by Brian Taylor, AuD
“Signal & Noise” is a bimonthly column by Brian Taylor, AuD.
It’s natural to feel frustrated and unappreciated when a patient with hearing loss rejects your recommendation of hearing aids. It’s even worse when patients with this chronic condition fail to even make an appointment for an evaluation.
Those negative feelings, alas, are the by-product of the binary world we live in, but it doesn’t have to be that way.
Our Binary World
On any given day, an audiologist is likely to encounter an individual who would benefit from hearing aids but, more often than not, that person coping with the ill-effects of poor hearing either cannot or will not use them. Although under-utilized, hearing aids, regulated by the FDA since 1973 and for the first time since then undergoing a well-publicized re-regulation process, are likely to remain the gold standard of care for medically benign cases of hearing loss in individuals who want to use them. After all, hearing aids are available at a variety of price points and fit virtually all hearing losses.
There are, however, several categories of adults with communication deficits stemming from hearing loss, who, when given a choice, are likely to opt for an alternative intervention. This edition of Signal & Noise will examine these non-custom, unregulated technological options that have the potential to meet the needs of non-hearing aids users and grow the market for audiology services.
Many of these underserved individuals may opt for a technological solution perhaps a PSAP, or, in the future they may choose to self-fit an OTC hearing aid. Others, when provided a range of options to improve their hearing, may select a non-technological solution such as self-management counseling or education – services rarely provided by clinicians today.
As we move into a future in which some number of patients are likely to embrace self-fitting, over-the-counter hearing aids (and benefit from them), audiologists must gear up to provide service and care that is valued by all individuals with hearing loss and communication deficits, rather just those willing to use conventional hearing aids.
The Need for Alternatives
Many people with hearing loss choose to do nothing because acquiring hearing aids through the conventional delivery channels, quite simply, is not a priority for many of them. Some combination of cost, convenience, stigma and inertia to maintain the status quo keep the hearing aid uptake rate at less than 30%.
This low uptake rate is certainly not new. It’s been a challenge that everyone in the industry has wrestled with for generations. Fortunately, technological innovations have broadened the number of possible devices that can be offered to those who desire better hearing but do not or cannot use hearing aids. Table 1 is a summary of non-custom amplifier categories currently available to adults with hearing loss.
Recent research indicates that some of the devices in Table 1 in the ear-level PSAP category performance comparably to hearing aids. Yes, the overall fidelity of these unregulated categories is uneven, but the quality of any of these devices can be easily assessed with standard probe microphone equipment found in any clinic in North American. Further, even though these are non-custom devices, the acoustic characteristics of some of them can be adjusted by the audiologist (or the patient can be taught to adjust the device), often with a smartphone-enabled app to better match a prescriptive target or preferred listening level. In addition, the coupling of these devices to the ear of the individual can be customized, allowing for a more comfortable, feedback-free fit, which perhaps marginally extends the fitting range of the device beyond the mild to moderate category.
Table 1. A summary of non-custom amplification devices.
Type of Non-custom Amplifier
Situational conversations with physicians, caretakers, etc.
Cumbersome to use full time
Performance with television
Limited to TV use
Ear-level neckband PSAP
Doesn’t look like a hearing aid, multi-tasking capability*, high quality products performance similar to hearing aids for mild to moderate losses**
Mild to (maybe)moderate losses only, uneven quality
Ear-level wireless PSAP
Multi-tasking capability*, high quality products performance similar to hearing aids for mild to moderate losses**
Mild to (maybe)moderate losses only, uneven quality, neckband appearance may be unsightly to some
Smartphone + amplification app + wired earbuds
Situational use (similar to headset amplifier)
Looks similar to traditional body aid, mild to (maybe)moderate losses only
*Besides providing amplification the device can be used to stream music, talk on a cell phone, attenuate noise and other features
**One peer reviewed study suggests a retail price above $250 may be a proxy for quality
The Underserved: Who and Why
There are at least four types of individuals, currently underserved by hearing aids that are candidates for these alternative devices. Three of the four categories are commonly encountered in the clinic, while the fourth category are in great abundance, but rarely find their way to a clinic for reasons we will discuss later. Table 2, below, is a summary of these four categories. Here are some added details on each one.
- The Older Old. Prone to cognitive decline and physical limitations, this group, which also has a tendency to be social isolated, is susceptible to losing their hearing aids. Additionally, they are often likely to not have the physical or cognitive capacity to wear hearing aids consistently. Thus, many in this group become non-hearing aid users.
Neckband multi-tasker PSAPs or other devices for situational use may be a viable alternative for this group.
- The Contemplator. The Stages of Change model, which describes the behaviors and attitudes of people with chronic conditions over a period of time, suggests that individuals in the early contemplation stages are still working though the burdens their hearing loss places on daily life. Thus, they are not ready to take action with respect to addressing their condition. Allowing a patient to dabble in a low-risk way from the comforts of home, has the potential to enable the contemplator to take action sooner, on their own terms.
In this scenario, the initial use of a non-custom product is a gateway product that culminates in the future with full time hearing aid use.
- The Patient with Cochlear Distortion. The cochlea, for a small number of individuals, fails to carry information to higher regions of the auditory system. Researchers have surmised that these cases can be identified by measuring word recognition at a low intensity level and comparing the results at a higher intensity. (A poor result on the Quick SIN also might be an indicator of this condition.) Unlike the typical performance-intensity function that shows improvement in word recognition ability as audibility of speech is increased, patients with cochlear distortion issues fail to show improvement in word recognition ability.
Because the patient with cochlear distortion fails to experience the same improvement in speech understanding when audibility is restored with hearing aids, it is presumed non-custom devices might be a more cost effective choice for these cases, as a fully featured set of hearing aids could be considered technological overkill.
The three previously mentioned groups of patients are likely to seek the services of an audiologist for testing or guidance. The final category, because they often have normal or near-normal hearing aid and do not consider their hearing to be a “problem,” are unlikely to seek help from an audiologist. Therefore, group 4 must be reached in other ways.
- The Tech Savvy Middle Aged. There are a large number of adults, often between the ages of 50 and 65, that experience occasional difficulty with their hearing, but do not think they have a problem that warrants a visit with an audiologist. Because they are younger, tech savvy individuals they might be open to a do-it-yourself approach to finding help in situations where hearing is a challenge.
In the past, if these individuals were to find their way to an audiology clinic, they were offered a $3000 solution for a problem they perceive to be worth fixing for less than $500. By combining amplification with other features that they find useful in their busy lives, the middle aged, tech savvy individual could address their communication challenges with any number of high quality ear-level PSAPs.
Because many of these individuals will not seek the services of the audiologist in a clinic, we must use tools like the internet and website to reach them.
Table 2. A summary of the four groups that may be receptive to the use of non-custom devices.
Red Flag Characteristics
How to Identify
Non-custom Solution to Consider
Chronological Age >85
Poor scores on cognitive and haptic screen
Ear-level Neckband PSAP or headset amplifier
During interview blame other people or the environment for their hearing problem
During interview process
Ear-level PSAP or smartphone-enabled app + wired earbuds
Poor word recognition score at PB Max
No change in word recognition between 45 dB and 75dB presentation levels, poor QSiN score
Ear-level wireless or neck-band PSAP
Tech Savvy Middle Aged
Struggle in with their hearing in one or two challenging listening situations
Self-assessment tools on a clinic-branded website
Ear-level wireless or neck-band PSAP with multi-tasking capability
Audiologists Can Take the Initiative
Considering less than 30% of adults with hearing loss use hearing aids, a real challenge for audiologists is to devise clinical services that identify and treat underserved patients. This requires going beyond the traditional test battery and provision of hearing aids as the sole solution for medically benign hearing loss. It is an initiative that cannot be left to highly profitable hearing aid manufacturers or ivory tower academics. They do not have the incentive to address the needs of these populations.
Clinicians on the front lines must use a combination of creativity, ambition and skill – -and actively seek efficacious alternatives to accomplish this task. For those willing to embrace new technology and apply it to clinical practice to address the unmet need of these groups can change the profession.
The next issue of Signal & Noise will examine non-technological counseling skills to address the needs of these populations.
Brian Taylor, AuD, is audiology advisor for the Fuel Medical Group. 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 andbusiness 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 firstname.lastname@example.org or email@example.com.
feature image courtesy of Cambridge in Color