Brian Taylor, AuD

by Brian Taylor

“Signal & Noise” is a bimonthly column by Brian Taylor, AuD

 

The May 30 installment of Signal and Noise “Good Audiology” series summarized the patient classification system devised by Stephens and Kramer a decade or so ago. It is a classification system that de-emphasizes the audiological assessment results and focuses on the emotions, attitudes and maladaptive behaviors of the individual and their communication partners.

 

A Fresh Approach for Unbundling

 

Their work laid the foundation for a fresher approach to patient care; an approach likely to gain traction in a future where the provision of unbundled counseling services will become popular.

To review, Stephens and Kramer devised a system based on four types of adult patients with hearing loss, with 80% to 90% of patients fitting into either the Type 1 or Type 2 categories. Here are their four patient categories:

  • Type 1: Positively motivated without complicating factors
  • Type 2: Positively motivated with complicating factors
  • Type 3: Wants help, but rejects a key component of your recommendation
  • Type 4: Denies any problems with hearing or communication

 

Determining Case Complexity

 

One of the challenges associated with adapting such a system is that the traditional audiological test battery, which works well for identification of ear disease when it is properly executed, has significant limitations for use in the Stephens & Kramer system. Besides the occasional asymmetrical hearing loss or poor word recognition scores, I can’t think of too many test results stemming from the traditional battery of tests that will help, say, differentiate between a Type 1 and Type 2 hearing loss.

There are, on the other hand, an abundance of non-audiologicaldimensions that contribute to differentiating a routine (Type 1) patient from the other three Types. Dimensions such as self-confidence, motivation and cognitive ability – areas beyond the degree of hearing loss – that oblige clinicians to expend more time and expertise addressing.

Surprisingly, much of the chatter and debate surrounding the creation of a direct-to-consumer device category has focused exclusively on degree of hearing loss as the sole indicator of complexity. That is, as I understand the argument, the worse an individual’s pure tone thresholds, the more crucial it is for that person to see a hearing care professional prior to using amplification.Although degree of hearing loss may have some value in necessitating the need to consult a licensed professional prior to purchase, it is the imprecise, somewhat fuzzy non-audiological dimensions that usually determine the complexity of a case.

 

A Call to Action

 

There are at least six dimensions of patient care that cannot be addressed from the traditional audiological assessment. Let’s refer to them as non-audiological or downstream components of care. Our ability to assess each of these components – either formally with a self-report or more objective screening procedure or through informal observation — is an essential part of patient care, requiring face-to-face interaction with a licensed professional.  Each of these six dimensions has sufficient evidence suggesting it influences treatment outcomes3.

Here are the six downstream dimensions, along with a brief explanation:

  1. Cognition: The executive function (memory, language comprehension, etc.) of the individual.
  2. Physical Ability: The fine motor skills of the individual, particularly haptic ability.
  3. Attitude/Motivation: The general outlook of the individual toward life and completing new tasks or changing/modifying behaviors. When judged on a continuum the individual could be stubborn to compliant or extremely optimistic to extremely pessimistic.
  4. Family Support: Consistent contact with either a family member or close friend (communication partner. On the opposite side of the family support continuum would be social isolation.
  5. Self-confidence: A trust in one’s abilities and judgements to complete a task or modify a behavior
  6. Self-perception of hearing loss: An individual’s own opinion or awareness of their ability to hear and its associated handicapping condition. Oftentimes a clinician can assess self-perception of hearing loss by asking a scaling question (“On a scale of 1 to 10 with a ten being perfect hearing, how would you rate your overall ability to hear?”).

Clinicians could go to PubMed and identify several validated tests and questionnaires that measure each of these dimensions, but it is doubtful that many of these well-designed tools would be consistently used in the clinic.

However, just because a clinician doesn’t have time to administer, score and discuss several different metrics, doesn’t mean these important dimensions of patient care can be ignored. Given the looming direct to consumer sales of hearing aids, clinicians cannot let the perfect be the enemy of the good.

 

A Practical Way to Separate Routine from Complex

 

Even though audiologists informally observe all of these dimensions, to date, there is not a consensus on how to assess each of downstream dimensions of patient care. Here is a practical approach to sizing up these critical non-audiological dimensions of patient care with the goal being categorizing each patient into one of four patient Types using the Stephens & Kramer system.

Figure 1. Communication Haxagram from Stephens and Kramer (2009)

While rank and file professionals wait for researchers to create the next generation of clinical tools, we cannot afford to idly stand by. One way to take action would be to use something like the Communication Hexagram shown in Figure 1.

The basic idea is that each of the six downstream dimensions could be assessed on a 0 to 3 continuum. The lower the number, the more problematic that particular dimension is judged to be by the clinician. Hence, a low overall score determines that an individual is deemed to be a complex case, requiring more time and/or expertise. Thus the complex case is charged more for services. Using the Communication Hexagram a perfect score would be 18. If the overall score is 12 or less, the patient could be classified as complex. Or, a score of 0 or 1 on any single dimension they classify a patient as complex. Trial and error would help us tweak these numbers, but intuitively it seems like a good starting point.

 

Jumping Off Points for Assessment, Triage and Assessment

 

Besides interpretation of the basic site of lesion audiological test battery, audiologists need to own the metrics and procedures associated with separating routine from complex cases. Work is already underway to create accurate cost effective systems that triage benign, age-related hearing loss from ear disease.Further work needs to be done to separate routine communication deficits that don’t require the intervention of a highly skilled audiologist from more complex cases that benefit from our expertise. 

  • The working definition of non-audiological dimensions are patient traits that are not determined by the routine audiological assessment of pure tone air and bone conduction audiometry, word recognition scores to ascertain best score (PB Max), acoustic reflexes, tympanometry and oto-acoustic emissions. See Jay Hall’s 2-part test battery series from June posted at Audiology Online.
  • In a 2009 Otolaryngology-Head & Neck Surgery commentary, Halpin & Rauch of Mass Eye & Ear provide a compelling case for providing a generic, one-size-fits-all, flat frequency response for cases of severe cochlear damage. Their data suggests that a patient’s word recognition ability (conducted at two different intensity levels) determines the degree of damage and not the thresholds on the audiogram. This important bit of evidence has managed to fly under the radar as the OTC debate has raged on the past few years.
  • Readers are encouraged to go to PubMed and enter hearing loss + each of the six dimensions listed above to get a flavor for the number of questionnaires, screeners and other tools used to assess each of these critical dimensions and how each contributes to treatment (hearing aid) outcomes.
  • Samantha Kleindeinst and colleagues recently published an update on CEDRA – a consumer- driven questionnaire designed to cost effectively separate cases of ear disease from benign age-related hearing problems in adults. According to their recent paper, the current version of CEDRA would miss 15% of cases with ear disease and over-refer 53% of cases without ear disease. As they continue to refine this tool, keep in mind their work is a great example of how machine learning principles, likelihood ratios and risk scores are going to change the way we practice audiology in the near future.

 

References

 

Halpin C & Rauch SD. Clinical implications of a damaged cochlea: pure tone thresholds vs information-carrying capacity. Otolaryngol Head Neck Surg. 2009 Apr;140(4):473-6. doi: 10.1016/j.otohns.2008.12.021.

Stephens D & Kramer S. (2009). Living with Hearing Difficulties: the Process of EnablementHoboken NJ: Wiley.

 

Brian Taylor, AuD, is Senior Director, Clinical Affairs, for Turtle Beach/Hypersound.   He continues to serve as Editor of Audiology Practices, the quarterly publication of the Academy of Doctors of Audiology. During the first fifteen years of his career, he practiced clinical audiology in both medical and retail settings. Since 2005, Dr. Taylor has held a variety of leadership & management positions within the hearing aid industry in both the United States and Europe. He has published over 50 articles and book chapters on topics related to hearing aids, diagnostic audiology and business management. Brian has authored three text books:  Fitting and Dispensing Hearing Aids(co-authored with Gus Mueller), Consultative Selling Skills for Audiologists, and Quality in Audiology: Design & Implementation of the Patient Experience.  His latest book, Marketing in an Audiology Practice, was published in March, 2015.  Brian lives in Golden Valley, MN with his wife and three sons.  He can be reached at brian.taylor.aud@gmail.com or brian.taylor@turtlebeach.com.

feature image courtesy of Cambridge in Color (edit)

Sound has been used throughout history as a way of exerting power and control. (Lawrence English, 2016)

The age of Personal Sound devices comes with a variety of names: PSAPs, OTCs, hearing aids, Hearables. Regardless of the name, manufacturer, or means of distribution, the core goal of such devices is to “aid” and improve communication, social interaction and (by inference) physical/mental health. Today’s list, below, is replete with a variety of methods, systems and devices along those lines.

 

So That’s Why They Don’t Eat in the Dining Room!

 

USPTO #9693548 (System and Method for Disrupting Auditory Communications Among Animals in a Defined Locale) does not make the list. It offers a contrarian approach in which low level sound disrupts communication, which is not what people with hearing difficulty need. They already face a multitude of scenarios in which their communications are disrupted; otherwise they wouldn’t need personal amplification systems. 

Nevertheless, #9693548 holds fascination and offers hints of what our futures may hold, thanks to parabolic speakers (see feature image).  The inventors (aptly named Swaddle & Hinders) make their case for a “benign” system of stationary or mobile parametric speaker arrays configured to disrupt auditory communications of a species and drive them from the ground, air, water, dining room, etc:

 “It has been found that when animals cannot communicate effectively in their usual auditory manner, [they] tend to move to a location where such auditory communication is possible. … Animal species’ auditory communications are disrupted with low sound level noise as the means to substantially reduce or eliminate the[ir] presence…in a defined locale [while]…minimizing/eliminating any noise impact on surround communities.”

Swaddle & Hinders aim to keep birds from flying in air traffic spaces, and other desirable species displacements.  But, it is a short step to substitute “humans” for “species” and imagine a variety of present and future sound environments which discourage communication and encourage human migration to more amenable spaces. Communal dining halls offer proof of concept, although the “benign” part is debatable.

It’s another short step to envision Swaddle and Hinders’ patent applied to protected open spaces (no more need for “keep off the grass” signs), galleries and libraries (no more need for “Quiet please” signs), and over-crowded public spaces. The patent offers an interesting concept to use low-level noise pollution to clean up other kinds of pollution in a benign manner.

Ultimately, though, the steps lead back to the age-old use of noise to exert power and control, per the quote that began this post. Disrupting,displacing, even sequestering large swaths of populations is not out of the question and is far from benign, no matter how low the noise level.  

Thank goodness the devices described below aim to enhance persona communication.

 

The June/July List

 

Description

Patent Number

Assignee

Issued

Hearing aid compatible audio device with acoustic noise cancellation

9672804

Apple Inc. (Cupertino, CA)

6/06/2017

Combining auditory attention cues with phoneme posterior scores for phone/vowel/syllable boundary detection

9672811

Sony Interactive Entertainment Inc. (Tokyo, JP)

6/06/2017

Arrangement with a handset device, an interface unit and a hearing device

9674326

Sonova AG (Staefa, CH)

6/06/2017

Auditory prosthesis using stimulation rate as a multiple of periodicity of sensed sound

 

9674621

Med-El Elektromedizinische Geraete GmbH (Innsbruck, AT)

6/06/2017

RF antenna and hearing device with RF antenna

9680209

Oticon A/S (Smorum, DK)

6/13/2017

Assistive hearing device for use with a telephone and a hearing aid

9681237

Bendetti, Richard J (Malibu, CA)

6/13/2017

System and method for auditory canal measuring, facial contouring

9681238

Chan, Benjamin (Markham, CA);  Ho, Stephen Kun Chung (Toronto, CA)

6/13/2017

Personalized auditory-somatosensory stimulation to treat tinnitus

9682232

The Regents of the University of Michigan (Ann Arbor, MI)

6/20/2017

Audio control using auditory event detection

9685924

Dolby Laboratories Licensing Corp (San Francisco, CA)

6/20/2017

Method of adjusting a hearing apparatus with the aid of the sensory memory

9686620

Sivantos Pte. Ltd. (Singapore, SG)

6/20/2017

Hearing aid with an antenna

9686621

GN Hearing A/S (Ballerup, DK)

6/20/2017

Hearing aid battery charging base

D789884

ZPower, LLC (Camarillo, CA)

6/20/2017

Systems and methods for positioning an intraneural electrode array in an auditory nerve

9687648

Advanced Bionics AG (Staefa, CH)

6/27/2017

Hearing assistance device control

9693152

Northwestern University (Evanston, IL)

6/27/2017

Method and apparatus for suppressing transient sounds in hearing assistance devices

9693153

Starkey Laboratories, Inc. (Eden Prairie, MN)

6/27/2017

Modular connection assembly for a hearing assistance device

9693154

Starkey Laboratories, Inc. (Eden Prairie, MN)

6/27/2017

Magnetic means assembly for bone conducting hearing aid

9693156

Oticon Medical A/S (Smorum, DK)

6/27/2017

Hearing aid system with a positioning tool

9693157

Med-El Elektromedizinische Geraete GmbH (Innsbruck, AT)

6/27/2017

Method of fitting a hearing aid and a hearing aid

 

9693159

Widex A/S (Lynge, DK)

6/27/2017

Manufacturing an electrode array for a stimulating medical device

9694174

Cochlear Limited (Macquarie University, NSW, AU)

7/04/2017

Audio control using auditory event detection

9698744

Dolby Laboratories Licensing Corporation (San Francisco, CA)

7/04/2017

Hearing aid system adapted for providing enriched sound and a method of generating enriched sound

9699571

Widex A/S (Lynge, DK)

7/04/2017

Method and apparatus for suppressing transient sounds in hearing assistance devices

9699572

Starkey Laboratories, Inc. (Eden Prairie, MN)

7/04/2017

Hearing assistance system with own voice detection

9699573

Starkey Laboratories, Inc. (Eden Prairie, MN)

7/04/2017

Method of superimposing spatial auditory cues on externally picked-up microphone signals

9699574

GN Hearing A/S (Ballerup, DK)

7/04/2017

Hearing aid device

9699575

Sonion Nederland BV (Hoofddorp, NL)

7/04/2017

Hearing aid fitting procedure and processing based on subjective space representation

9699576

University of California, Berkeley (Berkeley, CA)

7/04/2017

Electromyography response detection systems and methods

9693698

Advanced Bionics AG (Staefa, CH)

7/04/2017

Connectorized cochlear implant systems and methods

9694179

Advanced Bionics AG (Staefa, CH)

7/04/2017

Hearing assistance system comprising electrodes for picking up brain wave signals

9700261

Oticon A/S (Smorum, DK)

7/11/2017

External speech processor unit for an auditory prosthesis

9700720

Cochlear Limited (Macquarie University, NSW, AU)

7/11/2017

Hearing aid device

9706313

Oticon A/S (Smorum, DK)

7/11/2017

Transceiver for a hearing aid and a method for operating such a transceiver

9706315

Widex A/S (Lynge, DK)

7/11/2017

Method of auditory training and a hearing aid system

9706316

Widex A/S (Lynge, DK)

7/11/2017

Packet loss concealment techniques for phone-to-hearing-aid streaming

9706317

Starkey Laboratories, Inc. (Eden Prairie, MN)

7/11/2017

Adaptive residual feedback suppression

9712908

GN Hearing A/S (Ballerup, DK)

7/18/2017

System and method for master-slave data transmission based on a flexible serial bus for use in hearing devices

9710419

Sonova AG (Staefa, CH)

7/18/2017

Dual antenna system and method for charging one or more hearing aids

9712925

Siemens Aktiengesellschaft (Munich, DE)

7/18/2017

Hearing assistance system with own voice detection 

9712926

Starkey Laboratories, Inc. (Eden Prairie, MN)

7/18/2017

Packet loss concealment for bidirectional ear-to-ear streaming

9712930

Starkey Laboratories, Inc. (Eden Prairie, MN)

7/18/2017

Binaural hearing assistance system comprising two wireless interfaces

9712927

Oticon A/S (Smorum, DK)

7/18/2017

Binaural hearing system

9712928

Oticon A/S (Smorum, DK)

7/18/2017

Hearing aid gain determination system, hearing aid gain determination method, and computer program

9712931

Panasonic Intellectual Property Management Co., Ltd. (Osaka, JP)

7/18/2017

User interface control of multiple parameters for a hearing assistance device

9712932

Starkey Laboratories, Inc. (Eden Prairie, MN)

7/18/2017

Diminishing tinnitus loudness by hearing instrument treatment

9712933

Oticon A/S (Smorum, DK)

7/18/2017

System and method for calibration and reproduction of audio signals based on auditory feedback

9712934

EarIQ, Inc. (Nashville, TN)

7/18/2017

System and method for user controllable auditory environment customization

9716939

Harman International Industries, Inc. (Stamford, CT)

7/25/2017

Electromagnetic transducer with specific internal geometry

9716953

Cochlear Limited (Macquarie University, NSW, AU)

7/25/2017

Sound processing in a hearing device using externally and internally received sounds

9716952

Cochlear Limited (Macquarie University, NSW, AU)

7/25/2017

Cochlear implant electrode assembly insertion tool

9713713

Cochlear Limited (Macquarie University, NSW, AU)

7/25/2017

Stimulus timing for a stimulating medical device

9713715

Cochlear Limited (Macquarie University, NSW, AU)

7/25/2017

Method and system for electrical stimulation of a patient’s cochlea

9713714

Advanced Bionics AG (Staefa, CH)

7/25/2017

feature image from sheet 8 of USPTO #9693548