Veteran and Provider Perspectives on Rehabilitation for Severe Hearing Loss.

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Published in final edited form as: J Am Geriatr Soc. 2026 Feb 20;74(4):1089–1098. doi: 10.1111/jgs.70353 Veteran and Provider Perspectives on Rehabilitation for Severe Hearing Loss David R Friedmann 1, 2 , Arianna Winchester 1 , Olivia Bender 1, 2 , Julienne Ching 1, 2 , Andrew Nicholson 2, 3 , Frankie Hamilton 5 , Joshua Chodosh 2, 4, * , Victoria Vaughan Dickson 6, * Author information Article notes Copyright and License information 1. Department of Otolaryngology-Head & Neck Surgery, NYU Grossman School of Medicine, New York, NY 2. Veterans Affairs New York Harbor Healthcare System, New York, NY 3. Department of Population Health, NYU Grossman School of Medicine, New York, NY 4. Department of Medicine, Division of Geriatric Medicine and Palliative Care, NYU Grossman School of Medicine, New York, NY 5. NYU Rory Meyers College of Nursing, New York, NY 6. University of Connecticut Elisabeth DeLuca School of Nursing, Storrs, CT * Denotes co-senior authors ✉ Correspondence: David R Friedmann, MD, MSc, David.friedmann@va.org , David.friedmann@nyulangone.org , 550 1 st Ave Skirball Suite 7Q, New York, NY 10016. Issue date 2026 Apr. PMC Copyright notice PMCID: PMC13236391  NIHMSID: NIHMS2180804  PMID: 41720576 The publisher's version of this article is available at J Am Geriatr Soc Abstract Background: Age-related hearing loss is common and a particularly prevalent disability among Veterans. In response, comprehensive hearing services are available within the Veterans Affairs (VA) integrated healthcare system. Severe hearing loss may pose distinct communication challenges inadequately addressed by hearing aids but data suggest severe hearing loss is often not treated differently. We sought to identify barriers and facilitators to evidence-based and individualized management of severe hearing loss from the perspectives of VA clinicians and Veterans. Methods: We used purposeful sampling to conduct remote semi-structured video interviews with 33 current VA clinicians encompassing multiple disciplines and 39 Veterans with severe hearing loss over approximately an 18 month period (May 2022 to December 2023). We analyzed qualitative data using content thematic analysis. Coding categories were summarized within each participant; then across all participants to yield clinician-specific and Veteran themes. Results: In the sample of 33 VA clinicians (20 audiologists, 9 otolaryngologists and 4 primary care clinicans), the overarching theme of qualitative data is that hearing loss is undertreated in the Veteran population. Across clinician groups, the qualitative data revealed multi-level factors (system-, clinician- and patient-level) that influence the delivery of hearing care and management for Veterans with severe hearing loss. Interviews revealed that efficient access and collaborative care facilitate evidence-based practice. Among Veterans, inadequately managed hearing loss impacts quality of life; lack of knowledge and misconceptions about hearing care options and system-level barriers influence Veterans’ perceptions of their hearing care and management. Conclusion: Although hearing care is available to Veterans, multi-level factors influence the delivery of hearing care and management for Veterans with severe hearing loss. Greater attention both in primary and specialty care is needed to ensure tailored treatments are available to Veterans with severe hearing loss across the integrated VA health care system. Introduction Age-related hearing loss is the most common sensory deficit in older adults and is underrecognized and undertreated. Its prevalence is greater than 50% in those 75 years of age and older and increases with each decade of life. 1 This hearing loss pattern associated with presbycusis affects perception of high frequency sounds, important for speech understanding. The rate of hearing loss progression is multifactorial. Hearing loss is influenced by intrinsic factors such as genetic predisposition and extrinsic factors such as chronic medical conditions and environmental noise exposure. Consequently, hearing loss is not only common among older adults, but is also a common service-connected health condition among Veterans related to military noise exposure. 2 , 3 Hearing loss is associated with an array of negative health effects, 4 , 5 and communication difficulties, which negatively impact quality of life compounded by social isolation. 6 Patients with hearing loss are also less likely to participate in medical decision-making, 7 with impacts on health outcomes. The Veterans Affairs (VA) Healthcare System prioritizes comprehensive and accessible hearing care and is the largest purchaser of hearing aids in the United States. In 2022, the VA spent $430 million for 1 million hearing aids. 8 Hearing aids rehabilitate hearing loss through amplification and are effective for mild and moderate hearing loss; some patients with severe hearing loss also benefit. However, the effectiveness of hearing aids may be limited in patients with severe hearing loss because of insufficient audibility limiting speech clarity. Cochlear implantation (CI) is indicated for adults with severe-profound hearing loss when hearing aids are of limited benefit for communication. CI involves an ambulatory surgical procedure in which the implanted auditory prosthesis bypasses damaged cochlear hair cells and directly stimulates the cochlear nerve with electric pulses. This is unlike hearing aids which amplify acoustic input relying on surviving cochlear sensory hair cells for transduction to the auditory nerve. CI technology was FDA-approved for adults in 1984 but is underutilized in civilian 9 , 10 populations with ongoing analyses in the VA. 11 In recognition of the importance of age-related hearing loss, The American Geriatric Society (AGS) recently collaborated on multi-disciplinary clinical practice guidelines 12 including the key action statement that clinicians should refer patients with persistent hearing difficulty despite use of hearing aids for an evaluation of cochlear implant candidacy. This highlights an important role for primary care clinicians to consider hearing loss in care recommendations. Given limited access to hearing specialists and underutilization of hearing rehabilitation, all clinicians may play a role in recognizing quality improvement opportunities in hearing care. Our overall hypothesis is that Veterans with severe hearing loss, despite having unique rehabilitative needs, may not be treated distinctly related to a variety of patient, clinician, and organization-level factors. We conducted a qualitative investigation to identify barriers and facilitators to evidence-based delivery of hearing care for Veterans with severe hearing loss from the perspectives of VA clinicians and Veterans. Methods Study design We analyzed qualitative data elicited from in-depth interviews with audiologists, otolaryngologists/ear nose and throat doctors (ENT), primary care clinicians and Veterans with severe hearing loss. This research protocol was approved by the VA New York Harbor Healthcare System institutional review board (NYHHS IRB ID 01694). Sampling and recruitment strategy Clinicians We applied a purposive sampling strategy 13 to enroll audiologists, ENT and primary care clinicians within the VA to participate in in-depth interviews about the delivery of hearing care and management of Veterans with severe hearing loss. Our approach using key stakeholders at the different VA facilities to identify clinicians from each practice category is similar to “snowball” sampling in that we were provided contacts. However, we then used maximum variation sampling to ensure maximal heterogeneity on specific attributes (i.e., clinician type, practice population, and geographic region) that may affect treatment options and patient experience. 10 We did not restrict sampling to particular VA facilities. Clincians were contacted via e-mail including listservs of VA audiologists available to the study team. Contacted clinicians were asked to share information about our study with their colleagues and provided with our contact information. The sampling strategy yielded a diverse sample of clinicians and rich qualitative data regarding their perspectives. Veterans For Veterans, we also used a maximum variation sampling strategy, 13 a type of purposive sampling, to enroll Veterans with audiologic testing demonstrating bilateral severe hearing loss. We have previously described the procedural steps to obtain and clean the audiometric data extracted from the VA Audiometric Repository to be able to identify Veterans with severe or worse hearing loss. 11 From this database of Veterans with severe hearing loss, we obtained a random sample of 400 Veterans, oversampling for women Veterans to ensure a recruitment sample of 10% women. We applied maximum variation sampling to ensure maximal heterogeneity on specific patient-level attributes including: age, gender, race, geography, and hearing rehabilitation modality. We sent US mailings to the identified group of 400 Veterans using an opt out strategy. For those Veterans who did not opt out, we followed up by phone call to recruit them to participate. Each participant – clinicians and Veterans - provided verbal consent which included consent for audiorecording of interviews. This study adhered to the principles of the Declaration of Helsinki. 14 For clinician interviews, union notification concurrence was received from the VA Office of Labor Management Relations after review of the study and interview guide and signified that all union obligations were met. Inclusion/Exclusion Criteria Audiologists and ENT clinicians were eligible to participate if they reported working in the VA and providing care to Veterans with hearing loss. To ensure representation of varied clinical practices, we purposively sampled ENT clinicians who did and did not focus specifically on hearing loss. Similarly, we sampled audiologists that did and did not report directly providing CI care. The inclusion criteria for primary care clinicians included providing care in VA medicine clinics. We excluded clinicians with less than one year of experience working in the VA system. Veterans were eligible if they had documented bilateral severe or worse hearing loss, alive at the time of contact, and had a valid US address. Qualitative data collection A trained research assistant who is a licensed audiologist conducted 1:1 interviews with clinicians and Veterans. The semi-structured interview guide (see appendices ) for clinicians interviews consisted of open-ended questions (“ What treatment options do you consider for Veterans with severe hearing loss?”) and follow-up probes (“ Tell me about your experience with cochlear implants as a treatment option ”) to elicit in depth descriptions of the clinician perspectives of hearing care and management for severe hearing loss. The semi-structured interview guide for Veterans included open-ended questions to elicit their perspectives on hearing care (“How did you realize that you had hearing problems?”; “How are you involved in decisions related to your hearing care?”) Semi-structured interviews were conducted using videoconference platform (WebEx) and scheduled based on participant’s preference between May- September 2022 for clinicians and between June- December 2023 for Veterans. All interviews were audiorecorded and transcribed verbatim with accuracy confirmed; transcribed interviews were augmented with field notes. Interviews varied in length from 20–80 minutes, but averaged 40 minutes. Qualitative Data Analysis Qualitative data were analyzed by an expert in qualitative methods using content thematic analysis 15 and ATLAS.ti version 22.0, a qualitative analytical tool. Preliminary data coding was conducted by two trained research assistants. Intercoder reliability, 16 defined as the consistency in coding, was calculated as .94, considered adequate. We developed codes a priori based on study aims; consistent with standard practices in qualitative research; additional codes were added during the analysis. 17 Preliminary analysis included a line-by-line review yielding clusters of data that were labeled into brief headings or codes. Using ATLAS.ti analytic functions, 17 we summarized group-related codes or coding categories within-cases, that is, for each participant. We then summarized across cases for each clinician type and for Veterans. This within-across case analysis yielded a rich descriptive analysis. Patterns of coding categories derived through the ATLAS.ti networking function formed potential themes that reflected the meaning of the qualitative data. In this study, the qualitative data analytic process yielded clinician-specific and Veteran-specific themes as well as overarching themes. We maintained methodological rigor 18 throughout all phases of this analysis, including an audit trail of analytic decisions, regular meetings with experts, and member checking, the process by which findings are validated as representative of the experience of participants. Results Participant characteristics Clinicians We conducted clinician interviews with a total of 20 VA audiologists, 4 primary care and 9 ENT clinicians. Figure 1 displays a map of the Veteran-Integrated Service Networks (VISNs) from where participating audiologists practiced comprising 17 different states. We recruited VA audiologists from both high and low utilizer CI sites, as identified in the parent mixed methods study. 19 Clinical experience of clinicians at the VA ranged from one year to over 20 years; as expected, experience with CI varied by clinician type. Specific c haracteristics of the 20 audiologists indicated that 50% (10/20) had more than 5 years of experience in the VA, 90% (18/20) were involved in hearing aid dispensing while only 45% (9/20) reported being directly involved in the delivery of CI care. The four primary care clinicians included three internists and one geriatrician from three different VISNs. The otolaryngologists were widely distributed geographically representing 7 unique VISNs. Four of the nine ENT clinicians were comprehensive /general otolaryngologists or advanced practice providers while the remaining five were dedicated otologists. Figure 1. Map of the Veteran-Integrated Service Networks (VISNs) from which participating audiologists practiced. Open in a new tab Each outlined area represents a VISN and clinician participants represented 17 different states (No.: Number). Veterans In addition, 39 Veterans (90% male, 90% over age 70 years, 74% White) with severe hearing loss confirmed from audiometric records participated in in-depth interviews about their hearing loss and perceptions of facilitators and barriers to hearing care in the VA. Characteristics of Veterans participants are described in Table 1 while Figure 2 displays a map of the Veteran-Integrated Service Networks (VISNs) where these Veterans lived at time of interview. Table 1. Characteristics of participating Veterans with severe hearing loss. Maximal variation sampling was used to recruit a diverse group of participants with regards to sociodemographics and modality of hearing rehabilitation. Veterans with severe hearing loss (N=39) Characteristic N(%) Gender Male 35 (90%) Female 4 (10%) Age, years 51–70 6 (15%) 71–85 24 (62%) 85+ 9 (23% Race White 29 (74%) Non-white 10 (26%) Rurality Rural 13 (33%) Urban 26 (67%) Hearing treatment Hearing aids only 35 (87.5%) Cochlear implant 4 (10%) No hearing device 1 (2.5%) Open in a new tab Figure 2. Map of the Veteran-Integrated Service Networks (VISNs) from which Veteran participants lived. Open in a new tab Each outlined area represents a VISN and only Veterans with documented severe hearing loss participated in interviews (No.: Number). Clinician interviews System-level Factors: Barriers and Facilitators System-level factors that influence clinical management of Veterans with severe hearing loss, including referrals for CI evaluation, centered on the availability of designated CI programs within VA facilities or geographic proximity to specialists available to Veterans. As one Audiologist explained, “ Each VA is different…it can depend on the staff and the working relationships of ENT and the audiologists…” Workflow issues, including challenges in communicating with Veterans with severe hearing loss, were also cited as barriers. Several clinicians described how existing methods, including telephone and technology (for example, secure email) were often “ insufficient.” Organizational practices and referral processes seemed to vary across VA locations. Established collaborations between clinicians facilitated referrals and treatment. Conversely, the distance between referring clinicians and the implanting surgeon limits access and was identified consistently as a barrier to care. Indeed, some clinicians identified that location and distance was a criteria to consider in the referral for CI evaluation. As one Audiologist reported, “… when I want to refer…the Vet has to travel 3–4 hours…to even talk to someone…” . Table 2 provides the themes and illustrative quotes of findings from clinician interviews. Table 2: Multi-level determinants of the care of Veterans with severe hearing loss. System- provider- and patient-level factors are summarized by subtheme and accompanied by illustrative quotes. Subtheme Description Illustrative quotes System-level factors as barriers and facilitators Availability/Accessibility of resources “… we’re here in <large urban VA setting>… it’s different once you get out there…to a VA in the country…even if <CI> was available in private sector which is unlikely…the Veteran will have to come here to get treatment…” Workflow “it can be hard to communicate with patients…we do a quite a bit of secure messaging…but there is a technology gap where a lot of the patients with bad hearing loss don’t use a computer…” Referral process “We have an embedded Audiologist… great collaboration” Provider-level specific knowledge and experience influence delivery of care Knowledge and experience “I was in a CI practice, I am very comfortable talking to the Veteran…” . “…regular education programs…increasing awareness…especially for the primary care…would help get Veterans the care they need faster” “I go by the criteria but also think about the person… what other issues…heart.. dementia…” Time limitations “it’s obvious that they’re having hearing issues just doing the regular interaction. And some, I’m sure we’re missing, because we’re not screening… partially because there’s so many other things to do during the visit.” Patient-level factors inform hearing care plan Provider perceptions of Veterans “(Veterans)…see it as surgery on the brain…that can be scary…” . “The number one motivator is quality of life…to hear the grandkids…or TV…be social…” if a Vet has not kept appointments or done the other care prescribed…how will they do what’s needed for the <CI>…” Open in a new tab Clinician-level Factors Influence Delivery of Care Audiologists reported distinct roles stemming from their training and clinical experience. Most audiologists reported that the scope of their work was related to diagnostic audiology (performing hearing evaluations) and dispensing and counseling about hearing aids. Fewer were involved in delivering CI care directly and a subset of others worked at a facility that offered these services. Otolaryngologists had varied experience with clinical management of severe hearing loss and CI; none of the primary care clinicians reported knowledge or experience with CI. Across all clinician types, knowledge of and experience with clinical management of severe hearing loss including criteria for CI referral varied, thereby contributing to variations in practice patterns. Primary care clinicians were consistently identified by audiologists and otolaryngologists as lacking knowledge about hearing care and clinical management and self-endorsed this knowledge and experience gap (“I really don’t know who I should be encouraging for a referral to be considered for a cochlear implant…there’s a whole lot I don’t know about how to help people with hearing loss”) . Limited time allotted to clinical visits was cited as another barrier. Interestingly, none of the four primary care clinicians we interviewed were familiar with or knowledgeable about the hearing benefits available for Veterans. The criteria used to refer Veterans for a CI evaluation were in part influenced by knowledge and experience. When audiologists and/or ENT were familiar with VA Clinical Practice Recommendations for Cochlear Implants 20 and other published guidelines, 21 they reported adhering to specific criteria, while others seemed to add patient-specific critieria. Not all audiologists expressed confidence in their ability to identify and refer candidates for cochlear implantation. In some cases, audiologists reported consideration of a patient’s overall health and perceived or actual willingness to travel required distances to a VA facility offering CI. Audiologists were identified as the gatekeepers by all three clinician groups; primary care and ENT routinely referred Veterans with known or suspected hearing loss to audiologists for further evaluation of their hearing loss. Thus, audiologists were key to generating a recommendation for a referral for CI evaluation. In practices where the audiologist had an ongoing collaboration with a CI center, referrals for CI evaluation were more likely to be facilitated ( “… Audio facilitates so much of that process…they’re seeing patients we never see …they capture the candidates and determine candidacy on their end… ”) . The need for regular education about hearing loss and treatment was identified by all clinician groups, with a focused need on primary care clinician training. Models of care that were identified as facilitating hearing care included flexible clinical hours for “walk ins,” onsite diagnostic testing, or co-location of audiologists in specialty practice. For example, an ENT doctor described how the model of care in his practice facilitated clinical management of Veterans with severe hearing loss, “There’s a group of four cochlear implant audiologists…we have monthly meetings and communicate frequently. If other audiologists need anything, they go through one of them because they have the most direct line to us. At our VA, speech and audiology are under the same administrative structure…we have a very direct relationship with <administration>…” Patient-level Factors inform Hearing Care Plan Clinicians in our sample also identified patient-level factors that influence their clinical management. Hearing care clinicians reported that a Veteran’s attitude and acceptability of hearing aid use and/or CI as a treatment for severe hearing loss were significant considerations when planning care. Audiologists and ENT in our sample described their perception that Veterans may feel stigmatized about using hearing aids (“…Some Vets don’t want the aid…I don’t think it’s vanity…more like stigma or denial…I’m old…I’m disabled…” ). When Veterans report fear or uneasiness about the CI process, clinicians may not pursue the referral. Clinicians also reported that Veterans can be motivated to pursue care for hearing loss when they perceive quality of life will be improved. However, clinicians also identified clinical conditions that are common among many Veterans, such as dementia, severe chronic conditions (e.g., heart failure) that are likely to influence clinical management. Some also considered a Veteran’s past history of treatment adherence as an influence. Audiologists described how they evaluated outcomes of their treatment approach, which included objective verification of hearing aid function as well as patient usability and acceptability. Many of the audiologists described using measures to verify audibility, for example, to ensure the ability to hear consonant sounds in addition to subjective patient feedback. Audiologists described how weighing objective measurement of hearing with perceived self-assessment of hearing may influence treatment discussions, for example if the patient does not “ perceive their hearing as a handicap ” despite objective measurement. Another audiologist described the importance of balancing objective and subjective assessment which can change over time. In one account an audiologist explained that a Veteran’s hearing “ could be improved ” but the patient reported [his hearing] was “ good enough .” This Veteran was intially resistant to CI, but later, as he reported increased communication difficulty, he was pleased with his outcome from CI. Veteran interviews Most Veterans (35 of 39) reported hearing aids as the current treatment for their severe hearing loss; four had a CI and one reported opting for no hearing rehabilitation. In general, Veterans in this study described long histories of hearing loss (“it started in 1953 while I was in the Air Corp ”); for some hearing loss was a result of an event (“ever since that cannon went off that night…”) while others experienced progressive deterioration in their hearing (“…we didn’t have hearing protection…”) . Table 3 provides illustrative quotes for the qualitative themes that emerged from Veteran perspectives about hearing care. Table 3: Perspectives of Veterans with severe hearing loss on hearing care. Themes are summarized and accompanied by illustrative quotes. Theme Description Illustrative quotes Impact of hearing loss on quality of life Veterans’ experiences of hearing loss interfere with family, social and work activities. “I have adjusted to it. I do not depend any more on hearing and understanding 100% of everything around me.” “<hearing loss> got to a point where I just stop bothering and talking to people” Veterans’ experiences with hearing rehabilitation Hearing aid use: benefits and barriers “(hearing aids)…changes your whole perception of life…I heard birds singing and people talk…they improve your quality of life tremendously…” . “… all of a sudden [my] hearing aids go down, [I] got to wait for the 5 year period to get new…I don’t know what to do in that case …” Cochlear implants: Misconceptions and lack of knowledge. “they drill a hole in the back of the ear somewhere and then implant something…it’s a little too invasive….” “<provider> said they cut your hearing off totally forever, I don’t feel I’m ready for that…” “…I brought it up, because I had recently at the time, read an article in the paper about somebody who had gotten a cochlear implant that was 90 years old. And the gist of the article was that you’re never too old to have the procedure …” Open in a new tab The overarching theme from Veteran interviews was that hearing loss impacted their quality of life by interfering with family and other social interactions, as well as their ability to carry out necessary activities. As one Veteran explained his hearing loss, “My ears don’t pick up… it’s peaks and valleys, I lose whole parts of the word when people speak I would love to be able to hear…I miss a lot in general conversation.” Veterans described the impact of their hearing loss on their mental health as “miserable” and limiting social interactions . “I’m really out of the circle when I am in a group… I can’t hear anybody…Ive been turning down a lot of invitations.” All the Veterans in this sample reported receiving hearing aids as part of the VA benefits and most reported hearing aids were effective and impactful. Prior issues with self-management of hearing aids had improved (“…this set of hearing aids I do hear a little better…I like the idea they’re charged every night and I don’t have to carry batteries …”). New technology including Bluetooth ™ was mentioned as resolving issues with prior hearing aids. Other facilitators to hearing loss care and management included direct scheduling of appointments with VA audiologists. Audiologists were cited frequently as essential to hearing care; those that received care at a VA site with integrated services (ENT and audiology) reported efficiencies in care and decreased need for additional travel and appointments (“I never walk out without understanding”) . Consistent with clinician interviews, system-level factors including knowledgeable audiologists, access to care and integrated services facilitated hearing care. Barriers to hearing care included perceived changes in hearing aid replacement benefits, and difficulty accessing VA services including lack of transportation or safety concerns when there was a need to travel distances for care. Financial barriers to hearing aid costs and replacements were cited and may reflect a lack of knowledge about VA benefits. Several Veterans also described issues related to cost and coordination of benefits when care was accessed outside of the VA system through a contracted provider (“VA Community Care”) that influenced their decisions about hearing care. Only 12 Veterans recalled being informed about CI as a treatment option and four reported that they raised the topic to their audiologist but were either told they were not candidates or did not have questions answered sufficiently. Of the four Veterans who received CIs––each were informed of the treatment option by their VA audiologist when their hearing had deteriorated signficiantly. In two cases, surgery was not available through the Veteran’s local VA facility; referrals for care were facilitated by the VA. The four Veterans who underwent CI reported improved hearing but described challenges in adjusting after the cochlear implant surgery (“it isn’t perfect…”) . In general, there was a lack of knowledge about CIs as a treatment option for severe hearing loss and misconceptions were expressed. Many who had concern about CI described fear of invasiveness of the procedure and surgery in general. Moreover, Veterans had many unanswered questions about CIs (“How the procedure works and the cons and the pros, once you have it done, can you still shower and things like that…”) . Others described doing their own research and discussing concerns with their clinician. For those who were candidates, personal concerns about risks seemed to outweigh potential benefits; several Veterans elected to “wait and see if technology improves.” Discussion Age-related hearing loss impairs interpersonal communication. Recent studies highlight more distal negative effects on cognition 22 and overall health demonstrating the importance of hearing rehabilitation. Given the prevalence and prioritization of hearing rehabiliation in the VA, one might expect more facilitators of evidence-based care for Veterans with severe hearing loss. In this study, we identified many more barriers that influence care delivery within this integrated healthcare system. The prevailing theme of qualitative data across clinician groups was that while the VA system, in general, provides quality care to Veterans, hearing loss is often deemed a low priority and that multi-level determinants including system-, clinician- and patient-level factors influence delivery of hearing care for Veterans with severe hearing loss. The consensus among clinicians was that hearing loss was undertreated in Veterans and more Veterans would benefit from hearing evaluation and treatment. This aligns with our observed quantitative data of audiometric evaluations and management showing that 80% of Veterans with severe hearing loss are managed with hearing aids and less than 1–2% of anticipated candidates receive a CI. 19 While audiologists in the civilan population may have competing financial incentives to sell hearing aids even when patients derive limited benefit, VA audiologists do not work on commission. Instead, referral patterns may be influenced by perceived intervention efficacy, system-imposed barriers that may limit access, and perceptions surrounding patient preference including aversion towards a surgical solution to mitigate hearing loss. Greater awareness of rehabiliation options for severe hearing loss among primary care clinicians can facilitate advocacy and actionable steps to promote healthy aging across the hearing loss spectrum. Our findings align with a prior qualitative study from the United Kingdom and Australia, which also included interviews with primary care clinicians. 23 Identified barriers included poor knowledge and awareness of CI which can affect referrals and influence care recommendations. In addition to greater awareness of VA resources, work is needed to make clear to patients and all clinicians that hearing aids are not a panacea for hearing loss and that there are limitations of amplification for severe hearing loss that may be overcome with CI. Current VA recommendations require Veterans demonstrate a “lack of benefit” from hearing aids to qualify for a CI, yet until being evaluated for a CI, audiologists do not regularly assess functional or subjective outcomes of “aided” benefit. A number of publications 24 , 25 highlight this gap. However, direct outcomes assessment can help identify Veterans having persistent communication difficulties despite use of amplification. Particularly with severe hearing loss, “aided” benefit cannot be inferred from routine diagnostic audiology testing. 26 Veteran interviews provided additional insight into barriers and facilitators to hearing care. Veterans consistently identified audiologists as the clinician who initatiated the discussion about CI and to whom Veterans asked questions about surgery as a potential treatment for severe hearing loss. This suggests audiologists who often have longstanding relationships with Veterans are seen as trusted clinicians and may serve as the gatekeeper to referrals for cochlear implantation. Silos between audiologists who dispense hearing aids and audiologists who deliver CI care may contribute to the observed underutilization in CI. Globally, it has been noted that adult CI utilization lags behind children. This may be explained by a lack of hearing screening for adults and the fact that primary care clinicians (and some audiologists) are unfamiliar with CI candidacy criteria and outcomes. Collectively, this may limit patient referrals. 9 While primary care clinicians frequently also develop long standing patient relationships built on trust, primary care interviewees in this study indicated a lack of familiarty counseling patients about hearing loss and rehabilitation. It is in this context that recent guidelines 12 highlight the role for all patient-facing clinicians to advocate and recommend a CI evaluation when communication difficulty persists in patients’ with hearing aids. Veteran and clinician narratives were consistent in that both highlighted the need for clinician- and patient-education strategies to ensure Veterans are informed about treatment options. For example, clear and factual patient education to eliminate misconceptions about surgery is needed. Our study identified lack of clinician knowledge as a negative effect on treatment referral patterns. Prior studies in VA populations, 27 have demonstrated care gaps for chronic conditions attributed to geographic practice variations despite the existence of practice guidelines. Specific to CI delivery in VA 28 and non-VA settings, 10 disparate care patterns have been demonstrated based on geographic location of sites relative to where CI is available. Within the VA, coverage eligibility for services is consistent and so targeted interventions can focus on care that align with evidence-based guidelines across different geopgraphic settings and diverse facilities. To address the needs of Veterans with severe hearing loss, a collaborative work force across primary and specialty care where the spectrum of hearing loss is recognized and individualized treatment approaches are promoted. This study has several limitations. Our maximum variation sampling strategy intentionally yielded a diverse clinician sample; however, we cannot make claims that this is representative of all perspectives. Our primary care clinician sample was small but thematic saturation was achieved and the narratives were consistent with the other clinician groups. Our findings account for Veterans’ knowledge and preferences surrounding management of severe hearing loss but, of note, this was an older age (90% over the age of 70), predominantly white and, as reflected in the VA population, predominantly male. Additionally, Veterans communication ability may have limited recruitment by phone from those most impacted by hearing loss. We acknowledge this may have biased our sample towards those with better speech perception abilities; however, we did offer to speak with family members and interviews were offered through a web-based HIPAA-compliant video conference to facilitate captioning and visual cues from speech reading during the interviews. Conclusion While hearing care is available to Veterans, various barriers and facilitators were identified that impact the management of Veterans with severe hearing loss in different VA settings. As a major theme, while audiologists are the gatekeepers of hearing care, greater attention and knowledge of hearing rehabiliation at the level of primary and specialty care is needed. This would support tailored treatments consistently available to Veterans across the integrated VA health care system. Supplementary Material Veteran and clinician interview guide NIHMS2180804-supplement-Veteran_and_clinician_interview_guide.pdf (123.5KB, pdf) Key Points: Severe hearing loss leads to communication challenges requiring distinct rehabilitation strategies. Rehabilitation for severe hearing loss is impacted by patient preferences and provider knowledge both in primary and specialty care. Qualitative research with Veterans and clinicians may help explain current hearing care management and provide actionable steps toward improving care. Why does this paper matter? Rehabilitating age-related hearing loss has broad implications for healthy aging. Veterans are at particular risk for accelerated hearing loss related to exposures during training and deployment. Severe hearing loss poses particular communication challenges that require distinct treatment paradigms. The Veterans Affairs (VA) network is the nation’s largest integrated health care system and prioritizes hearing care and rehabiliation through the provision of millions of hearing aidsThis provides a unique lens to explore the management of Veteranse with severe hearing loss While cochlear implants are known to be underutilized globally, one might expect that Veterans with persistent communication challenges would be more likely to receive cochlear implants if recommended. In this paper, we identify and contextualize barriers and facilitators of evidence-based care for Veterans with severe hearing loss through semi-structured interviews with a national sample of VA clinicians including audiologists, otolaryngologists and primary care providers. We also recruited a diverse national sample of Veterans all with severe hearing loss to describe their experiences with hearing care in the VA and their preferences for rehabilitation. Understanding the system- clinician- and patient- factors that impact care are critical context to developing an intervention that support evidence-based hearing rehabilitation. Acknowledgements: Sponsor’s role: This material is based upon work supported by the Department of Veterans Affairs, Veterans Health Administration, Office of Research and Development, Health Services Research 1I21HX003141-01A1 (PI: Friedmann). Study conception and design: D.R.F. J.C., V.D.D. Data collection and analysis: O.B., J.C., A.W., F.H., A.N., D.R.F., V.D.D. Manuscript preparation, edits and approval: all co-authors. There are no conflicts of interest to disclose. This work was supported by VA Health Services Research Grant PPO 19-397 (PI: Friedmann). References. 1. Lin FR, Niparko JK, Ferrucci L. 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