Changes

May 2024 — reviewed. A literature search was conducted in March 2024 to identify evidence-based guidelines, UK policy, systematic reviews, and key randomized controlled trials published since the last revision of this topic. The recommendations have been updated in line with current evidence in the literature. The topic structure has been amended to improve clarity and navigation.

Update

Goals

To support primary healthcare professionals to:

• Carry out a thorough assessment of adults presenting with hearing loss.
• Recognise clinical features that require immediate, urgent, or routine referral to secondary care.
• Manage reversible causes where appropriate in primary care.
• Refer for further audiological assessment and follow-up where appropriate.

Outcome measures

Audit criteria

QOF indicators

QIPP - Options for local implementation

NICE quality standards

• Adults with earwax that is contributing to hearing loss or other symptoms, or preventing ear examination or ear canal impressions being taken, have earwax removed in primary care or community ear care services.
• Adults with sudden onset of hearing loss in one or both ears that is not explained by external or middle ear causes are referred for immediate or urgent specialist medical care.
• Adults with rapid worsening of hearing loss in one or both ears that is not explained by external or middle ear causes are referred for urgent specialist medical care.
• Adults presenting for the first time with hearing difficulties not caused by impacted earwax or acute infection have an audiological assessment.
• Adults presenting with hearing loss affecting their ability to communicate and hear are offered hearing aids.
• Adults with hearing aids have a follow-up audiology appointment 6 to 12 weeks after the hearing aids are fitted.

[NICE, 2019]

What is it?

• Hearing loss is common and can occur at any age. Depending on the underlying cause, it can be temporary or permanent, of sudden onset (developing within 72 hours), or slowly progressive [NICE, 2023].
  • It can be categorised as conductive, sensorineural, or mixed [Cunningham, 2017] [Michels, 2019].
    • Conductive hearing loss occurs due to abnormalities of the outer or middle ear which impair conduction of sound waves from the external ear (pinna, ear canal, or tympanic membrane) through the ossicles (malleus, incus, and stapes) in the middle ear to the cochlea in the inner ear.
    • Sensorineural hearing loss occurs due to abnormalities in the cochlea, auditory nerve, or other structures in the neural pathway leading from the inner ear to the auditory cortex.
    • Mixed hearing loss occurs when abnormalities causing both conductive and sensorineural hearing loss are present.
  • It can be categorised as mild, moderate, severe, or profound, based on the quietest sound that can be heard measured in decibels (dB HL [decibel hearing level]) on pure tone audiometry. Thresholds vary widely depending on the criteria used, for example, [Michels, 2019; RNID, 2020a]:
    • Mild hearing loss (25–39 dB) — difficulty hearing soft speech or in noisy situations.
    • Moderate hearing loss (40–69 dB) — difficulty hearing normal conversational speech at close distances without hearing aids.
    • Severe hearing loss (70–94 dB) — difficulty hearing most conversational speech; can hear loud sounds such as alarm clock; usually need to lip read or use sign language.
    • Profound deafness (more than 95 dB) — usually need to lip read or use sign language; hearing aids often not helpful; may perceive loud sounds such as machinery or car horn as vibrations.

What causes it?

The most common causes of hearing loss are ageing and exposure to excessive noise. Other causes include exposure to ototoxic substances and a wide variety of genetic, systemic, and infectious conditions.

• Causes of conductive hearing loss include [Cunningham, 2017] [Michels, 2019] [NICE, 2023]:
  • Impacted earwax (cerumen). See the CKS on Earwax for more information.
  • Foreign bodies — for example cotton bud tips.
  • Tympanic membrane perforation — may be caused by direct trauma (for example, from a head injury or cotton bud), barotrauma (for example, from scuba diving or explosive noise), or infection (for example, otitis media).
  • Infection due to otitis externa or otitis media. See the CKS topics on Otitis externa and Otitis media - acute for more information.
  • Cholesteatoma. See the CKS topic on Cholesteatoma for more information.
  • Middle ear effusion. See the CKS topic on Otitis media with effusion for more information.
  • Otosclerosis — abnormal bone growth affecting the ossicles (may cause fixation of the stapes, for example); typically presents with gradual-onset, bilateral, painless hearing loss in adults aged 30–50 years; there may be a family history; ear examination is usually normal.
  • Neoplasm — such as squamous cell carcinoma of the external ear (may present with bloody ear discharge) or vascular glomus tumour behind the tympanic membrane (typically presents with pulsatile tinnitus, a feeling of fullness in the ear, and hearing loss).
  • Exostoses — hard bony growths in the ear canal (associated with cold water swimming).
• Causes of sensorineural hearing loss include [Cunningham, 2017] [Lee, 2019] [Michels, 2019] [Nieman, 2020] [NICE, 2023]:
  • Age-related changes (presbycusis) — the most common cause of sensorineural hearing loss due to damage to the cochlear. Typically presents with slowly progressive bilateral high-frequency hearing loss after the age of 50–60 years, resulting in reduced speech perception; there may be a family history.
  • Noise exposure — this may be temporary (acute exposure to sudden loud noise typically resolves within 48 hours) or permanent, depending on the intensity and duration of exposure.
  • Sudden sensorineural hearing loss (SSHL) — this is defined as sudden-onset hearing loss (developing within 72 hours) of 30 dB HL (decibel hearing level) or more which involves three consecutive frequencies and cannot be explained by outer or middle ear conditions.
    • In 90% of cases, it is idiopathic; it may be due to viral, vascular, autoimmune, or neoplastic causes. It is usually unilateral.
    • Hearing loss can range from mild to profound and may be temporary or permanent.
  • Ménière's disease. See the CKS topic on Ménière's disease for more information.
  • Exposure to ototoxic substances — typically causes hearing loss over weeks (usually dose-dependent effect), such as:
    • Drugs including antibiotics such as gentamicin or tetracyclines; loop diuretics such as bumetanide or furosemide; nonsteroidal anti-inflammatory drugs (NSAIDs) and aspirin; anti-malarials such as quinine and chloroquine; and cytotoxic drugs such as cisplatin and bleomycin.
    • Environmental, occupational, or other toxins such as pesticides, carbon monoxide, tobacco smoke, nitriles, solvents, and heavy metals such as mercury and lead (may be occupational exposure, for example, increased risk in mechanics, boat builders, construction workers, manufacturers of metal, leather, batteries, or petroleum products, painters and decorators, vehicle or aircraft fuelling.
  • Labyrinthitis. See the CKS topic on Vertigo for more information.
  • Vestibular schwannoma (also known as acoustic neuroma) and other cerebellopontine angle lesions — a slow-growing, benign tumour which can cause hearing loss by compressing the vestibulocochlear nerve. It may rarely grow into the posterior cranial fossa and cause brain stem compression.
  • Neurological conditions — such as multiple sclerosis or stroke. See the CKS topics on Multiple sclerosis and Stroke and TIA for more information.
  • Malignancy — including nasopharyngeal cancer and intracranial tumours. See the CKS topic on Head and neck cancers - recognition and referral for more information.
    • Nasopharyngeal cancer may present with hearing loss and middle ear effusion (especially unilateral), which is not associated with an upper respiratory tract infection.
  • Trauma to the head, neck, or ear. See the CKS topic on Head injury for more information.
  • Systemic infections — congenital (such as cytomegalovirus, toxoplasmosis, syphilis) or acquired (such as meningitis, HIV, measles, mumps, Lyme disease, or herpes zoster). See the CKS topics on HIV infection and AIDS, Lyme disease, Measles, Meningitis - bacterial meningitis and meningococcal disease, Mumps, Shingles, and Syphilis for more information.
  • Autoimmune conditions — including rheumatoid arthritis, systemic lupus erythematosus, sarcoidosis, and granulomatosis with polyangiitis. These typically present with bilateral, rapidly progressive or fluctuating hearing loss. See the CKS topic on Rheumatoid arthritis for more information.
  • Genetics — the genetic basis of hearing loss is complex involving over 110 causative genes and over 6000 genetic variants. Congenital hearing loss has a genetic cause in 80% of cases. Over 400 genetic syndromes are associated with hearing loss, with variable patterns of inheritance and expressivity.

How common is it?

The reported prevalence of hearing loss is likely to be underestimated, as it is often unrecognized and a person may not present to healthcare services [Nieman, 2020] [RNID, 2022].

• Hearing loss is a common condition which can occur at any age.
  • The Royal National Institute for Deaf People (RNID) web statistics state that hearing loss affects more than 12 million people in the UK, and provides a breakdown of the prevalence of hearing loss by NHS and local authority area in the UK [RNID, 2020a].
• A key RNID Hearing Matters report states that [RNID, 2020a]:
  • There is evidence of an average delay of 10 years in people seeking help for their hearing loss. When people do seek help, GPs fail to refer 45% of people reporting hearing loss to NHS hearing services.
  • Most people with hearing loss are aged over 50 years, and prevalence increases with age. It cites evidence from a previous Medical Research Council national study of hearing, which found:
    • Hearing loss affects 41.7% of people over 50 in the UK, increasing to 71.1% of people over 70.
  • With an increasingly ageing population, it is estimated that by 2035, over 15.6 million people in the UK (one-fifth of the population) will be affected by hearing loss.
  • About 900,000 people have severe or profound deafness, and at least 24,000 of these people use sign language as their main form of language. However, the report notes that this is likely to be an underestimate.
• Additional RNID guidance on care settings states that [RNID, 2020b]:
  • An estimated 75% of people in care home settings have hearing loss. This is expected to increase to 80% by 2032.

What are the complications?

The prognosis of hearing loss depends on the underlying cause. Early identification and treatment may prevent or limit the risk of complications, such as:

• Quality of life
  • May impact social relationships and participation due to communication difficulties, leading to loss of confidence, social withdrawal, isolation, loneliness, and loss of independence [Cunningham, 2017; NHS England, 2017; Lee, 2019; Michels, 2019; NICE, 2023].
• Mental health
  • Increased risk of stress, anger and frustration, depression, and anxiety [Cunningham, 2017; NHS England, 2017; RNID, 2020a; NICE, 2023]. See the CKS topics on Depression and Generalized anxiety disorder for more information.
• Cognition
  • A Royal National Institute for Deaf People (RNID) report cites evidence from various studies that people with mild hearing loss are twice as likely to develop all-cause dementia as those without hearing loss, those with moderate hearing loss have a three-fold increased risk, and those with severe hearing loss have a five-fold increased risk [RNID, 2020a]. See the CKS topic on Dementia for more information.
  • In addition, people with cognitive impairment and dementia are less likely to recognize hearing loss as a problem and may not present, or present late, to primary care [Nieman, 2020]  [RNID, 2022].
• Physical health
  • Age-related hearing loss has been associated with increased risk of mobility problems, reduced postural control, falls, and functional decline [Cunningham, 2017; NHS England, 2017; Michels, 2019; Nieman, 2020]. See the CKS topic on Falls - risk assessment for more information.
• Healthcare use
  • Hearing loss may lead to missed healthcare appointments and visits, misunderstanding of diagnosis or treatment, failure to take medication correctly, and increased health and social care use and costs [RNID, 2022; NHS England, 2017].
  • The NHSE report also states the health of the signing Deaf community in the UK is poorer than that of the general population, with possible under-diagnosis and under-treatment of chronic conditions [NHS England, 2017].
• Education and work
  • There is an increased risk of educational underachievement, unemployment, loss of productivity, early retirement, and lower income compared with control groups with normal hearing  [Cunningham, 2017; NHS England, 2017].
  • Noise-induced hearing loss from prolonged occupational exposure is a common cause of work-related morbidity, with an estimated 11,000 people with self-reported work-related hearing problems in the years 2020–2023 [HSE, 2023].

What is the prognosis?

The prognosis of hearing loss depends on the underlying cause. Early identification and treatment may prevent or limit the risk of complications [RNID, 2020a].

• Conductive hearing loss
  • Many causes of conductive hearing loss can be fully treated in primary care (such as uncomplicated otitis media, otitis externa, or wax impaction). See the CKS topics on Earwax, Otitis externa, and Otitis media - acute for more information.
  • Rarely, some causes of conductive hearing loss can be serious or life-threatening if not identified and treated early, such as necrotising otitis externa (an invasive bacterial infection involving the external ear canal and skull base). See the CKS topic on Otitis externa for more information.

• Sensorineural hearing loss
  • Hearing loss associated with ageing and/or exposure to excessive noise is usually permanent and slowly progressive over time [Cunningham, 2017; Michels, 2019].
  • Sudden sensorineural hearing loss (SSHL)
    • Hearing loss can range from mild to profound and may be temporary or permanent.
    • A clinical practice guideline review of the literature states that 32–65% of people with SSHL have spontaneous hearing recovery. Prognosis varies with factors such as age, presence of vertigo at onset, degree of hearing loss, and duration between onset of hearing loss and treatment (Chandrasekhar, 2019).

What clinical features are associated with hearing loss?

The presenting clinical features associated with hearing loss in adults vary widely depending on the likely underlying cause.

• Conductive hearing loss occurs as a result of obstruction or damage to the outer or middle ear which can often be visualised on examination.
  • There may be symptoms of ear pain (may disturb sleep) and ear discharge. See the CKS topics on Cholesteatoma and Otitis externa for more information.
    • Be aware that potentially serious necrotising otitis externa should be excluded if ear pain and discharge do not respond to treatment within 72 hours in a person who is immunocompromised. See the CKS topic on  Otitis externa for more information.
  • There may be signs of wax impaction; foreign body; ear canal discharge, debris, or inflammation if otitis externa; or signs of otitis media. See the CKS topics on Earwax, Otitis externa, and Otitis media - acute for more information.
  • There may be signs of tympanic membrane perforation and blood in the ear canal. Small perforations may be difficult to visualise.
  • There may be signs of middle ear effusion. See the CKS topics on Otitis media - acute and Otitis media with effusion for more information.
  • There may be an abnormal appearance behind the tympanic membrane, for example a glomus tumour may present as a reddish blue mass visible behind a normal-looking tympanic membrane.
• Sensorineural hearing loss occurs as a result of abnormalities in the cochlea or other structures in the neural pathway from the inner ear to the auditory cortex. Ear examination may be normal.
  • Age-related hearing loss (presbycusis) — the person may be unaware of hearing loss. Friends or family may have noticed increasing television volume or difficulty hearing conversations. Examination is usually normal.
  • Noise-related hearing loss — typically a history of previous exposure to persistent high levels of noise or sudden loud noises (such as machinery, gunfire, or loud music). May be associated with tinnitus. Examination is usually normal.
  • Sudden sensorineural hearing loss (SSHL) — sudden-onset unilateral or bilateral hearing loss within 72 hours; may be associated with tinnitus, ear fullness or pressure, and vertigo. Examination is usually normal.
  • Labyrinthitis — hearing loss associated with tinnitus, a sensation of ear pressure or fullness, and vertigo. See the CKS topic on Vertigo for more information.
  • Ménière's disease. See the CKS topic on Ménière's disease for more information.
  • Vestibular schwannoma — typically presents with gradual onset, unilateral hearing loss which may be associated with tinnitus and/or vertigo. Ear examination is usually normal. Neurological symptoms and signs may be present if tumour is advanced and has extended into the posterior cranial fossa causing cerebellar/brainstem compression.
  • Ototoxin exposure — hearing loss is typically dose-dependent and develops over weeks. Ear examination is usually normal.

How should I assess a person presenting with hearing loss?

If a person presents with a history of hearing loss:

• Ask about:
  • Whether hearing loss is self-reported by the person, and/or others such as friends or family have noticed difficulty understanding conversations, turning the television volume up, or asking others to repeat things, for example.
  • The duration of hearing loss and whether it is sudden-onset (developing within 72 hours), rapidly progressive (within 90 days), slowly progressive, or fluctuating; unilateral or bilateral.
  • The onset, characteristics, duration, and progression of any associated symptoms, such as tinnitus, vertigo, ear pain or discharge, sensation of ear fullness or pressure, sensitivity to loud noises, cognitive impairment, or any neurological or systemic symptoms.
  • The impact of symptoms on daily and social functioning; awareness of warning sounds, the environment, and appreciation of music; communication needs and strategies at home, work, education, and social settings; impact on relationships, mood, and emotional wellbeing.
  • Any history of head or neck trauma or surgery; exposure to excessive noise (including occupational); previous chronic ear infections or hearing loss; any cognitive impairment or learning disability which may also affect recognition of hearing problems and ability to use hearing technology.
  • Any long-term conditions including immunosuppression or diabetes mellitus, stroke, dexterity issues, kidney disease, autoimmune disease, vascular disease, or neurological conditions.
  • Any family history of ear conditions or hearing loss including Ménière's disease or autoimmune disease.
  • Current or past use of any ototoxic medications; potential occupational ototoxin exposure; and smoking status.
• Examine the person:
  • Assess for any evidence of hearing difficulty, inattention, or cognitive impairment during the consultation and which ear(s) are involved.
    • Assessment may include the finger rub test or whispered voice test.
    • Be aware that a person may have normal hearing in a quiet consulting room, but could be losing sensitivity to high frequency sounds in other situations.
  • Assess the pinna and surrounding skin for signs of inflammation, infection, abnormal skin lesions, or trauma (such as haematoma).
  • Assess the ear canal and tympanic membrane (using otoscopy) to identify clinical features suggestive of conductive hearing loss such as impacted earwax; foreign body; ear canal discharge, debris, swelling, inflammation, or bleeding; tympanic membrane perforation or retraction; the absence of middle ear landmarks; or the presence of middle ear fluid.
    • Advise on the need for earwax removal if full visualisation is not possible, and arrange to re-examine the person. See the CKS topic on Earwax for more information.
  • Assess for additional signs of head or neck trauma, such as haemotympanum.
  • Assess cranial nerves and cerebellar function to exclude focal neurology, including facial nerve weakness, altered facial sensation, and ataxia.
  • Assess the head and neck for lymphadenopathy or other masses.
  • Consider use of Weber and Rinne tuning fork tests to assess for symmetrical hearing loss and distinguish between conductive and sensorineural hearing loss.
    • The British Society of Audiology (2022) publication Rinne and Weber tuning fork tests gives information on tuning fork test procedures, and how to interpret patient responses.
    • Be aware that tuning fork test results should not be interpreted in isolation.
• Advise that the Royal National Institute for Deaf People (RNID) has a free online hearing test which may be helpful for self-screening if a person suspects they have hearing loss.

Management in primary care

From age 18 years onwards.

Search strategy

Scope of search

A literature search was conducted for guidelines and systematic reviews on primary care management of hearing loss in adults. 

Search dates

August 2019 - March 2024

Key search terms

The terms listed below are the core search terms that were used for EBSCOhost MEDLINE (searched 18th July 2019). These were combined with filters to identify guidelines, systematic reviews and primary care relevant literature in EBSCOhost MEDLINE. The strategy was adapted for The Cochrane Library databases. 

S6    S1 OR S2 OR S3 OR S4 OR S5
S5    AB ( (presbyacus* or presbycus* or sociocus* or socioacus* or nosocus* or nosoacus* or anacus*) ) OR TI ( (presbyacus* or presbycus* or sociocus* or socioacus* or nosocus* or nosoacus* or anacus*) )
S4    AB deaf* OR TI deaf*
S3    AB ( (hearing N2 (loss* or difficult* or impair* or deteriorat* or deficit* or degenerat* or diminish* or disabilit*)) ) OR TI ( (hearing N2 (loss* or difficult* or impair* or deteriorat* or deficit* or degenerat* or diminish* or disabilit*)) )
S2    (MH "Persons With Hearing Impairments")
S1    (MH "Hearing Loss+")

Sources of guidelines

• National Institute for Health and Care Excellence (NICE)
• Scottish Intercollegiate Guidelines Network (SIGN)
• Royal College of Physicians
• Royal College of General Practitioners
• Royal College of Nursing
• NICE Evidence
• World Health Organization
• Guidelines International Network
• TRIP database
• Agency for Healthcare Research and Quality
• Institute for Clinical Systems Improvement
• National Health and Medical Research Council (Australia)
• Royal Australian College of General Practitioners
• British Columbia Medical Association
• Canadian Medical Association
• Alberta Medical Association
• Michigan Quality Improvement Consortium
• Singapore Ministry of Health
• National Resource for Infection Control
• RefHELP NHS Lothian Referral Guidelines
• Medline (with guideline filter)
• Driver and Vehicle Licensing Agency
• NHS Health at Work (occupational health practice)

Sources of systematic reviews and meta-analyses

• The Cochrane Library:
  • Systematic reviews
  • Protocols
  • Database of Abstracts of Reviews of Effects
• Medline (with systematic review filter)
• EMBASE (with systematic review filter)

Sources of health technology assessments and economic appraisals

• NIHR Health Technology Assessment programme
• The Cochrane Library:
  • NHS Economic Evaluations
  • Health Technology Assessments
• Canadian Agency for Drugs and Technologies in Health
• International Network of Agencies for Health Technology Assessment

Sources of randomized controlled trials

• The Cochrane Library:
  • Central Register of Controlled Trials
• Medline (with randomized controlled trial filter)
• EMBASE (with randomized controlled trial filter)

Sources of evidence based reviews and evidence summaries

• Bandolier
• Drug and Therapeutics Bulletin
• TRIP database
• Central Services Agency COMPASS Therapeutic Notes

Sources of national policy

• Department of Health
• Health Management Information Consortium (HMIC)

Patient experiences

• Healthtalk
• BMJ - Patient Journeys

Sources of medicines information

The following sources are used by CKS pharmacists and are not necessarily searched by CKS information specialists for all topics. Some of these resources are not freely available and require subscriptions to access content.

• British National Formulary (BNF)
• electronic Medicines Compendium (eMC)
• European Medicines Agency (EMEA)
• LactMed
• Medicines and Healthcare products Regulatory Agency (MHRA)
• REPROTOX
• Scottish Medicines Consortium
• Stockley's Drug Interactions
• TERIS
• TOXBASE
• Micromedex
• UK Medicines Information

Stakeholder engagement

Our policy

The external review process is an essential part of CKS topic development. Consultation with a wide range of stakeholders provides quality assurance of the topic in terms of:

• Clinical accuracy.
• Consistency with other providers of clinical knowledge for primary care.
• Accuracy of implementation of national guidance (in particular NICE guidelines).
• Usability.

Principles of the consultation process

• The process is inclusive and any individual may participate.
• To participate, an individual must declare whether they have any competing interests or not. If they do not declare whether or not they have competing interests, their comments will not be considered.
• Comments received after the deadline will be considered, but they may not be acted upon before the clinical topic is issued onto the website.
• Comments are accepted in any format that is convenient to the reviewer, although an electronic format is encouraged.
• External reviewers are not paid for commenting on the draft topics.
• Discussion with an individual or an organization about the CKS response to their comments is only undertaken in exceptional circumstances (at the discretion of the Clinical Editor or Editorial Steering Group).
• All reviewers are thanked and offered a letter acknowledging their contribution for the purposes of appraisal/revalidation.
• All reviewers are invited to be acknowledged on the website. All reviewers are given the opportunity to feedback about the external review process, enabling improvements to be made where appropriate.

Stakeholders

• Key stakeholders identified by the CKS team are invited to comment on draft CKS topics. Individuals and organizations can also register an interest to feedback on a specific topic, or topics in a particular clinical area, through the Getting involved section of the Clarity Informatics website.
• Stakeholders identified from the following groups are invited to review draft topics:
  • Experts in the topic area.
  • Professional organizations and societies (for example, Royal Colleges).
  • Patient organizations, Clarity has established close links with groups such as Age UK and the Alzheimer’s Society specifically for their input into new topic development, review of current topic content and advice on relevant areas of expert knowledge.
  • Guideline development groups where the topic is an implementation of a guideline.
  • The British National Formulary team.
  • The editorial team that develop MeReC Publications.
• Reviewers are provided with clear instructions about what to review, what comments are particularly helpful, how to submit comments, and declaring interests.

Patient engagement

Clarity Informatics has enlisted the support and involvement of patients and lay persons at all stages in the process of creating the content which include:

• Topic selection
• Scoping of topic
• Selection of clinical scenarios
• First draft internal review
• Second draft internal review
• External review
• Final draft and pre-publication

Our lay and patient involvement includes membership on the editorial steering group, contacting expert patient groups, organizations and individuals.

Evidence exclusion criteria

Our policy

Scoping a literature search, and reviewing the evidence for CKS is a methodical and systematic process that is carried out by the lead clinical author for each topic. Relevant evidence is gathered in order that the clinical author can make fully informed decisions and recommendations. It is important to note that some evidence may be excluded for a variety of reasons. These reasons may be applied across all CKS topics or may be specific to a given topic.

Studies identified during literature searches are reviewed to identify the most appropriate information to author a CKS topic, ensuring any recommendations are based on the best evidence. We use the principles of the GRADE and PICOT approaches to assess the quality of published research. We use the principles of AGREE II to assess the quality of published guidelines.

Standard exclusions for scoping literature:

• Animal studies
• Original research is not written in English

Possible exclusions for reviewed literature:

• Sample size too small or study underpowered
• Bias evident or promotional literature
• Population not relevant
• Intervention/treatment not relevant
• Outcomes not relevant
• Outcomes have no clear evidence of clinical effectiveness
• Setting not relevant
• Not relevant to UK
• Incorrect study type
• Review article
• Duplicate reference

Organizational, behavioural and financial barriers

Our policy

The CKS literature searches take into consideration the following concepts, which are discussed at the initial scoping of the topic.

• Feasibility
  • Studies are selected depending on whether the intervention under investigation is available in the NHS and can be practically and safely undertaken in primary care.
• Organizational and Financial Impact Analysis
• Studies are selected and evaluated on whether the intervention under investigations may have an impact on local clinical service provision or national impact on cost for the NHS. The principles of clinical budget impact analysis are adhered to, evaluated and recorded by the author. The following factors are considered when making this assessment and analysis.
  • Eligible population
  • Current interventions
  • Likely uptake of new intervention or recommendation
  • Cost of the current or new intervention mix
  • Impact on other costs
  • Condition-related costs
  • In-direct costs and service impacts
  • Time dependencies
• Cost-effectiveness or cost-benefit analysis studies are identified where available. 

We also evaluate and include evidence from NICE accredited sources which provide economic evaluations of recommendations, such as NICE guidelines. When a recommended action may not be possible because of resource constraints, this is explicitly indicated to healthcare professionals by the wording of the CKS recommendation.

Declarations of interest

Our policy

Clarity Informatics requests that all those involved in the writing and reviewing of topics, and those involved in the external review process to declare any competing interests. Signed copies are securely held by Clarity Informatics and are available on request with the permission of the individual. A copy of the declaration of interest form which participants are asked to complete annually is also available on request. A brief outline of the declarations of interest policy is described here and full details of the policy is available on the Clarity Informatics website. Declarations of interests of the authors are not routinely published, however competing interests of all those involved in the topic update or development are listed below. Competing interests include:

• Personal financial interests
• Personal family interest
• Personal non-financial interest
• Non-personal financial gain or benefit

Although particular attention is given to interests that could result in financial gains or losses for the individual, competing interests may also arise from academic competition or for political, personal, religious, and reputational reasons. An individual is not obliged to seek out knowledge of work done for, or on behalf of, the healthcare industry within the departments for which they are responsible if they would not normally expect to be informed.

Who should declare competing interests?

Any individual (or organization) involved in developing, reviewing, or commenting on clinical content, particularly the recommendations should declare competing interests. This includes the authoring team members, expert advisers, external reviewers of draft topics, individuals providing feedback on published topics, and Editorial Steering Group members. Declarations of interest are completed annually for authoring team and editorial steering group members, and are completed at the start of the topic update and development process for external stakeholders.

Competing interests declared for this topic:

None.