Hearing Aid Adoption and Satisfaction Increase With Audiologist Involvement Participants who received audiologic services were more likely to purchase their devices, according to a study comparing “audiology best practices” with a “consumer-decides” service delivery model. Features
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Features  |   May 01, 2017
Hearing Aid Adoption and Satisfaction Increase With Audiologist Involvement
Author Notes
  • Margaret Rogers, PhD, CCC-SLP, is ASHA chief staff officer for science and research. mrogers@asha.org
    Margaret Rogers, PhD, CCC-SLP, is ASHA chief staff officer for science and research. mrogers@asha.org×
  • Bridget Murray Law, ASHA Leader editor-in-chief, and Lisa Satterfield, MS, CCC-A, associate director of ASHA’s National Center for Evidence-Based Practice, contributed to this article.
    Bridget Murray Law, ASHA Leader editor-in-chief, and Lisa Satterfield, MS, CCC-A, associate director of ASHA’s National Center for Evidence-Based Practice, contributed to this article.×
Article Information
Hearing Disorders / Hearing Aids, Cochlear Implants & Assistive Technology / Features
Features   |   May 01, 2017
Hearing Aid Adoption and Satisfaction Increase With Audiologist Involvement
The ASHA Leader, May 2017, Vol. 22, 54-57. doi:10.1044/leader.FTR3.22052017.54
The ASHA Leader, May 2017, Vol. 22, 54-57. doi:10.1044/leader.FTR3.22052017.54
Consumers are more likely to follow through with purchasing hearing aids—and are more likely to report satisfaction with their aids—when an audiologist following best practices is involved in the process, indicates the first placebo-controlled, double-blind, randomized clinical trial of hearing aid outcomes.
In the study, participants who received customized hearing aid programming and real-ear verification, education, and related counseling from an audiologist were nearly one-and-a-half times more likely to keep their hearing aids than those who did not. With 81 percent of those in the “audiology best practices” group and only 55 percent of those in the “consumer-decides” group electing to purchase the hearing aids after six weeks, the study found a 26 percentage-point higher rate of adoption for the “audiology best practices” group.
The study was led by Larry Humes, a distinguished professor in the Department of Speech and Hearing Sciences at Indiana University Bloomington, and was published in March in the American Journal of Audiology.
“Even though millions of Americans have hearing loss, there has been an absence of rigorous clinical research that has demonstrated clear benefits provided by hearing aids to older adults,” says Humes. “Consequently, the U.S. Preventive Services Task Force has not been able to support widespread hearing screening for adults over age 50. This study, along with others to follow, will help establish the evidence base needed to foster better hearing health care for many older Americans.”
To examine potential benefits of receiving hearing health care from an audiologist, the study compared the outcomes of a placebo (P) group and two service delivery conditions—an audiology “best practices” (AB) group and a “consumer-decides” (CD) group. Regardless of group assignment, all participants received the exact same high-end, digital, mini-behind-the-ear hearing aids fitted bilaterally (ReSound Alera 9). The aids have multiple-channel compression, as well as options for feedback cancellation, noise reduction and directional microphones. Additionally, all participants received a comprehensive audiologic assessment prior to randomization to one of the three study groups.
Three conditions
To reach its results, the study assigned 154 adults, ages 55 to 79, with symmetrical, mild–moderate sensorineural hearing loss into three groups. The groups received the exact same device but the provision of services differed as did the programming options (see chart below).
  • Audiology best practices (AB): An audiologist conducted a comprehensive audiologic assessment, recommended hearing aids and fitted and programmed the hearing aids for optimal performance. Participants in the AB group also received a 45- to 60-minute hearing aid orientation session that, according to the article, included a review of the “components, features, and functions of the hearing aid; the insertion and removal of batteries; the insertion and removal of the hearing aids; maintenance practices; telephone use; and adjustment of volume. Supervised hands-on practice was provided for several of these skills. Participants were also counseled about benefits and limitations of hearing aids and effective communication strategies to use. A graduated usage schedule was also recommended.”

  • Consumer decides (CD): An audiologist conducted a comprehensive audiologic assessment of all participants. Following video instructions, participants in the CD group were presented with three bins of hearing aids that varied with respect to three preset programming configurations (to match the three most common patterns of hearing loss among older adults), each in three different colors, and several sizes of domes and tubes from which to choose. They were instructed to try them and select what they wanted. Participants in the CD group did not receive real-ear verification or adjustments of their hearing aids’ response, a hearing aid orientation or any other services from an audiologist until the end of the study.

  • Placebo (P): An audiologist conducted a comprehensive audiologic assessment and recommended hearing aids, but programmed the hearing aids for those in the P group to noncustomized (not beneficial) settings with a 0-dB insertion gain.

Note that there is a distinction between “audiology best practices” and “audiology common practices.” Unfortunately, these are not one and the same, as practice surveys show that not all audiologists’ common clinical practice coincides with the best practices recommended by various professional organizations, including ASHA.
Results and implications
Because prior research has demonstrated that hearing aid outcomes in older adults is a multidimensional construct, Humes and his team examined outcomes across a number of domains. These included measuring participants’ ability to comprehend connected speech in noise with and without the device, their satisfaction with the device, the perceived benefit of the device, and the amount of time that the device was used. Another outcome measure considered to have high ecological validity was whether participants wanted to retain their hearing aid at the end of the trial.
A key outcome of interest in this study was the perceived real-world benefit of the hearing aids in everyday life as judged by the users. The 66-item Profile of Hearing Aid Performance (PHAP) was used to compare the perceived benefit of using the device. The difference between unaided and aided PHAP global scores, which is the average score across five communication-related subscales (Familiar Talkers, Ease of Communication, Reverberation, Reduced Cues and Background Noise) yielded the Profile of Hearing Aid Benefit (PHABglobal). This was the primary outcome measure in this study. The scores for the AB and CD groups on this relative benefit measure were significantly better than the P group, but did not differ significantly from one another. The same pattern of findings was observed for the secondary outcome measure in this study: perception of speech in noise.
The study also found that the CD group demonstrated significantly lower hearing aid satisfaction scores than the AB group on the Hearing Aid Satisfaction Survey, including both the 19-item set on hearing aid features and the 13-item set pertaining to dispenser-related processes. The responses of participants in the CD group on the latter set was predictable given that the CD group had no real interactions with a dispensing audiologist. According to the article, “the CD service-delivery model yielded considerably smaller effect sizes than the AB model for measures of satisfaction with the hearing aids’ function and features and the daily usage of the devices.”
In addition, the participants in both the AB and CD groups reported 12–18 percentage points of improvement on a measure of perceived hearing handicap (Handicap Inventory for the Elderly), both significantly better than the P group.
The researchers also evaluated two price options, and cost was not a significant factor for any of the outcome measures. However, it did have some bearing on the final decision to purchase hearing aids. A significantly higher percentage of those who were not likely to retain their hearing aids at the end of the six-week trial had paid the higher purchase price ($3,600 versus $600 per pair). Further study revealed that those who returned their hearing aids at the end of the study—after six weeks for AB participants and after 10 weeks for the CD and P participants—tended to have less hearing loss and were younger than those who kept them.
At the end of the six-week trial, 81 percent of those who received the AB model decided to keep their hearing aids, compared with 55 percent of the CD group and 35 percent of the P group. When offered an additional four-week trial with programming, hearing aid orientation and counseling from an audiologist, 95 percent of those in the CD and P groups combined took the opportunity, and 91 percent of those ultimately purchased the hearing aids.
After using their hearing aids for six weeks, participants in both the CD and AB groups performed significantly better than the P group on the Connected Speech Test. Those CD and P participants who later received continued services from audiologists reported significantly greater benefit and greater satisfaction with their hearing aids and they were more likely to purchase the hearing aids at the end of the study. These statistically significant advantages for the audiology best-practices group are clinically important because when hearing aid users experience benefits early on, they may be more motivated to continue using the aids.
At present, there is no FDA regulatory classification specific for over-the-counter (OTC) hearing aids, though the FDA has moved in that direction. In response to recently introduced OTC hearing aid legislation in Congress, ASHA released a position statement reiterating the value of the audiology best-practices model, but positing that in some cases OTC hearing aids may be appropriate as “an early gateway, specifically for adults with mild hearing loss, with the hearing aids restricted in gain and output thresholds.” The statement also maintains that OTC hearing aids should not be a substitute for coverage of audiologic services by third-party payers.
Hearing aids are already available for direct-to-consumer online purchase, often with a video orientation and manual, and that changes care, notes Lisa Satterfield, associate director of audiology for ASHA’s National Center for Evidence-Based Practice. “When purchased online—and not through an audiologist—the consumer has limited technical assistance and less likelihood of programming devices according to their hearing loss, and they risk letting a potentially serious condition that may underlie their hearing difficulties go undetected,” says Satterfield. “We know from U.S. and international studies that most individuals with hearing loss wait until their hearing severity is moderate or worse before seeking hearing aids. It is promising that the research demonstrated similar clinical outcomes and that OTC could be a potential entry for individuals with mild hearing loss. However, it is not clear if they will take advantage of the option.”
Also, Satterfield points out, as found in this study, there is less likelihood that the patient will be satisfied with the hearing aid and keep it. “One key takeaway was that those who worked with an audiologist did better in ways that, in real-world terms, would lead to greater long-term outcomes for use and perceived benefit of the hearing aid,” she says.
When asked about the bottom line, Humes says, “Although tempting to declare a winner, AB or CD, such a determination would be premature. Statistics from the hearing aid industry since 1970 have repeatedly demonstrated that about 20 percent of American adults who have hearing loss and could benefit from hearing aids actually seek help and purchase hearing aids. The outcomes reported in our clinical trial are positive and on par with those from other less rigorous studies for audiology-based service provision.
“In sum,” continues Humes, “audiology-based services have been doing a good job for the 20 percent seeking help. The CD approach, and OTC approach in general, however, target the other 80 percent—those who don’t seek services through the conventional pathway. The fact that most of the outcomes were similar for the AB and CD approaches is encouraging for the 80 percent not being served currently. As those who enter the hearing health care arena through such CD or OTC pathways will probably need additional help in the future, they would likely turn to health care professionals, such as audiologists, for such assistance. This would be even more likely if the audiologist’s practice facilitated their initial entry into the CD/OTC pathway, perhaps by incorporating such service-delivery options within their practices.”
Meanwhile, Humes calls for further research to assess the generalizability of this study’s results across other patient populations and service-delivery models—one of these being “unbundling,” which involves breaking out and separately billing costs of the hearing aid, accessories and associated audiologic services. “The results of this study should serve as a yardstick for comparing outcomes of future hearing aid studies,” he says.
What Does ‘Consumer Decides’ Mean? And How is OTC Defined?

The “consumer decides” (CD) model of hearing aid delivery tested in the Humes study is not the typical “consumer does everything” model associated with over-the-counter (OTC) dispensing, as explained by Larry Humes in a video available on YouTube.

Typically, in many OTC models:

  • Consumers determine whether they need a hearing aid.

  • Consumers have a wide range of choices, from simple to very sophisticated devices.

  • Purchase decisions are based largely on information provided by the manufacturer, recommendations or consumer reports, but opportunities to try devices without a purchase commitment are not typical.

  • Consumers must troubleshoot and manage problems themselves.

  • Consumers are not provided with an orientation, consultation, guided practice or other components of auditory rehabilitation.

The CD model in the Humes study differs from a typical “consumer does everything” OTC model in several important ways. In the Humes study:

  • Participants in the CD group did not have a wide array of choices. They could choose only one type of hearing aid—a high-end model with three pre-set programming options.

  • Participants in the CD group watched an instructional video on the self-selection process. Three notebook binders of step-by-step instructions were also provided.

  • Participants in the CD group were able to try the hearing aids, with the various sizes of domes, tubes and the three pre-set programming options, for as long as they needed to make their selection. They could also use a tablet computer to listen to speech, music and other sounds to help them compare options.

Also, because audiologists conducted comprehensive audiologic examinations on all participants, they identified any concomitant conditions that might affect participants’ hearing or cognitive ability. Participants were excluded from the study if there were any ear canal obstructions, eardrum abnormalities, middle-ear pathologies, or evidence of declining cognition or fluctuating or rapidly progressing hearing loss. Those using medications that affect hearing or with multiple sclerosis (MS) or Meniere’s disease were also excluded. Humes noted that “of the 135 participants excluded from participation in the clinical trial, 17 (or 12.6 percent) had contraindications noted above (10 with otological issues; nine with conductive hearing loss components; five failed the cognitive screening; and two had MS), with the rest excluded because their hearing loss was either too mild or too severe for inclusion in this study.”

In a typical OTC model, there are no such opportunities to detect conditions that can complicate the intervention or that might be reversible, progressive or possibly life-threatening.

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May 2017
Volume 22, Issue 5