Roles in Successful Hearing Aid Fitting: Consumers, Audiologists and Manufacturers

We've all been bombarded with concepts and ideas to help us be more effective and efficient while fitting patients with hearing aids. Some ideas, such as real-ear measurements and target formulas, as well as advanced hearing aid prescriptive formulas have indeed allowed us better starting points for hearing instrument fittings. Additionally, manufacturers have provided us with dramatic improvements in technology as well as hearing aid fitting software and tools, with resultant increases in patient satisfaction.

Yet interestingly, rates of hearing instrument returns are not appreciably lower, and market penetration is not appreciably higher despite implementation and application of these procedures and protocols. Indeed, reported hearing aid sales per practice are down (Kirkwood, 2001).

As an audiologist working for a manufacturer, it is often my role to try to 'save' unsuccessful fittings. I have come to believe that there is a common thread which can be identified when a fitting needs saving -- that common thread is the lack of a 'comprehensive approach' in the process.

Rather than drawing upon appropriate clinical test procedures, coupled with high quality products and professional services sought by an informed consumer, the evaluation and fitting process has typically been a rushed, hodgepodge of superficial testing, anecdotal information and the latest flavor of the week hearing aid.

In brief, we fail because we set ourselves up to fail! I believe the failures occur because each party in the process has not fulfilled the responsibilities required for success.

Each party involved in the hearing aid fitting process (patient, audiologist and manufacturer) have responsibilities regarding hearing aid selection and fitting.

It is my contention that if each party maximally participates in, and attends to their unique responsibilities, the likelihood of success is dramatically increased. Therefore, I offer the following assignment of responsibilities for your consideration. These are, of course, my opinions. I hope they inspire thought, discussion and help us all improve the delivery of hearing health care.

A. Responsibilities of the Patient/Consumer:


1-- The patient is responsible to purchase hearing aids through clinical venues. As you know, people purchase hearing aids through alternative venues. Mail order hearing aids and internet hearing aids -good grief! While I am an advocate of purchasing amplification locally, I believe working with a qualified, skilled, audiologist is more important than the distance between the audiologist's office and the patient. I know. Some people don't live near an audiologist or other qualified dispensing professionals. OK, that's a given. They also don't live near a cardiologist or a pediatrician. Nonetheless, if it's important, they do what they need to do and they get where they need to go.

2-- It is the consumer's responsibility to be educated regarding the marketplace. Reading, researching, speaking with friends who have amplification, checking with professional associations and better business groups, are all critical components to successful selection of an office and an audiologist for hearing aid selection and fitting. The internet has more articles and information on hearing aids than any one person could ever read. Of course, articles regarding hearing aids and technology are also printed in periodicals such as Time and Newsweek. AARP has a very nice and informative document on hearing aids, as do many other associations. The local library is another excellent resource. While the consumer might not be able to know specific circuits or technologies, they can typically understand the general concepts if they choose to seek the information.

3-- It is the consumer's responsibility to pick the style/type of hearing aid they wish to wear. Kaplan (1991) found that one primary reason hearing aids were not worn was the inability of the patient to manipulate the instrument. Of course, selecting an instrument which one can manipulate, is now much more obvious than it may have been ten years ago. Nonetheless, sometimes professionals have a bias towards one style and will try to promote that style -- regardless of the patient's opinion, need or lifestyle. I remember a patient many years ago... A woman with severe arthritis wanted to order the smallest hearing aid on the market. At that time, it was an in-the-canal (ITC) hearing aid. Her fingers moved as a package and could not be separated. I told her she needed a larger instrument because she would not be able to insert the canal aid or it's size 312 batteries. She told me that she, not me, would select the most appropriate style for her and indeed, she wanted a canal aid. When I fit her for the first time, she could not insert the hearing aid or the battery. She left the office without being able to do either. I felt vindicated and correct. However, she returned two days later and she could remove the instrument and insert a battery more rapidly than me. I learned my lesson. Bottom line -- she knew her abilities, I did not. She knew what she required, I did not. I should not have allowed my bias to influence her hearing aid style. Since that time, my patients make the choice regarding style, not me. Consequently, consumer/patients sometimes need to take a firm stance to convince the audiologist that they (the consumer/patient) are able to pick the style of hearing aid that best meets their needs and desires and abilities. As far as I'm concerned, the days of limiting CICs to mild hearing losses is over.

4-- I believe it is the consumer's responsibility to select the most sophisticated amplification technology they can afford. This is, of course, a sore point, and one difficult to discuss because I work for a hearing aid manufacturer. I see the irony here. Nonetheless, I am going to take my manufacturer's hat off for a moment and speak as a clinician. I often encounter individuals struggling to communicate due to hearing problems. For those individuals, I recommend technology which I know will provide them with improved signal-to-noise ratios, better control of loudness, less noisy backgrounds and less distortion. Unfortunately, they often opt not to purchase technology that would help them -- due to cost! I believe we all know this to be true and common. There are many places and times where costs can be successfully contained: We can go to McDonald's instead of fancy restaurants or we can cook at home. We can probably survive very well without all of the options available through our phone and cable TV providers and we can probably even survive without cell phones. Probably. Nonetheless, when it comes to communication, cost should not be the primary consideration. The trade-off of quality versus price is too significant. Being an informed consumer and being willing to pay for better communication technology is an important part of succeeding with amplification. I cannot win the Daytona 500 in a Yugo. I cannot reach the moon in Lindberg's Spirit of Saint Louis, I cannot surf the internet with a 1968 Time magazine and I cannot communicate effectively or maximally with an analog peak clipper. You get what you pay for. It is the responsibility of the consumer/patient to spend what is required to achieve what is desired.

5-- It is the consumer's responsibility to include their family in the rehabilitation process. Davis and Mueller (1987) showed that the combined role of the family and spouse of the hearing impaired individual, was the single most motivating factor in obtaining amplification. The role of the family is so critical in successful rehabilitation processes that several researchers have stressed that we should analyze the structure of the family, the familiar interaction, the affect of the members of the family and the exchanges of assistance and support in order to plan a rehabilitation process. I am not sure if a complete family analysis is required for successful hearing aid fitting. However, I do know that if the family is included, success is much more likely.

6-- It is the responsibility of the consumer/patient to take responsibility for, and to manage their listening environment to maximize communication. Often, hearing impaired consumers/patients believe they are at the mercy of their environment and it is impossible to manipulate conditions to achieve maximum success. However, selecting a seat close to the speaker, using an infrared system at movies or in the theater, sitting in booths rather than open tables at restaurants, selecting restaurants with good acoustics, sitting so the light is on the speakers face, are all examples of communication strategies the consumer/patient can and should employ.

7-- It is the consumer's responsibility to sincerely desire to improve their hearing. If they are coming into the office to 'prove' to their spouse that they don't have a hearing loss and that amplification doesn't work, they are least likely to succeed. However, if the patient accepts their hearing loss, we can all expect a higher use time associated with hearing aids. (Jerram and Purdy, 2001)

B. Responsibilities of the Audiologist:

1-- It is the responsibility of the audiologist to take the time to perform, interpret and utilize the required tests for diagnostic and amplification and fitting purposes. When I am asked to consult as to why a given patient might not like their hearing aid I ask: Where are the patient's loudness growth contours? What are the patient's word recognition scores? How did the patient perform in noise? What was the patient's UCL scores for puretones and speech? Inevitably, those tests were not performed. It is difficult to make decisions regarding altering the patents' electroacoustic parameters when pertinent data is absent. Using and obtaining appropriate audiometric information is the responsibility of the professional. We must do what is necessary to accomplish the goal. We must take the time to explain, counsel and productively interact with our patients to educate them and to provide aural rehabilitative services (Ross and Beck, 2001).

2-- It is the responsibility of the audiologist to remain 'current' via reading the professional literature, studying, attending courses, earning CEUs and similar activities. Understanding and applying technology takes an increasingly large amount of time in the busy lives of audiologists. Maintaining competency and expertise regarding technology is the responsibility of the professional.

3-- It is the responsibility of the audiologist to discuss, explore and demonstrate Assistive Listening Devices (ALDs) with every patient. ALDs aren't highly profitable when sold and they take a large amount of time to discuss, explore and demonstrate. Yet, ALDs can often make or break a patient's ability to function in a given environment. The satisfaction of knowing patients are communicating well is worth the extra time and effort.

4-- Perhaps the most important responsibilities of the audiologist are the basic tenets of being a health care professional. Practicing within the guidelines of your license, your profession, your expertise and your ability. Doing the best you possibly can for each patient, every time. Referring the patient when necessary. Practicing within your own, and the professions moral and ethical guidelines. Providing clinical excellence and always putting the needs and welfare of the patient first. In essence, acting like a professional at all times.

5-- It is the responsibility of the audiologist to promote the profession and the products and services we provide. I believe we each have an obligation to the profession to nurture it, promote it and help assure a solid future for the benefit of the patients, the professionals who come after us, and for the benefit of the hearing health care industry.

6-- Price. We must price our services and products responsibly, with the financial status of the patients in mind. The best product, the best service and the best price combine to create the best value. The audiologist who offers the best value will garnish the greatest market share. Some manufacturing costs can be reduced (or eliminated) by highly skilled audiologists who are able to modify instruments in their office. Additionally, audiologists can help reduce or eliminate costs by taking consistently excellent ear impressions, picking flexible circuits, and packaging ear impressions carefully. The audiologist and the manufacturer, together, must take responsibility for the ultimate price of the instruments. (please see point 3 below under 'Responsibilities of the Manufacturer')

C. Responsibilities of the Manufacturer

1-- It is the responsibility of the manufacturer to continue to provide audiologists with increased flexibility and innovation regarding hearing instruments. Recently, we have had many new and exciting developments from the manufacturers...one hundred percent digital hearing aids, noise reduction circuits, feedback control circuits, multiple programs, directional mics, disposables, instant-fits, watch-controlled hearing aids, soft hearing aids and on and on. This is an exciting time. Increased flexibility and innovation is necessary for increased market penetration, increased user satisfaction, and to allow the mass media to occasionally say 'WOW - Hearing aids have sure come a long way!'

2-- It is the responsibility of the manufacturer to address 'problem areas.' We know that background noise continues to be a major problem for patients. Additionally, maintenance - specifically cerumen management-- is another area which has posed a significant problem to hearing aid manufacturers. When manufacturers successfully address these problem areas, they can anticipate a receptive audience.

3-- Price. New technology is expensive: Research is expensive. Components are expensive and the programming systems are expensive. Shipping, paperwork, administrative costs and related costs are expensive too. Nonetheless, the manufacturer who offers the best product, the best service and the best price, will do very well in a free market system. I realize manufacturers do not 'set the price' of the hearing aids, that is generally done by the audiologists. However, the price of advanced technology hearing aids has increased rapidly. Kirkwood (2001) reports these instruments were 18 percent more expensive in 2000 than in 1999. Additionally, he reported that the price of advanced technology hearing aids in 2000 was 49 percent higher than the mean price in 1997. The audiologist and the manufacturer, together, must take responsibility for the ultimate price of the instruments. (see point 6 above, in 'Responsibilites of the Audiologist')

4-- It is a responsibility of the manufacturer to develop better fitting tools and paradigms. Raymond Carhart (Carhart, 1946) said many years ago: 'The field of hearing aids is in rapid flux. Substantial changes in instrument design and performance are occurring. Our understanding of patient requirements and of the important criteria for instrument selection is becoming more definite. We may expect the confusion which has clouded the field to dissipate steadily.' Obviously, the flux that was present in 1946 is still present today. I believe we will continue to develop more definitive fitting tools to assist with improved fittings and we will indeed see Carhart's predicted dissipation of confusion in the not too distant future.

5-- It is the responsibility of the manufacturers to produce outcomes data to verify and support the statements and claims made in marketing and advertising campaigns. When a new product or circuit is designed and developed - it should be clinically tested on target patients before the product is marketed to the audiologists or the public. I am proud to inform the reader that Starkey does perform extensive clinical trials prior to releasing new products. I believe this is a practice all manufacturers would benefit from and I believe there would be definitive value in releasing outcomes data to the audiologists to help establish clinical utility.

SUMMARY:

To allow a greater and more successful symbiotic relationship to occur for consumers, audiologists and manufacturers, each must determine and accept their responsibilities. We simply cannot 'shoot from the hip.' Taking responsibility can be frightening, but by taking responsibility we assure that all the players truly do their best for the patient, the profession and the industry.

One thing is for certain, each party has a contribution to make and a responsibility to take. Perhaps the time has come to think about and accept specific responsibilities, so we can work together more successfully in the future, than we have in the past.

References:

Carhart, R. (1946) : Selection of Hearing Aids. Archives of Otolaryngology, 44, 1-18.

Davis, J.D. & Mueller, H.G. (1987): Hearing aid selection. In Communication Disorders in Aging. pp 408-436. Washington, D.C.: Gaulledet Press.

Jerram, J. C. K. and Purdy, S.C. (2001): Technology, Expectations and Adjustment to Hearing Loss: Predictors of Hearing Aid Outcome. J. Am. Acad. Audiol. 12: 64-79, February, 2001.

Kaplan, H. (1991): Benefits and limitations of amplification and speech reading for the elderly. In Adjustment to Adult Hearing Loss (ed. H. Orleans), pp 85-98. San Diego, CA: Singular Press.

Kirkwood, D. H. (2001): Most Dispensers in Journal's Survey report Greater Satisfaction With Digitals. The Hearing Journal, March, 2001, Vol 54, No. 3.

Ross, M. and Beck D.L. (2001): Expensive Hearing Aids: Investing in Technology and the Audiologist's Time. Audiology Online, March, 2001. www.audiologyonline.com.

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