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Dr. Ross on Hearing Loss

The Hearing Aid Dispenser as the Key Factor in Determining Successful Use of a Hearing Aid

by Mark Ross, Ph.D.

Since l989 Sergei Kochkin, Executive Director of the Better Hearing Institute, has been the undisputed demographic "guru" of the hearing aid industry. Through his frequent MarkeTrak surveys, he has provided the hearing aid industry with information on the number and types of aids sold, average costs, user characteristics, return and non-use rates, problems noted, and so on. In a recent survey (The Hearing Review, April 2010) he co-authored an article called "The Impact of the Hearing Healthcare Professional on Hearing Aid User Success." What gives this article an extra boost of saliency is that he was joined by a virtual "who's-who" of leading Audiologists, thirteen as co-authors and five as reviewers. By being listed as co-authors and reviewers, these professionals are, in fact, endorsing its findings.

The basic population surveyed was drawn from the 80,000 members of the National Family Opinion panel. This panel consists of families demographically balanced using the latest census information. Several thousand new and experienced users of hearing aids less than four years old were drawn from this larger group and completed a detailed, seven-page survey. This procedure ensured: (1) that the results reflect hearing aid fitting procedures throughout the entire country and (2) that only the newest aids and current practices were sampled. It is, in brief, a valid sample of the current hearing aid fitting realities confronting hearing aid users.

One could hardly find a more important topic for consumers than this one. What this article does is take a closer look at the entire process - from selection and follow-up procedures to the personal characteristics of the dispenser. Basically, it is looking at what factors, under the control of the healthcare professional, most likely determine how successful a hearing aid user will be with his or her hearing aids. It is an article that every hearing aid dispenser should read very carefully – and then read it again. In this article, I will discuss some of the key points.

It doesn't take a rocket scientist to understand what should be done; we've known for a number of years what the various components of a "best practices" protocol should include. These have been published by the American Academy of Audiology and the American Speech-Hearing-Language Association and frequently cited in the professional literature. But knowing is one thing and actually doing is something else. The consumer survey queried whether such components as the following were included (essentially these appear to be a restatement of the recommended "best practices" protocol):

• Hearing tested in sound booth.

• Real-ear verification measurements (considered a primary factor)

• Subjective and objective benefit measurements

• Loudness discomfort measurements

• Consumer satisfaction measurements

• And a number of other components which broadly fit into the category of Aural Rehabilitation. These included auditory retraining software therapy, group follow-up program, utilization of self-help books and videos, and referral to a self-help group such as the Hearing Loss Association of America (specifically cited).

The survey also queried the respondents on the fit and comfort of their aids, whether desirable sound quality had been achieved, the attributes of the hearing health professional and the office, how many fitting visits took place and, finally, the number of counseling hours provided.

All of the above factors, separately and in combination, were then related to determine whether, and the degree to which, a person could be considered successfully fit with a hearing aid. The following, common-sense, criteria of success were used:

• Hours per day the hearing aid was used - or if it was used at all

• Rating of the aid's ability to "improve their hearing'

• Estimate of hearing problems specifically resolved by using hearing aids

• Number of listening situations, selected from a list of 19 possible ones, in which they were satisfied or very satisfied that hearing improvements were noted

• The respondent's satisfaction: Would he or she repurchase aid and recommend it and/or the dispenser to others?

The results proved to be extremely interesting and have direct implications for current clinical practices. It turns out that those people who are administered five of the specific tests in the protocol are much more likely to be satisfied users of hearing aids than those people who did not receive them. These are:

• Objective benefit measurement. This would include one of a selection of speech perception tests, preferably in the presence of noise.

• Subjective benefit measurement. An example of this type of test is the Abbreviated Profile of Hearing Aid Benefit (or APHAB). This is a 24 item test which queries people on their speech understanding in everyday types of listening environments.

• Loudness discomfort measures. These determine the maximum tolerable loudness level, preferably while wearing the hearing aid.

• Real-Ear (probe-tube microphone) test. This test measures the actual sound levels exiting the hearing aid receiver while the hearing aid is being worn by the user.

• Patient satisfaction measurement. A good example – there are a number of others – of a patient satisfaction measure is the Satisfaction with Amplification in Daily Life scale (or SADL – Audiologists do love their acronyms!).

The information these tests provide a dispenser markedly increases the chances that a consumer will be successfully fit with a hearing aid. Unfortunately, the reality situation, in terms of how many people recall actually receiving these tests, is not a cause for optimism about the state of hearing aid dispensing practices. In this survey (which provides the best large-scale data available), it appears that less than 70% of the respondents recall receiving objective benefit and loudness discomfort tests; only about 40% of the respondents received real-ear measures, while subjective benefit and satisfaction measures were obtained on only 20% of the survey respondents. These are troublesome statistics and their implications are clear: The majority of hearing aid wearers have not received services that can best help them be successful hearing aid users.

These five tests/measurements were not the only factors that were related to whether someone can be considered a successful user of hearing aids. As noted above, the people completing this survey were also asked to respond to a number of other questions regarding their hearing aid selection experiences. As we would expect, positive personal attributes of the hearing aid dispenser and the office environment itself contributed to a positive result, as did the number of hours devoted to counseling.

While the relationship of each of the factors surveyed in the study was individually analyzed, a review of each would be beyond the scope of this article. What I found most interesting was the cumulative effect of the factors in determining successful versus unsuccessful hearing aid use. While all of them may not be of equal importance, still, as each new factor is added to the selection process, success rates clearly increase. In other words, they all made a contribution, albeit some more than others. The most successful users were those who received all of the protocol factors considered in the survey. As I read the results of this study, they essentially validate the "best fitting" hearing aid fitting protocol recommended by the professional associations.

It is my impression, probably shared by the authors of this study, that most hearing aid dispensers are well aware that they could be doing more for their clients to ensure a successful fit. Many and varied are the excuses that are given why they don't do so. For example, in regards to the frequent omission of real-ear measures when fitting a hearing aid, we hear such reasons as the high cost of the equipment, the extra time expended, inconsistency with the accepted practice in a clinic, disbelief in its efficacy, and the belief that what is being done is "good enough." Probably the most potent is simple inertia; getting out of a rut, simply doing something differently than one has been comfortably doing for a number of years. For those who feel this way, some other results reported in the survey may help them change their minds and, perhaps, climb out of their rut.

When the most successful and least successful hearing aid users were compared in respect to whether they would repurchase the hearing aid brand, or would recommend the hearing aid and the dispenser to others, the successful ones unambiguously said yes, they would recommend the dispenser and the hearing aid to others. Furthermore, successful users are not the people who return their aids during the trial period or whose aids wind up in the dresser drawer. On the contrary, these individuals are satisfied customers, likely to be the best source of referrals for new and repeat business. In other words, investing the extra time and effort to ensure that hearing aids are fit properly is a wise business decision. But more importantly, it is also a professional obligation, as was made very clear in a provocative and much discussed article that appeared late last year in Audiology Today (the organ of the American Academy of Audiology).

In the article, the author (Dr. Catherine Palmer) presented a very strong argument that following "best practices" when fitting hearing aids is not some optional choice ("You do it your way and I'll do it mine"), but rather a matter of professional ethics. Ordinarily, when one thinks of "ethics" it is for such matters as real or perceived conflicts of business interests, engaging in deceptive sales practice, etc. But Dr. Palmer makes the case that ethical practices also involve clinical procedures. Thus, for example, when a dispenser does not personally measure the maximum output of a hearing aid, or verify its performance through real-ear measures, it is not only poor clinical practice but may indeed be unethical. Indeed, the code of ethics of both the American Speech-Language-Hearing Association and the American Academy of Audiology makes it very clear that failure to follow best practices is a violation. And, in my opinion, it should be treated as such with violators held responsible for their actions (or lack of them). I understand that the details in best practices are not engraved in stone, that personal variations are a necessity in a clinical practice, and that ethical dispensers will differ on this or that detail. But, still, as the Kochkin article makes clear, there are irreducible minimums that must be adhered to if one is to be considered engaging in the "best practices" fitting of hearing aids. In the long run, we all benefit, hearing aid dispensers and consumers alike.

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