The Economics of Computer-Based Auditory Training

Most audiologists agree that fitting hearing aids is just the initial step in the treatment of acquired hearing loss in adults, as there is evidence of the effectiveness of aural rehabilitation to improve long-term benefit from amplification (Sweetow & Palmer, 2005;Hawkins, 2005;Sweetow & Sabes, 2006). Some such evidence includes published reports suggesting that return for credit rates for participants in group aural rehabilitation (AR) classes is p to three times less than for patients who opt not to participate in group AR (Northern & Beyer, 1999). Few audiologists offer any type of aural rehabilitation or auditory training in their daily clinical practice, however, despite evidence supporting its effectiveness.

Historically, AR has failed to become embraced by the wider dispensing community for a number of reasons. First, it is viewed as time consuming by many practitioners. Even in the face of solid evidence supporting its effectiveness, AR has not been widely embraced because it has taken time away from the more lucrative and perhaps more rewarding task of fitting hearing aids.

Second, since the advent of digital hearing aid technology more than a decade ago, many audiologists have believed that the quality of the digital technology was enough to overcome many of the obstacles associated with postlingually acquired sensorineural hearing loss in adults. Only recently has the majority of audiologists come to realize the shortcomings of digital technology on improving listening skills. Third, many traditional AR techniques used in the past had relatively poor face validity. That is, AR exercises often have little resemblance to real-world listening situations;therefore, they were not widely embraced by clinicians or patients.

As patients have gained more access to information through the Internet and other sources, they have come to realize that there are supplemental exercises available that will help them improve their listening skills. Additionally, better educated patients seeking these types of services tend to be more demanding and are willing to shop around for this service until they can find it. For practitioners, this means they must be ready to incorporate new and innovative tools into their practices in order to remain competitive.

Although AR programs have failed to be widely embraced by patients and the profession alike, recently published reports indicate that the winds of change may be blowing. One recent article advised audiologists to change the name of the hearing aid evaluation to the functional communication assessment (Sweetow, 2007). The reason for this name change, according to the author, is to take the focus off the product and place it on the end goal of improving communication. In other words, communication is a much broader term that incorporates the value of aural rehabilitation and auditory training into a total communication package for the patient. The basic idea is that if you change the name of the procedure to reflect the current thinking, patients and clinicians will be receptive to the benefits of auditory training and therefore more likely to embrace it.

Patients are also being encouraged to think beyond the product as a solution for their communication deficits. In a recently published open letter to patients, patients were urged to fully participate in the rehabilitation process in order to get their money's worth from their investment in new hearing aids (McSpaden, 2008). An unsolicited article published in an audiology trade journal touted the overall effectiveness of self-guided AR programs on lowering the high return for credit rates that have plagued the entire industry for decades (Sederholm, 2007).

It is important to point out the difference between the terms aural rehabilitation and auditory training that, until now, have been used interchangeably in this article. AR is a much broader term encompassing several aspects of non-medical treatment for hearing loss. Traditionally, AR is offered to patients as a supplemental service when hearing aids are acquired. For example, AR includes programs such as speech reading classes, hearing aid orientation groups, and formal instruction on communication skills. In contrast, the term auditory training relates to a much narrower view of therapy. Auditory training relates to exercises patients can do to improve listening and communication in order to improve various components of auditory memory and comprehension.

Even though there is evidence supporting its effectiveness, auditory training has been thought to be both repetitive and dull. Recently, however, computer-based self-guided tools have been introduced commercially. These tools are thought to be more engaging for the patient, which is likely to result in their greater use by patients.

Currently, two computer-based self-guided auditory training programs are commercially available. The Listening and Communication Enhancement (LACE) program was developed by Neurotone and has been available clinically since 2005. The LACETM software utilizes a top-down auditory training approach automatically quantifying and reporting improvements in auditory comprehension and other related skills. Specifically, LACETM tasks target comprehension of degraded speech, enhancement of cognitive skills, and improvement of communication strategies. For the degraded speech exercises, LACE uses time compressed speech with multi-talker babble as the background noise. The Quick Speech in Noise test (Quick SIN, Etymotic Research, 2001), which is a relatively popular clinical test for assessing speech understanding in noise, is incorporated into LACE. Additionally, LACE automatically calculates improvement in these tasks and reports the results to the patient and the clinician.

Currently, Neurotone recommends that LACE exercises are completed by the patient five times per week for 20 minutes per session. LACE software is available on CD and the program can be assessed with a high speed Internet connection. A DVD version of LACE that does not require an Internet connection is also available. For a detailed overview of how LACE works, the reader is encouraged to see Sweetow and Sabes (2006) or go to www.neurotone.com.

Siemens Hearing Instruments, Inc. has recently introduced another computer-based, self-guided auditory training program, called eARena. Although similar in function to LACE, eARena uses a "bottom-up" approach in which the speech stimuli, rather than the background noise, are increased in intensity. Additionally, eARena offers some exercises that focus on non-auditory processing, such as visual memory. eARena is available on DVD and does not require a high-speed Internet connection to complete the exercises. Despite these differences with LACE, Siemens suggests that use of eARena improves overall hearing aid benefit and quality of life for patients completing the exercises (Chalupper, 2007). For more information on eARena, go to www.siemens-hearing.com.

The effectiveness of LACE has been well documented in carefully controlled studies that have been published in peer reviewed literature. Sweetow and Sabes (2006) randomly placed sixty-five patients into two groups. One group received LACE training for 30 minutes, five days per week for a period of four weeks while the control group did not receive LACE training. Patients that received the LACE training showed significant improvement in both objective and subjective measures of hearing aid outcomes. Specifically, Quick SIN scores improved 2.2 dB for the 45 dB HL presentation and 1.5 dB for the 70 dB HL presentation for LACE participants while there was no change in Quick SIN scores for the non-LACE control group.

In another carefully designed study, Sabes and Sweetow (2007) demonstrated that patients with the greatest degree of hearing loss, the poorest scores on measures of degraded speech and competing speech, and those with the highest hearing handicap scores were more likely to have greater overall improvement as a result of LACE training. Although the authors were careful to point out that there was considerable variability among the subjects' reported outcomes following LACE training, their results suggest that patients with the largest amount of measurable and perceived hearing impairment are likely to benefit the most from LACE.

Observational studies have been conducted in order to see the effect of participation in LACE training on returns for credit. Martin (2007) compared a group of 173 LACE users to a group of 452 non-LACE users over a six-month time period. Results showed that patients not participating in LACE training were four times more likely to return their hearing aids for credit.

Based on the results of these studies, participation in LACE is likely to result in a significant improvement in speech intelligibility in noise and self-perceived handicap, independent of hearing aid use. These studies, furthermore, indicate that participation in LACE has potential economic consequences for the clinic. The exact impact LACE has on the productivity of the hearing aid dispensing practice has not been formally quantified. The aim of this paper is to address the economic impact of LACE when it is systematically implemented on a wide scale in a typical practice.

In order to highlight the effectiveness of computer-based auditory training programs, a study of the impact of patient compliance on returns for credit was conducted in a typical American dispensing business. Three hearing aid dispensing offices in the state of Pennsylvania participated in this study. The mean number of hearing aids fitted per month in each office is 27, 73% of which are fitted bilaterally. During the summer of 2007, hearing care professionals in the three offices were informally trained on the administration of LACE and began randomly dispensing the program to patients at that time.

Given the reported success of LACE on reducing returns for credit (Martin, 2007) the owner of these three practices decided to implement a more systematic rehabilitation program using LACE. Beginning in January 2008, all patients fitted with hearing aids in these three offices were strongly encouraged to use LACE, regardless of audiogram thresholds, signal-to-noise ratio loss, or other key fitting variables.

In order to improve compliance, patients were strongly encouraged to complete the first LACE session in the office on the day of the fitting appointment. At subsequent follow-up appointments one, two, and three weeks post fitting, two additional LACE sessions were completed in the office. At three weeks post fitting, patients had completed a total of nine LACE sessions in the office. After the three week follow-up appointment, patients that had access to the Internet were encouraged to continue LACE independently from home.

LACE is intended to be completed by patients at home, using their personal computers. However, many patients still do not have personal computers available for easy access to LACE from home via the Internet. Therefore, an important component of the implementation of LACE in this study was conducting the sessions in the office with the support of the hearing care professional and office staff rather than self-guided home study. In all three offices participating in this study, a relatively inexpensive laptop computer was purchased and set up in a conveniently located exam room where the patient could independently complete the exercises upon arrival at the clinic for their routine appointment. This arrangement had the added patient benefit of convenient access to the clinician if a problem or question arose during training.

Ninety-six patients were randomly selected from these three offices to complete LACE in the manner described above between January 1 and March 31, 2008. Approximately 40% of the participants were experienced hearing aid users, and 60% were first-time hearing aids users. All of the patients were fitted with digital hearing aids utilizing multiple channels of wide dynamic range compression. Participants were fitted according to a clinical protocol, including the matching of a prescriptive fitting target verified with probe microphone measures. Because this was an observational study examining the effect of required compliance on returns for credit, no attempt was made to categorize participants according to audiometric variables such as threshold loss or SNR loss.

Ninety-three of the original 96 patients decided to keep their hearing aids at the end of the 30-day trial period. Based on the total number of units dispensed over the three month time period, this translated into a return-for-credit rate of 3%. All 96 patients were strongly encouraged to participate in the LACE program in the office;however, 33 (34%) of the participants did not complete all nine in-office LACE sessions. Of the individuals that did not complete all nine in-office sessions, some completed part of the nine mandatory sessions and decided to drop out of the LACE sessions. The reasons for dropping out were not determined. Of the 63 (66%) participants completing the nine sessions, all but one decided to keep the hearing aids at the end of the 30-day trial period.

Even though approximately one-third of the participants decided not to complete all nine in-office LACE sessions, only two of them returned their hearing aids for credit at the end of the 30-day trial. The average number of sessions completed for the group that did complete all nine mandatory LACE sessions was not calculated. Given this relatively low number of returns for credit for participants completing part of the mandatory sessions, it would be useful to know the minimum of LACE sessions required to maximize patient satisfaction and benefit. This question warrants further study.

Although a low return for credit rate does not equate to higher levels of patient satisfaction, as a business owner or manager, return for credit rate is an important metric of success. Based on these findings, compliance seems to be an influential factor in the success of a computer-based auditory training program, as only one of the participants who completed all nine in-office LACE sessions returned his hearing aids for credit during the time frame of this study.

The return for credit data for this practice for the first quarter of 2008 was compared to return for credit data for the same time period in 2007. For the first quarter of 2007, the return for credit rate for the three offices participating in this study was 15%, compared to a return rate of 3% for the first quarter of 2008. This improvement in return rate represents an estimated $150,000 retained revenue when extrapolated over an entire fiscal year.

Utilizing the same personnel, and with no significant changes in clinical protocol or product line, the rather dramatic improvement in return rates can be attributed to the implementation of LACE within the follow-up protocol of these offices. These findings are consistent with similar studies examining return for credit rates and patient compliance. One unpublished study (Kearby, March 17, 2008, personal communication) indicated a 75% patient compliance rate and a corresponding $400,000 in extra revenue resulting from a dramatic reduction in returns for credit.

The results of the current clinical study suggest that a key factor in the success of computer-based auditory training programs is patient compliance. The compliance issue can be managed successfully by conducting the self-guided sessions in the office as part of routine follow-up services. Moreover, there is a trend indicating that when patient compliance is 66% or better, return rates will be substantially lower, thus lost revenue will be captured. Although current implementations of computer-based auditory training programs tout the convenience of a completing the exercises from the privacy of your own home, our findings indicate that requiring the patient to complete the exercises from the clinic during routine follow-up appointments contributes to the success of the program.

Although implementation of a computer-based auditory training program within the clinician's office is somewhat contrary to the published guidelines, these findings suggest that it is worth the extra time and effort to require patients to complete the program in the office, rather than from their home. Given the facts that the reported in-the-drawer rate is over 15% (Kochkin, 2007) and that patients are constantly looking for low-cost alternatives to notoriously high- priced hearing instruments, requiring patients to complete computer-based auditory training in the office during routine follow-up appointments is likely to result in higher levels of patient satisfaction and lower return-for-credit rates.

References

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Hawkins, D. (2005). Effectiveness of counseling-based adult group rehabilitation programs: A systematic review of the evidence. Journal of the American Academy of Audiology. 16, 485-493.

Kochkin, S. (2007). MarkeTrak VII: obstacles to adult non-users adoption of hearing aids. The Hearing Journal. 60 (4), 27- 43.

Martin, M. (2007). Software-based auditory training programs found to reduce hearing aid return rate. The Hearing Journal. 60, 8.

McSpaden, J. (2008). Open letter to patients: Hard truths and "straight talk" on hearing better. The Hearing Review, 15(2), 32.

Northern, J. & Beyer, C. (1999). Reducing hearing aid returns through patient education. Audiology Today, 11(2), 10-11.

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Sederholm, S. (2007). LACE up profit and productivity. Advance for Audiologists. 9(3), 44.

Sweetow, R. (2007) Instead of a hearing aid evaluation, let's assess functional communication ability. The Hearing Journal. 60(9), 26-31.

Sweetow, R. & Palmer, C. (2005). Efficacy of individual auditory training in adults: A systematic review of the evidence. Journal of the American Academy of Audiology. 16 (7), 494-504.

Sweetow, R. & Sabes, J. (2006). The need for and development of an adaptive Listening and Communication Enhancement (LACE) Program. Journal of the American Academy of Audiology, 17(8), 538-858.