By Garrett Thompson, AuD
The fourth and final panel installment of this series continues to examine why audiologists need not be so fearful about the possibility of a future rife with OTC devices. The data pretty clearly shows that there will be a continued demand from consumers for customized hearing care delivered by audiologists and other licensed professionals.
Japanese Model
Japan has offered OTC available hearing devices for many years. Image courtesy The Telegraph
An important model to study on a national scale is the hearing aid market of Japan, where OTC devices are readily available in retail stores, on the Internet, and via mail order (Hougaard et al., 2013).
In one particular study (Hougaard et al., 2013), hearing aid uptake in Japan was the lowest of all developed countries, at 14%, compared to an average of 35% in France, Germany, the United Kingdom, and the United States. Additionally, only 39% of hearing aid users were satisfied with their devices, compared to approximately 80% in the other developed countries.
However, who is to say what the results will be in a model that offers both conventional and OTC hearing aids? Could these OTC users add to the ones that are already using the traditional model?
Cultural difference between West and East also play a confounding role in trying to analyze these data, as views on aging and disability are quite different.
As the patients will ultimately decide if they want to engage with an OTC device at some point along their journey, it is essential to consider the evidence about perceptions of OTCs. Here’s what we know so far:
Patient Perception Study #1
A recent survey (Plotnick & Dybala, 2017) of 809 adults was conducted to assess their opinion of a potential OTC hearing aid. The sample was adults aged 50 years and older, geographically and socioeconomically diverse, and most had little experience with hearing aids; this is thought to be emblematic of the market interested in low cost OTC hearing devices.
The results indicated that 93.8% of survey respondents considered the involvement of a hearing care professional in the selection, fitting, and programming of a hearing aid to be either very important or absolutely important. Interestingly, 95.3% of respondents were only willing to spend $200 or less on an OTC hearing aid (Plotnick & Dybala, 2017).
On the whole, consumers understand the potential benefits of direct-to-consumer hearing aids, but they also express reservations and a preference for the involvement of an audiologist (Kochkin, 2014; Chandra & Searchfield, 2016; Plotnick & Dybala, 2017).
Patient Perception Study #2
In a semi-structured interview survey of 18 older adults (Chandra & Searchfield, 2016), the perception of internet-purchased HAs is mixed. Most participants were unaware that hearing aids can be purchased online. When the process was described to them, several themes emerged from participants’ responses. They recognized potential benefits of purchasing aids online, such as perceived lower cost and increased convenience and physical accessibility.
There were reservations among participants about purchasing aids online, though, including whether and how clinical procedures would be performed in the assessment and fitting of hearing aids; procedures noted were hearing evaluation, fine-tuning of hearing aids, and physical ear mold modifications.
Participants also conveyed a general distrust of online retailers, which included a lack of trustworthiness, a lack of trust in the brand of hearing aid, and a fear of scammers. Several participants stated that they preferred involvement of an experienced professional in the hearing aid fitting process, and they considered this type of expert advice and support to not be available in an online retail framework (Chandra & Searchfield, 2016).
Patient Perception Study #3
Similar results were found in a survey asking 80 older adults about their perception of a hearing aid which is self-fit without the involvement of an audiologist (Convery et al., 2011). Participants noted potential benefits such as increased convenience and the ability to self-adjust the device, however they also expressed a preference for professional guidance through the fitting process.
About half of the participants responded affirmatively to all three of the following: that a self-fitting aid was a good idea, that it would be of personal benefit, and that it could be managed independently by the user (Convery et al., 2011).
The way I interpret these data is that OTC devices will produce mixed results, helping a sizeable proportion of customers but leaving many others unsatisfied. From the relatively limited evidence that exists, the proportion of successful OTC consumers, characterized as those that are at least somewhat satisfied or have at least moderate improvement in QOL, ranges from 39-58% (Hougaard, 2013; Kochkin, 2014; Convery et al., 2015; Convery et al., 2016; Tedeschi & Kihm, 2016; Humes et al., 2017).
For individuals that are successful with the devices, OTCs represent a high value product that may improve hearing, reduce the handicap associated with hearing loss, and increase quality of life (PCAST, 2015). This represents a public health boon that audiologists should support. However, although OTCs provide decent benefit and great value, an overwhelming majority of patients have reservations about self-care and still want a professional to be involved in the process (Convery et al., 2011; Kochkin, 2014; Chandra & Searchfield, 2016; Plotnick & Dybala, 2017).
OTCs may be a reasonable self-treatment option, used in conjunction with professional collaboration, for the vast majority of people with mild-to-moderate hearing loss who do not seek treatment from the traditional hearing healthcare delivery model (see below).
Hearing loss segmented by degree. Courtesy Brian Taylor (2015)
Although they have the potential to make a positive public health impact, OTC devices have significant weaknesses and don’t fix non-cost-related reasons why people don’t wear hearing aids. The legislation and OTC devices themselves fail to overcome the stigma associated with wearing hearing aids or the difficulties that individuals in the target market have with dexterity problems, among other shortcomings. The focus on OTC devices fails to address the importance of family and community support networks and self-management of hearing loss in difficult listening situations (Hogan et al., 2015).
If I haven’t lost you in that too-long look at OTC studies, congratulations to you and for your reward, here is a photo of a turtle that chose fight:
In the fight-or-flight decision over OTC hearing aids, the obvious choice is fight. Ironically, I don’t mean fight the legislation or fight change in general. I mean fight the urge to give up.
Anyone suggesting that OTCs will take down our profession is implicitly saying that our knowledge and skills can be replaced by a device and a CVS clerk. To that I say: come at me, bro!
I find that sentiment to be utterly ridiculous, and the evidence clearly suggests that patients want a professional’s involvement in the hearing aid process. Future-thinking audiologists should see OTCs as an opportunity, and they should be prepared to augment the hearing healthcare of both satisfied and unsatisfied OTC users. For patients who are experiencing success with OTC devices, audiologists have a role in objectively documenting their status and adding value via counseling, real ear measures, speech in noise testing, and validation questionnaires.
For OTC users who are not satisfied with their devices, the audiologist has a role in improving their performance and introducing them to services and devices that may provide more benefit including aural rehabilitation, hearing assistive technologies, and traditional hearing aids.
In a more general sense, the future will bring more change to our profession, not less. If we think every threat will end us, and our strategy is to be discouraged and run away, then this will become a self-fulfilling prophecy. One example of this I have seen is people explicitly discouraging potential audiology students from joining the profession. I’m all for giving people the whole truth and letting them decide for themselves, but in my opinion this recommendation and this attitude in general, is a much, much, much greater threat to the profession than OTC devices.
Final Remarks
In conclusion, the OTC conversation has stirred the pot tremendously, but I hope the information presented in this series will calm some nerves. In my opinion OTCs will not trivialize our profession, and they will help (to some degree) millions of people who have previously not engaged with hearing healthcare. As audiologists, our core mission is to help people communicate better, not to help them communicate better with hearing aids, on our terms.
We should be excited to help people hear better regardless of whether the technology we employ is via an app, OTC, hearing aid, cochlear implant, or even hair cell regeneration.
Thanks for reading. Here is that cute baby again:
References:
Chandra, N., & Searchfield, G. D. (2016). Perceptions Toward Internet-Based Delivery of HAs among Older Hearing-Impaired Adults. Journal of the American Academy of Audiology, 27(6), 441-457.
Convery, E., Keidser, G., & Hartley, L. (2011). Perception of a self-fitting hearing aid among urban-dwelling hearing-impaired adults in a developed country. Trends in Amplification, 15(4), 175-183.
Convery, E., Keidser, G., Seeto, M., Yeend, I., & Freeston, K. (2015). Factors affecting reliability and validity of self-directed automatic in situ audiometry: Implications for self-fitting hearing aids. Journal of the American Academy of Audiology, 26(1), 5-18.
Convery, E., Keidser, G., Seeto, M., & McLelland, M. (2016). Evaluation of the self-fitting process with a commercially available hearing aid. Journal of the American Academy of Audiology.
Hogan, A., Phillips, R. L., Brumby, S. A., Williams, W., & Mercer-Grant, C. (2015). Higher social distress and lower psycho-social wellbeing: examining the coping capacity and health of people with hearing impairment. Disability and Rehabilitation, 37(22), 2070-2075.
Hougaard, S., Ruf, S., & Egger, C. (2013). EuroTrak+ JapanTrak 2012: Societal and personal benefits of hearing rehabilitation with hearing aids. Hearing Review, 20(3), 16-26.
Humes, L. E., Rogers, S. E., Quigley, T. M., Main, A. K., Kinney, D. L., & Herring, C. (2017). The Effects of Service-Delivery Model and Purchase Price on Hearing-Aid Outcomes in Older Adults: A Randomized Double-Blind Placebo-Controlled Clinical Trial. American Journal of Audiology, 26(1), 53-79.
Keidser, G., & Convery, E. (2016). Self-fitting hearing aids: Status quo and future predictions. Trends in Hearing, 20, 2331216516643284.
Kochkin, S. (2007). MarkeTrak VII: Obstacles to adult non‐user adoption of hearing aids. The Hearing Journal, 60(4), 24-51.
Kochkin, S. (2012). MarkeTrak VIII: The key influencing factors in hearing aid purchase intent. Hearing Review, 19(3), 12-25.
Kochkin, S. A Comparison of Consumer Satisfaction, Subjective Benefit, and Quality of Life Changes Associated with Traditional and Direct-mail Hearing Aid Use. Hearing Review. Published on January 8, 2014.
Plotnick, B., & Dybala, P. (2017, April 06). OTC hearing aids – survey says consumers aren’t sold. Retrieved April 16, 2017.
Taylor, B. (2015, April 20). The “Good Enough” Era and Hearing Healthcare. Retrieved May 26, 2017, from Hearing Review, an abridged version of “Just Good Enough on the a la Carte Menu” published March 17, 2015 at Hearing Health and Technology Matters
Tedeschi, T., & Kihm, J. (2016, December 22). Implications of an Over-the-Counter Approach to Hearing Healthcare: A Consumer Study. Retrieved January 30, 2017, from Hearing Review
Garrett Thompson, AuD is a recent graduate of the City University of New York and just completed his externship at the Callier Center of UT-Dallas. He was a national finalist in the 2015 Academy of Doctors of Audiology student business plan competition. His writing has previously been featured in Audiology Today and Audiology Practices. Thompson received a BA in Economics from Boston College. Contact him at [email protected] or @Dr_Audball
Garrett: First of all, I very much appreciate the many hours you put into preparing this article. It is clear that you are trying to help audiologists and dispensers feel better about the future of their profession. Despite my following comments, I thank you for your efforts and courtesy.
I understand that the OTC issue is complicated and controversial. However, I share a differing opinion, based upon my 35+ years in the industry dispensing hearing instruments and visiting hundreds of hearing aid practices, while working for a major hearing aid manufacturer. I also talk to audiologists and dispensers on a daily basis, regarding their sincere concerns.
Costco hearing aid dispensing has become the largest player in the industry. Some Costco stores now have as many as four sound booths. You mentioned, “The evidence clearly suggests that patients want a professional’s involvement in the hearing aid process.” While that may be true in many cases, the exponential growth of Costco hearing aid centers would suggest otherwise, in a great many cases.
You also write, “For patients who are experiencing success with OTC devices, audiologists have a role in objectively documenting their status and adding value via counseling, real ear measures, speech in noise testing, and validation questionnaires.” That might certainly be true, but from a business perspective, counseling, Real Ear and validation questionnaires do not pay the rent. The reality of the modern audiology practice is that the vast majority of revenue comes from hearing instrument purchases. If the OTC market pulls a significant amount of that revenue away from the audiology community, your optimistic scenario is likely far too optimistic. I hope that my somewhat pessimistic outlook is inaccurate and that the OTC issue will end up being a positive. However, we live in a changing world, where a large number of formerly solid companies are now struggling or have disappeared. Let’s hope that audiology finds its way through this potentially difficult transition.
The logic of this article totally ignores the of psychosocial and psychological barriers that hold back the hearing impaired from getting help with their hearing aids. Japan’s hearing aid satisfaction rate is incredibly low precisely because of the OTC phenomena and the fact that unlicensed dispensers have a super highway to promoting their inferior wares and those abide by the ethics and regulations of the field are strapped down from competing.
Big money from companies like Bose, Samsung, Sony, etc. in the form of campaign contributions to politicians like Senator Elizabeth Warren and others are what is driving the political process into turning a blind eye to the deeper reasons we should all be opposed to this Trojan Horse of feel good legislation.
HLAA is supporting it for purely erroneous reasons. They are unwittingly about to demolish the FDA consumer safety net and are exposing at least 85% of the hearing impaired to an army of unlicensed dispensers who will have no obligations to do any more than give unsuspecting consumers a slick sales pitch, a brochure of cautions that few will read, and a device that won’t fit and likely not be worn but by few purchasers. Meanwhile, the unsatisfied consumer will say, “I tried hearing aids and they didn’t work for me”. There is no consolation that this so called “disruption” is a good thing fur anybody but the erstwhile electronics firms that are posed to take over and introduce a trail of disillusionment to the hearing aid field.