With smartphone apps that amplify speech (Mimi Hearing Test, 2016), and effective (Ear Machine, 2016) over-the-counter (OTC) hearing aids and personal sound amplification products (PSAPs) on the market, consumers may now obtain hearing devices from the comfort of home, completely bypassing the attention of an audiologist. Recent reports from the President’s Council of Advisors on Science and Technology (PCAST, 2015) and the Institute of Medicine (IoM, 2016) have called for greater access to affordable hearing aids, and the Over-the-Counter Hearing Aid Act of 2016 threatens to both legalize OTC hearing aids and remove the “burdensome requirement” that consumers obtain a medical evaluation or sign a waiver before purchasing an OTC hearing aid. With comparatively high hearing aid pricing, and inconsistent service delivery, our profession is poorly positioned to face such challenges. To remain relevant, we must defend our role as the gatekeepers of better hearing, and prove to consumers that audiologists can consistently deliver superior hearing outcomes and exceptional levels of consumer satisfaction.
Research Then and Now
As a profession, how can we achieve this ambitious goal? As it turns out, the answer has been sitting right in front of us—for at least a decade. In 2006, an extensive critical analysis of audiology research was performed by an American Academy of Audiology (the Academy) task force to identify the audiological services that are most likely to make a difference to hearing aid benefit and satisfaction. The resulting publication, Guidelines for the Audiologic Management of Adult Hearing Impairment (Guidelines) (Valente et al, 2006), identified strong evidence for the effectiveness of services like real-ear measurement (REM), electroacoustic verification of special hearing aid features, and the administration of formal self-assessments. Guidelines laid the foundation for audiological best practice in our profession, and is currently endorsed by the Academy as a practice guideline for adult rehabilitation and hearing aids.
More recently, in MarkeTrak VIII: The Impact of the Hearing Health-Care Professional On Hearing Aid User Success, Sergei Kochkin (2014) reported that hearing aid users with above average success (a composite of benefit, usage, utility, positive attitudes toward hearing aids, and quality of life changes) were more likely to have received an objective benefit measurement, a subjective benefit measurement, a patient satisfaction measurement, a loudness discomfort measurement, REMs, and testing in a sound booth. The study also reported that patients with below average success were less likely to have received personal counseling from a hearing-health professional.
While Kochkin (2010) did not include OTC hearing aids in his study, it would seem logical to assume that users of OTC hearing devices would achieve limited success due (at least in part) to the complete absence of audiological services. As it turns out, this assumption is only partially true. In A Comparison of Consumer Satisfaction, Subjective Benefit, and Quality of Life Changes Associated with Traditional and Direct-mail Hearing Aid Use, Kochkin compared mail-order hearing aid outcomes with the traditional hearing aid outcomes assessed in MarkeTrak VIII. Kochkin reported that direct-mail and traditionally fit hearing aids were “nearly equivalent on overall satisfaction and perceived benefit by the consumer,” with direct-mail hearing aids delivering greater overall consumer success than traditional hearing aids in a large number of cases.
While traditionally fit hearing aids could not compare to direct mail in terms of value (defined as dollars spent per one-percent reduction in hearing handicap), traditionally fit hearing aids were more likely to deliver greater overall consumer success if above-average fitting protocols were employed. For example, in FIGURE 1, BP1 refers to using a minimal fitting protocol, BP5 refers to using an average protocol, and BP10 refers to using a comprehensive fitting protocol.
Kochkin’s findings suggest that best practices exceed product quality when determining overall consumer success. This conclusion is supported by research from Robyn Cox (2014) that reported that consumers fit with best practices “obtain essentially equivalent improvement in speech understanding and quality of life whether they use basic-level or premium-level feature technology.” While this type of research has not been conducted using smartphone apps and PSAPs, a number of studies (Smith, 2016; Cox, 2014; Mamo, 2016; Sacco, 2016; Amlani, 2016) have reported that smartphone apps and PSAPs can provide adequate audibility for consumers with mild-to-moderate high-frequency sensorineural hearing loss. Given their audibility potential, we might expect such solutions to deliver the same degree of overall consumer success provided by the OTC hearing aids studied by Kochkin. In other words, we might expect smartphone apps and PSAPs to deliver the same degree of success as hearing aids fitted using average (or below average) fitting protocols.
Digging into this kind of research can be overwhelming. Can OTC devices really lead to the same level of consumer success as traditionally fit hearing aids? Can “basic” hearing aids really be as good as “premium” hearing aids? Rather than speculate on the accuracy of any of these conclusions, we should focus on the recurring pattern: best practices are shown again and again, regardless of product, to be an effective means of delivering exceptional hearing outcomes and consumer satisfaction.
No product can match the skill of an audiologist, and the formula for success has been repeatedly reported in the literature. There is no need for trial and error and no need to reinvent the wheel. The answer is abundantly clear and is obvious to anyone seeking an answer. Delivering exceptional care has a greater impact on consumer satisfaction than choice of device, and the use of best practices will ensure that no product will ever marginalize the services of audiologists.
Practicing Best Practice
So where does the profession stand with regard to embracing best practices? Consider the use of REMs. In 2014, Mueller estimated that routine use of REMs among audiologists and hearing instrument specialists was no higher than 30 to 40 percent. He based this estimate on a formal survey of audiologists and hearing instrument specialists (Mueller, 2010), as well as informal surveys of manufacturers’ sales reps and trainers, as well as individuals involved in the sale of probe-mic equipment. Findings from the formal survey (Meuller, 2010), which estimated routine REMs use at around 40 percent, were essentially identical to those of a 2005 survey on REM use (Mueller, 2005), suggesting that REM use did not increase following the release of Guidelines in 2006. American Speech-Language-Hearing Association’s 2014 Audiology Survey (2015), which surveyed audiologists in a variety of work settings, reported that
- 25.3 percent perform REMs daily
- 23.3 percent perform REMs weekly
- 10.4 percent perform REMs monthly
- 11.4 percent perform REMs less than monthly
- 29.6 percent never perform REMs
So, the most optimistic estimate is that only half of audiologists are using REMs semi-regularly to regularly. The reality is that a significant number of consumers, cared for by audiologists, have never had their hearing aid settings verified using REMs. The same could be said for any number of recommended best-practice clinical services. How many patients have never taken a formal self-assessment? How many have never had their loudness discomfort levels measured? How many have malfunctioning directional microphones because their hearing aids have never been assessed using a hearing aid analyzer? Is it any wonder that we feel threatened by disruption? How many of these patients could achieve the same degree of success by purchasing their next hearing solution online at Wal-Mart or CVS?
In 2014, Sergei Kochkin argued that “current customers of hearing health care are a precious commodity. In fact, they are the key driver of industry growth and profitability. Given the difficulty in attracting new hearing aid users, ways must be found to enhance consumer loyalty of current hearing aid users.” Retaining existing customers, in the face of disruptive forces, will require consistent high-quality audiological care. It is in the interest of the profession to both increase the number of audiologists using best practices, and to the extent possible, direct consumers to audiologists that will enhance consumer loyalty through the provision of best-practice care.
So, how do we achieve these goals when it seems like we’ve tried everything already? We’ve shown that best practices make a real difference to our patients’ lives. We’ve proven that tests like real-ear verification can limit return visits and reduce the number of hearing aids returned for credit (Jorgensen, 2016). We’ve embraced best practices at the organizational level by publishing guidelines and encouraging their use. It’s clear that the majority of audiologists have not yet responded to these efforts, with many historically citing the cost of equipment and time constraints as primary objections to implementing best practices (Yanz, 2007).
While the economic argument in favor of best practices has always been strong, perhaps it wasn’t strong enough. Perhaps it wasn’t tangible enough. Could today’s very tangible market pressures finally motivate more audiologists to take action? Could retaining old customers and recruiting new ones in an era of mounting competition, ultimately lead more audiologists to give best practices a second look?
The Hearing Tracker Educational Mission
If history has taught us anything, it’s that when you’re given advanced warning of a changing market, use it. In the earliest days of digital photography, Kodak estimated that it had around ten years to prepare for the transition from film to digital. Unfortunately, during its 10-year window of opportunity, Kodak did little to prepare for the expected disruption (Mui, 2012), and consequently digital photography almost completely destroyed Kodak’s film business. As audiologists, we absolutely cannot wait until the very last minute to transition. We must aggressively improve our standard of care, and initiate a coordinated educational campaign to ensure consumers know what to expect from best-practice care, where to find best-practice care, and how to value best-practice care.
The field of audiology should strive to drive the perception of quality in hearing health care. We need more patients to experience the best we have to offer, at a higher rate than they are today. If you are not already providing best practices, or are not sure whether you are, please review the Academy's Guidelines for the Audiologic Management of Adult Hearing Impairment today. If you are in a leadership position in industry, please leverage your position to bring the conversation back to best practices. We must invite all stakeholders (providers, professional organizations, industry, etc.) to look at ways to advance best practice messages to consumers. I, for one, pledge my personal support to the cause, and invite all stakeholders to connect with me to formalize a consumer outreach campaign.
While the Internet has ushered in an unprecedented level of market turbulence for audiologists, the medium has also created a unique opportunity to communicate with consumers about the importance—and value—of audiological care. Our profession needs to offer outcomes that exceed those delivered by self-service options. To drive the perception of quality, we need more patients to experience the best we have to offer, at a higher rate than they are today. There has never been a more important time to defend our role as the gatekeepers of better hearing, and we believe Hearing Tracker is a step in the right direction to do just that.
The views and opinions expressed in this article are those of the author and do not necessarily represent the official policy, position, or opinion of the American Academy of Audiology; further, the Academy does not endorse any products or services mentioned in this article.