A Gold Standard

For any audiologist who watched the FTC hearings on April 15^th, you will recall the mention of audiology’s “gold standard” a number of times by the members of the first on-stage panel.  For those who didn’t watch, some on the panel seemed to imply that pure tone thresholds are the gold standard for hearing.

The Declining Price of Gold

Wide use of pure tone audiometry arrived after the Second World War.  Electric audiometers were new and not all that expensive.  And the whole world needed to have hearing tests.  It was a wonderful new ball game.

Sixty to seventy years later, there are lots of folks, evidently, who think that the pure tone test is still the “gold standard”.  It gets called that in articles, postings, advertising, and by just about everyone.  Maybe it became a “gold standard” because every single person interested in hearing acuity uses it, even if many who use the test are not well versed in any nuances.

In the 70s, the standard reimbursement for 92557—a complete audiogram  (pure tone air and bone, speech reception threshold and discrimination bilaterally)—was billed and paid at $90 to $100.  Reduced fees came from Medicare (about $80) and MediCal/Medicaid (about $75). The same tests today get reimbursed at about 40-50% of those amounts.  Site of lesion tests, when administered, were then and still are paid in proportion to 92557—very meagerly.  It is interesting to consider the factors that lead to these devaluations.

Today, the “Gold Standard” is well over 60 years old.  And reimbursement for 92557 is so low that the tests are given away in order to get patients into offices.  And everyone is providing these “gold standard’ tests to anyone who walks in their door. 

All That Glitters is Not Gold

So, how golden is our standard?  A pure tone audiogram is hardly valuable enough to allow it to represent the state of “audiology science”.  It should not be thrown aside, but it also cannot continue to be the standard.

Simple observations do not support 92557 as the standard by which critical judgments and decisions about hearing loss are made.  To wit:

• Pure Tone thresholds fail to precisely and reliability predict:
  • The site of lesion
  • The degree of difficulty the patient experiences
  • The potential success from rehabilitation.
  • Pure tones and simple speech tests fail to define:
  • Normal function other than very simply
  • Many problems within and most that are central to the cochlea
  • The cause and potential progression of disease or injury.

Pure tones and simple speech tests were devised from what was known about audition in the 50s and 60s and what those first simple electric instruments allowed.  This “gold standard” is analogous to the “Buster Brown” x-rays that, in the shoe stores of the 1950s, showed kids how their new shoes fit.

If patients had just a little knowledge of audition and the methods of its assessment, how many would be satisfied with air conduction pure tone thresholds?  How much is such a “gold standard” test worth?  The answer seems obvious.

Time for an Updated Standard

Since the present “gold standard” is outdated and has been so devalued as to be worth almost no reimbursement, what should audiologists do?  It would seem that the first order of business would be to reconstruct the standards to reflect the breadth and depth of what can be determined about the ear and hearing with non-invasive, “patient-friendly” tests. 

A few years ago, I experienced a sudden distortion in one ear.  Having determined it was not my car radio, I underwent a series of audiometric tests to see if the problem could be isolated.  The pure tone, speech, and immittance tests with reflexes were normal.  Central auditory tests were normal.  There were no retro-cochlear signs.  Only otoacoustic emissions indicated that the loss was cochlear—OAEs gone in one ear.  (I eventually recovered—don’t know why.)

I cannot guess how many complaining patients must have been told in the past, after a “gold standard” audiogram showed “normal” hearing, that there was nothing wrong with their hearing. 

What would you propose as a “gold standard”?  Certainly a 92557-procedure audiogram can be a starting point.  But, it cannot be the end or only point.  Patients deserve the benefit of all of the knowledge audiology has accumulated.  Our “gold standard” must also take into account reimbursement sufficient to support itself.  Third-party payers alone cannot determine or mandate our “gold standard” unless we are content to be defined by those who are not our patients or by those who use the pure tone audiogram as their only tool.

If the “gold standard” of our field reimburses so little that is administered freely to many patients and other “customers,” perhaps we shouldn’t care that others use the test in their businesses.  After all, if its use is not profitable for us, why should we care if it is not profitable to others?  Shouldn’t we, as a field supplement this outdated standard with procedures that do a better job, result in data that has more predictive value, and are reimbursed at a level that allow them to stand alone in the value arena?

If you are not doing anything other than 92557 tests, here is my question: How does your field move forward with a gold standard of such little value?

feature image from Penobscot McCrum