 45 years old and above in CHARLS by sex, residency and age groups during 2011–2015 in Table 2. For ORs no more than 1, the corresponding HLAF value equaled to 0, meaning that there was no hearing loss attributed fraction in the economic burden of diseases for certain subgroup. In 2011–2015, the HLAF value was the highest for the rural population aged 60 years and older with mental disability.

Table 2.

Hearing Loss Attributed Fraction (HLAF) among people aged 45 and above in China from 2011 to 2015 (%).

	Male				Female
	Urban		Rural		Urban		Rural
	45–59	60+	45–59	60+	45–59	60+	45–59	60+
Year 2011
Depressive symptoms	2.00	8.15	4.30	11.04	2.60	7.42	3.91	9.91
Mental disability	7.71	25.78	14.54	32.68	9.14	25.04	13.32	31.31
Hypertension	0.06	0.24	0.12	0.34	0.07	0.23	0.11	0.31
Hyperlipidemia	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00
Stroke	0.38	1.66	0.83	2.32	0.49	1.60	0.74	2.16
Heart diseases	0.74	3.03	1.53	4.23	0.90	2.89	1.37	3.95
Diabetes	0.11	0.48	0.24	0.67	0.14	0.46	0.21	0.62
Year 2013
Depressive symptoms	2.51	6.75	2.65	7.58	1.86	5.26	3.22	6.38
Mental disability	5.19	14.04	5.59	15.87	3.77	11.78	6.61	14.38
Hypertension	0.66	1.97	0.72	2.30	0.49	1.62	0.88	2.06
Hyperlipidemia	1.20	3.73	1.35	4.13	0.95	3.11	1.59	3.77
Stroke	0.88	2.63	0.96	3.04	0.65	2.15	1.17	2.73
Heart diseases	0.54	1.62	0.60	1.88	0.39	1.31	0.70	1.67
Diabetes	0.22	0.67	0.25	0.78	0.16	0.54	0.30	0.70
Year 2015
Depressive symptoms	3.89	7.10	4.91	10.21	4.00	7.27	5.47	10.55
Mental disability	4.56	8.50	5.73	12.38	4.84	9.29	6.50	13.09
Hypertension	0.72	1.32	0.91	2.06	0.71	1.44	1.02	2.20
Hyperlipidemia	0.42	0.77	0.54	1.18	0.40	0.82	0.57	1.28
Stroke	1.61	3.04	2.04	4.54	1.59	3.24	2.28	4.83
Heart diseases	1.58	2.92	1.99	4.45	1.53	3.28	2.20	4.68
Diabetes	1.34	2.50	1.70	3.80	1.34	2.78	1.95	4.08

^aZeros in HLAF mean the corresponding OR no more than 1.

Direct Economic Burden of Diseases

Table 3 shows annual per capita direct medical costs for hearing loss, mental disability, hypertension, hyperlipidemia, stroke, heart diseases, diabetes, and related non-medical costs for transportation, accommodation, and care. The costs of outpatient services were mostly the highest, followed by inpatient costs, transportation, accommodation, and care. The medical costs of the middle-aged adults were lower than those of the elderly population over 60 years old, and the medical costs of those in urban areas were higher than those in the rural areas. The dash for mental disability meant none of the patients with mental disability sought care in outpatient in CHARLS 2011.

Table 3.

Annual per capita direct economic burden of hearing loss and related diseases among people aged 45 and above in China from 2011 to 2015 (US$).

	Types of diseases							Sex		Age		Residency
	Hearing loss	Mental disability	Hypertension	Hyperlipidemia	Stroke	Heart diseases	Diabetes	Male	Female	45–59	60+	Urban	Rural
Year 2011
Outpatient costs	1573.6	—	1381.3	1381.3	4755.8	6521.7	2989.8	3829.1	3811.6	3671.7	3934.0	3969.0	3706.7
Inpatient costs	1258.9	419.6	1119.0	524.5	1661.0	3724.2	1521.1	2203.0	2273.0	2185.6	2255.5	2307.9	2168.1
Transportation, accommodation, and care costs	297.2	157.4	82.2	42.0	209.8	167.9	157.4	160.9	157.4	159.1	159.1	164.4	153.9
Total	3129.7	577.0	2587.7	1940.8	6626.6	10,420.7	4668.3	6189.5	6241.9	6014.6	6346.8	6451.8	6032.1
Year 2013
Outpatient costs	1442.5	2348.2	2532.7	1341.8	5208.4	4964.8	3259.2	4229.1	4088.6	3657.6	4625.3	4178.2	4038.9
Inpatient costs	2247.6	1945.7	1559.9	1056.7	2952.0	2750.8	2297.9	2549.5	2482.4	2415.2	2515.7	2515.9	2515.8
Transportation, accommodation and care costs	156.0	536.7	144.2	83.9	251.6	268.4	147.6	218.0	207.0	218.1	218.2	218.2	208.0
Total	3857.8	4830.6	4243.6	2482.4	8412.0	7967.2	5704.7	6996.6	6778.0	6290.9	7359.2	6912.3	6762.7
Year 2015
Outpatient costs	1824.1	2959.2	2649.7	2007.4	5677.5	5927.1	3691.3	4438.1	4322.0	4149.0	4998.7	4630.8	4193.6
Inpatient costs	1690.5	2076.6	1738.7	1803.0	3258.4	2690.5	2819.0	2530.8	2516.8	2220.5	2365.0	2681.1	2268.7
Transportation, accommodation and care costs	230.1	336.5	224.5	130.1	246.1	218.8	154.0	240.9	240.9	208.8	240.9	240.9	224.8
Total	3744.7	5372.3	4612.9	3940.5	9182.0	8836.4	6664.3	7209.8	7079.7	6578.3	7604.6	7552.8	6687.1

^aThe dash for mental disability meant none of the patients with mental disability sought care in outpatient in CHARLS 2011.

In Table 4, the total direct economic burden attributed to hearing loss was obtained by multiplying the direct economic burden per capita by the corresponding incidence and HLAF. Zeros meant no direct economic burden of diseases attributed to hearing loss and dashes meant no data available for certain subgroups in CHARLS 2011, 2013, and 2015. When adding together, the total direct economic burden of diseases attributed to hearing loss was US$2.88 billion in 2011, US$3.66 billion in 2013, and US$4.27 billion in 2015.

Table 4.

Direct economic burden of diseases attributed to hearing loss among people aged 45 and above in China from 2011 to 2015 (thousand US$).

	Male				Female				Total
	Urban		Rural		Urban		Rural
	45–59	60+	45–59	60+	45–59	60+	45–59	60+
Year 2011
Hearing loss	6268	—	20,020	17,994	17,389	19,579	—	8759	90,009
Mental disability	—	11,679	—	—	—	—	—	—	11,679
Hypertension	1141	4914	1266	8135	984	4732	1986	9652	32,811
Hyperlipidemia	0	—	0	—	—	0	0	0	0
Stroke	32,316	133,781	25,464	146,540	19,452	126,287	22,873	151,083	657,797
Heart diseases	49,654	470,029	52,330	417,068	94,071	439,891	113,210	420,058	2,056,312
Diabetes	2723	8480	1808	6085	2245	6566	3961	2879	34,747
Total	92,101	628,884	100,889	595,823	134,141	597,055	142,030	592,432	2,883,355
Year 2013
Hearing loss	3541	22,270	2979	19,302	16,050	5122	14,777	3496	87,535
Mental disability	—	83,387	9486	10,912	15,604	—	23,350	—	142,739
Hypertension	27,557	101,914	21,411	84,986	27,220	128,760	33,887	97,033	522,768
Hyperlipidemia	—	8784	—	6295	4468	2720	6128	5145	33,540
Stroke	82,874	539,123	76,864	342,344	38,293	292,142	63,367	278,311	1,713,319
Heart diseases	38,186	169,194	19,545	145,806	41,627	163,466	66,973	160,233	805,029
Diabetes	40,824	95,173	8276	48,103	30,310	66,612	12,315	57,066	358,678
Total	192,981	1,019,844	138,560	657,748	173,573	658,821	220,798	601,284	3,663,608
Year 2015
Hearing loss	10,228	13,048	12,414	19,861	31,937	16,336	14,240	7702	125,765
Mental disability	0	38,161	3378	5143	9607	0	10,006	11,710	78,005
Hypertension	39,238	90,017	28,255	104,605	38,542	127,058	42,369	143,472	613,556
Hyperlipidemia	1671	1429	687	2153	2179	5797	2893	5034	21,843
Stroke	134,186	458,940	90,380	349,338	75,182	356,691	88,658	356,095	1,909,470
Heart diseases	64,986	219,315	32,382	178,062	91,603	268,827	98,989	240,545	1,194,710
Diabetes	35,457	75,793	8676	35,580	32,282	79,507	20,851	35,933	324,078
Total	285,765	896,701	176,173	694,743	281,332	854,216	278,007	800,491	4,267,428

^aZeros mean no direct economic burden of diseases attributed to hearing loss and dashes mean no data available for certain subgroups in CHARLS 2011, 2013, and 2015.

Indirect Economic Burden of Productivity Loss during Hospitalization

First, we derived the mean number of hospitalization days per capita by dividing the total number of days in hospital of patients by the total number of hospitalized patients from 2011 to 2015 due to hearing loss, mental disability, hypertension, hyperlipidemia, stroke, heart diseases, and diabetes. Next, per capita productivity loss attributed to hearing loss during hospitalization was obtained by multiplying number of days in hospital per capita, average daily income, and proportion of people currently working. Last, the per capita productivity loss attributed to hearing loss during hospitalization was multiplied by the corresponding number of people hospitalized to obtain the total productivity loss, as shown in Table 5. Zeros meant no productivity loss attributed to hearing loss during hospitalization and dashes meant no data available for certain subgroups in CHARLS 2011, 2013, and 2015. When adding together, the total productivity loss attributed to hearing loss was about US$19.79 million in 2011, US$23.21 million in 2013, and US$30.29 million in 2015.

Table 5.

Indirect economic burden of productivity loss attributed to hearing loss during hospitalization among adults aged 45 and above in China from 2011 to 2015 (thousand US$).

	Male				Female				Total
	Urban		Rural		Urban		Rural
	45–59	60+	45–59	60+	45–59	60+	45–59	60+
Year 2011
Hearing loss	159.0	—	657.1	—	282.9	124.2	—	—	1223.2
Mental disability	—	1095.8	—	—	—	—	—	—	1095.8
Hypertension	89.5	129.2	29.3	98.3	35.3	109.7	36.9	55.9	584.2
Hyperlipidemia	0.0	—	—	—	—	0.0	—	0.0	—
Stroke	652.7	1940.4	184.8	943.9	152.7	582.5	220.2	531.1	5208.3
Heart diseases	838.6	3825.1	641.3	921.6	767.8	2155.2	755.7	1353.3	11,258.5
Diabetes	30.6	104.1	12.2	22.6	55.4	110.5	67.7	18.3	421.3
Total	1770.4	7094.6	1524.7	1986.4	1294.0	3082.1	1080.5	1958.6	19,791.4
Year 2013
Hearing loss	—	528.3	17.0	59.2	176.5	—	—	—	780.9
Mental disability	—	1025.6	—	44.2	700.9	—	440.2	39.1	2250.0
Hypertension	821.7	863.4	219.9	430.8	247.7	1083.3	727.5	385.4	4779.7
Hyperlipidemia	—	194.6	—	179.6	165.6	—	272.6	76.9	889.3
Stroke	1078.3	3602.3	574.1	878.7	317.2	800.5	349.3	653.8	8254.1
Heart diseases	668.8	1756.8	182.6	477.9	370.1	943.4	480.1	412.1	5291.7
Diabetes	223.5	379.3	12.8	39.1	43.4	201.4	19.3	43.3	962.1
Total	2792.3	8350.3	1006.4	2109.4	2021.2	3028.6	2288.8	1610.7	23,207.8
Year 2015
Hearing loss	137.5	160.1	139.1	130.0	248.6	126.0	138.5	45.4	1125.2
Mental disability	0.0	527.8	40.1	32.5	108.4	0.0	70.5	59.4	838.8
Hypertension	449.1	805.8	186.6	449.7	398.7	599.3	257.8	491.9	3638.8
Hyperlipidemia	26.4	14.1	6.6	11.8	35.2	38.2	19.9	22.0	174.3
Stroke	1556.0	3237.8	604.7	1512.3	648.9	1395.7	451.7	1584.7	10,991.7
Heart diseases	1093.0	2945.5	294.6	1039.1	1290.1	1716.5	871.3	1122.9	10,373.0
Diabetes	491.5	924.6	79.3	154.4	594.8	573.8	144.1	184.3	3146.7
Total	3753.4	8615.8	1351.0	3329.9	3324.5	4449.5	1953.7	3510.7	30,288.5

^aZeros mean no productivity loss attributed to hearing loss during hospitalization and dashes mean no data available for certain subgroups in CHARLS 2011, 2013, and 2015.

Indirect Economic Burden of Premature Deaths Attributed to Hearing Loss

First, the number of deaths from 2011 to 2015 was calculated by multiplying the disease-specific mortality rates with the number of population by age groups, sex, and residency. Second, the potential years of life lost (Supplementary Table 2) were obtained from the Global burden of disease (Institute for Health Metrics and Evaluation, U. o. W, 2022). Third, the present value of future income was obtained by multiplying the annual per capita income and the employment rate.

The potential years of life lost, the present value of future income, and the hearing loss attributed fraction were multiplied to obtain the indirect economic burden of premature deaths attributed to hearing loss, as shown in Table 6. Zeros meant no economic burden of premature deaths attributed to hearing loss in CHARLS 2011, 2013, and 2015. Adding together, the indirect economic burden of premature deaths attributed to hearing loss for Chinese population aged 45 and above in 2011 was US$3.23 billion; in 2013, it was US$3.70 billion; in 2015, it was US$4.20 billion.

Table 6.

Indirect economic burden of premature deaths attributed to hearing loss among adults aged 45 and above in China from 2011 to 2015 (million US$).

	Male					Female					Total
	Mental disability	Hypertension	Stroke	Heart diseases	Diabetes	Mental disability	Hypertension	Stroke	Heart diseases	Diabetes	Total
Year 2011
45–49 years old	13.9	0.8	59.9	99.1	1.3	10.6	0.6	38.3	48.1	1.1	273.8
50–54 years old	23.8	0.8	60.8	93.0	1.3	23.2	0.5	28.0	31.2	0.8	263.5
55–59 years old	62.6	1.6	109.7	155.2	2.3	48.8	0.7	38.4	43.0	1.3	463.6
60–64 years old	79.1	1.9	123.8	156.7	2.4	63.5	0.8	44.0	51.8	1.7	526.0
65–69 years old	63.6	1.3	86.8	100.4	1.6	71.3	1.0	46.6	54.6	1.7	428.9
70–74 years old	75.1	1.9	113.4	127.6	1.9	52.2	0.8	36.5	45.6	1.1	456.1
75–79 years old	73.2	1.7	93.8	107.6	1.4	55.1	0.8	35.0	44.2	0.8	413.9
80–84 years old	48.0	0.8	39.7	52.1	0.5	37.2	0.4	16.3	23.0	0.2	218.3
85+ years old	40.1	0.7	26.8	44.5	0.4	38.4	0.4	12.1	22.0	0.1	185.4
Total	479.5	11.9	714.7	936.1	13.1	400.2	6.0	295.2	363.5	9.1	3229.3
Year 2013
45–49 years old	12.6	13.7	178.1	102.6	3.5	11.1	5.9	61.0	25.5	1.5	415.7
50–54 years old	17.1	11.2	140.6	77.1	2.8	15.7	5.6	55.3	21.0	1.5	347.9
55–59 years old	31.1	13.0	160.9	79.1	3.1	34.6	4.8	81.1	32.1	2.5	442.1
60–64 years old	50.0	19.0	216.9	97.3	3.9	44.5	4.1	83.6	35.7	2.9	557.9
65–69 years old	47.3	16.9	181.7	75.2	3.1	48.6	5.9	85.3	35.3	2.8	502.0
70–74 years old	51.4	20.3	200.6	80.5	3.1	37.2	5.9	66.6	29.0	1.8	496.4
75–79 years old	44.4	15.1	140.8	59.2	2.0	36.1	4.5	54.7	24.2	1.3	382.3
80–84 years old	52.1	12.6	97.6	47.6	1.3	43.0	5.0	39.2	21.0	0.7	319.9
85+ years old	41.4	11.6	72.7	44.7	0.8	30.1	4.1	20.4	14.6	0.3	240.5
Total	347.3	133.6	1389.8	663.0	23.5	300.9	45.6	547.4	238.1	15.3	3704.7
Year 2015
45–49 years old	7.4	9.7	201.3	193.5	12.7	6.7	3.9	63.8	45.8	5.6	550.6
50–54 years old	9.8	7.9	155.4	134.4	10.5	14.0	5.7	97.1	60.2	9.3	504.3
55–59 years old	17.7	9.5	182.9	151.6	12.2	15.6	4.5	64.9	44.8	7.5	511.3
60–64 years old	24.7	10.7	194.3	141.1	11.9	27.9	6.5	95.0	65.9	11.5	589.5
65–69 years old	34.1	14.8	248.6	165.6	14.7	35.3	8.5	116.6	81.5	13.4	733.2
70–74 years old	27.1	11.8	185.1	122.9	10.2	28.7	7.7	95.8	69.3	9.3	568.1
75–79 years old	18.2	7.2	102.2	69.8	4.9	37.5	8.7	96.0	75.1	7.8	427.4
80–84 years old	20.1	5.5	65.5	52.7	2.8	15.4	2.5	23.8	21.8	1.4	211.5
85+ years old	9.7	3.0	28.6	28.7	1.1	9.5	1.3	9.5	11.2	0.5	103.2
Total	168.8	80.2	1363.8	1060.4	81.0	190.5	49.5	662.5	475.6	66.2	4198.7

^aZeros mean no economic burden of premature deaths attributed to hearing loss in CHARLS 2011, 2013, and 2015.

Total Economic Burden of Diseases Attributed to Hearing Loss

The total and per capita economic burden attributed to hearing loss were obtained by adding the direct and indirect economic burden of productivity loss and premature death attributed to hearing loss, as shown in Table 7.

Table 7.

Total economic burden of diseases attributed to hearing loss among adults aged 45 and above in China from 2011 to 2015.

	Year 2011 (%)	Year 2013 (%)	Year 2015 (%)
Direct economic burden (billion US$)	2.88 (46.99)	3.66 (49.57)	4.27 (50.24)
Indirect economic burden (billion US$)
Economic burden of productivity loss (billion US$)	0.019 (0.31)	0.023 (0.31)	0.030 (0.35)
Economic burden of premature deaths (billion US$)	3.23 (52.70)	3.70 (50.12)	4.20 (49.41)
Total economic burden (billion US$)	6.13 (100.00)	7.39 (100.00)	8.50 (100.00)
Per capita direct economic burden (US$)	82.35 (46.99)	97.96 (49.57)	106.64 (50.24)
Per capita indirect economic burden (US$)
Per capita economic burden of productivity loss (US$)	0.57 (0.31)	0.62 (0.31)	0.76 (0.35)
Per capita economic burden of premature deaths (US$)	92.23 (52.70)	99.05 (50.12)	104.92 (49.41)
Per capita total economic burden (US$)	175.14 (100.00)	197.63 (100.00)	212.32 (100.00)

The total economic burden attributed to hearing loss was US$6.13 billion in 2011, or US$175.14 per person. The direct economic burden accounted for 46.99% of the total economic burden; the productivity loss in the indirect economic burden accounted for 0.31% of the total economic burden; the premature death in the indirect economic burden accounted for 52.70% of the total economic burden.

The total economic burden attributed to hearing loss in 2013 was US$7.39 billion, or US$197.63 per person. The direct economic burden accounted for 49.57% of the total economic burden; the productivity loss of the indirect economic burden accounted for 0.31% of the total economic burden; the premature death of the indirect economic burden accounted for 50.12% of the total economic burden.

The total economic burden attributed to hearing loss in 2015 was US$8.50 billion, or US$212.32 per person. The direct economic burden accounted for 50.24% of the total economic burden; the productivity loss of the indirect economic burden accounted for 0.35% of the total economic burden; the premature death of the indirect economic burden accounted for 49.41% of the total economic burden.

Discussion

Our study is the first to estimate the economic burden of diseases attributed to hearing loss using the epidemiological attribution method. It was found that, in 2011, 2013, and 2015, the economic burden caused by hearing loss for middle-aged and older adults aged 45 and above in China was US$6.13 billion, US$7.39 billion, and US$8.50 billion, respectively. The per capita economic burden was US$175.14, US$197.63, and US$212.32, respectively, in 2011, 2013, and 2015. Among the total economic burden of hearing loss, the direct economic burden accounted for 46.99%–50.24%; the indirect economic burden of premature death accounted for 49.41%–52.70%; the indirect cost of productivity loss accounted for the least proportion of 0.31%–0.35%. It is fully confirmed that hearing loss has a significant impacts on the society and is a public health problem worthy of attention.

Our results were consistent with a previous research on the costs of hearing loss in China. The study used the Standard of Living (SoL) method and found that in 2006, the cost of rural patients with severe hearing loss was US$289; for rural people with mild hearing loss was US$139 (Loyalka et al., 2014). Turning to our study, the cost was estimated at US$175.14 to US$212.32 per person for hearing loss. The hearing loss attributed fraction for mental health was much larger than all other health conditions, meaning that hearing loss was much more related with mental health. Hearing loss can be a chronic physical stressor, which may give rise to cognition decline and lead to worse mental health (Chia et al., 2007). Furthermore, hearing loss was associated with communication breakdown, loss of images, relationships, and personal identity, resulting in other adverse psychosocial consequences (Carlsson et al., 2011).

Compared with most studies on the cost of hearing loss where productivity loss accounted for the vast majority of the total costs (e.g., 83.82% (Mohr et al., 2000) to 84.14% (Opitz & Zbaracki, 2006)), the productivity loss was relatively small in our study. It was probably because the sample of our study was limited to the middle-aged and elderly aged 45 and above, in which the elderly with zero productivity accounted for more than half of the sample. It was also worth noting that, due to data limitation, “0” in the results did not really mean true zero economic impact attributed to hearing loss, but rather the CHARLS data did not capture any samples who had the corresponding health expenditures attributed to hearing loss within the subgroups. Similarly, with the “-,” it could be that the CHARLS data by chance did not contain any samples with those health conditions, but these patients did exist in the population. We should be cautious when interpreting data “0” and “-.”

In terms of absolute values, the economic burden of hearing loss by the epidemiological attribution method can be underestimated. First, the epidemiological attribution method limited estimates for the economic burden in mental disability, hypertension, hyperlipidemia, stroke, heart diseases, and diabetes, ignoring that hearing loss may be caused by other diseases. Second, the indirect economic burden attributed to hearing loss was measured without taking into account the productivity loss due to family members taking time off work to care for patients. Besides, reduced productivity due to ill health was difficult to measure and therefore was not included. In addition, due to the complexity of reality and limitations of data, some indicators can only be roughly estimated. For example, the number of days in hospital was used to estimate the number of days off work, leading to an underestimate of the indirect economic burden attributed to hearing loss.

Our study is the first to estimate the direct and indirect economic burden attributed to hearing loss in China. The epidemiological attribution method was used to isolate the economic burden attributed to hearing loss, thus obtaining a more refined estimate and providing scientific evidence for the exact economic burden of hearing loss. However, due to data limitations, different indicators were stratified by different levels, thus causing discrepancies and certain bias to our calculation. Second, the sources of cost data in CHARLS were based on self-report, which inevitably lead to bias in the estimates. Third, due to data limitations in correlation studies of CHARLS, $O R$ was used to approximate $R R$ , which could overestimate $H L A F$ and further the economic burden of hearing loss (Schmidt & Kohlmann, 2008). Fourth, only people aged 45 and older with hearing loss were included in the study, and elderly with low productivity made up about half of the total hearing loss, making it impossible to get a complete picture of the economic burden of hearing loss. In addition, there is a lack of up-to-date hearing-related survey data nationwide, which prevents us from obtaining the most accurate estimate of the burden of hearing loss. Given the trend of increasing healthcare utilization and costs in recent years, economic burden attributed to hearing loss will continue to increase, thus placing a heavy burden on the society.

In conclusion, based on the epidemiological attribution method, our study made a conservative estimate of the economic burden of hearing loss in middle-aged and elderly people aged 45 and above in China in 2011, 2013, and 2015. It was found that the economic burden attributed to hearing loss was US$6.13 billion, US$7.39 billion and US$8.50 billion respectively. Our study can provide valuable reference for the government to formulate effective hearing prevention, screening and intervention measures to reduce the prevalence of hearing loss.

Supplemental Material

Supplemental Material - Economic Burden of Hearing Loss inMiddle‐Aged and Older Adults in China

Supplemental Material for Economic Burden of Hearing Loss inMiddle‐Aged and Older Adults in China by Xin Ye and Ping He in Journal of Applied Gerontology

Footnotes

Acknowledgments

We would like to thank all the participants in the China Health and Retirement Longitudinal Study (CHARLS).

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by the National Natural Science Foundation of China (71874005) and Major Project of National Social Science Fund of China (21&ZD187).

Ethics Approval and Consent to Participate

Ethical approval for collecting data on human subjects was received from the Biomedical Ethics Review Committee of Peking University (IRB00001052–11015). All participants provided written informed consent.

ORCID iD

Xin Ye

Supplemental Material

Supplemental material for this article is available online.

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