Self-Fitting Hearing Aids: Are They Effective?
Fortunately, audiologists at the National Acoustic Laboratories (NAL) have been on the forefront of self-fitting hearing aid (SFHA) research. Since 2001, they have published a series of important papers examining the efficacy of SFHAs, many of which have been published at the open access journal, Trends in Hearing. In May, Gitte Kiedser and Elizabeth Convery of NAL and the HEARing Cooperative Research Centre in Australia built on their SFHA work.
Their paper, titled, Outcomes with a Self-Fitting Hearing Aids, Kiedser & Convery examined results of one SFHA (SoundWorld Solutions Companion, RIC-style) for a group of 38 user-driven and 16 clinician-driven fittings over a 12-week time period. Study participants, ranging in age from 51 to 85 years, were divided into one of two fitting groups, user-driven or clinician-driven, depending on their ability to accurately follow self-fitting instructions or correctly identify when they had a problem with the procedure and then obtain help from a clinical assistant. Several attributes, including cognitive ability, self-efficacy, problem-solving skills and general audiometric information was gathered as part of a pre-fitting assessment process.
Forty-one participants who could complete one of these tasks were placed into the self-fitting category using captioned instructional videos embedded on a PowerPoint slide deck, and the availability of a trained clinical assistant upon request, the original group of 60 participants was divided into two user-driven subgroups: One group that could complete the entire self-fitting fitting process independently and another that successfully asked for assistance during the self-fitting process. The other 19 participants made at least one unresolved error that prevented successful completion of the self-fitting process, and thus were assigned to the clinician-driven group. (A few individuals dropped out of the study for various reasons, which explains discrepancies in participation numbers).
According to statistical analysis, individuals assigned to the user-driven fitting group were more likely to have had previous conventional hearing aid experience and to be owners of a smartphone or tablet PC. Additionally, within the user-driven fitting group, about 60% of the individuals sought help from a clinical assistant to accurately complete the self-fitting process, while the remaining 40% of the user-driven fitting group independently performed all the steps involved in the self-fitting process. Individuals in the user-driven fitting group who sought guidance from a clinical assistant were more likely to believe that health care professionals are primarily responsible who a patient’s health and wellbeing.
Thirty of the study participants were experienced hearing aid users, and outcomes with their conventional devices were collected and compared to SFHA results. Participants with no prior hearing aid experience attended a total of three appointments, while experienced hearing aid users attended a total of four appointments. The first appointment was conducted to largely determine candidacy for the study. It was during the second appointment that participants were divided into either the user-driven or clinician-driven fitting groups, depending on their ability to following basic, self-paced instructions. Participants who had questions about the instructions or needed help had access to a phone to call a clinical assistant for additional support.
Following the second appointment, participants wore the devices for 12 weeks. During this period, they had access to instructional material on a website and access to a clinical assistant via email or phone. At the end of the 12-week field trial, participants returned for outcome measures. (Experienced users went another 12 weeks with their current hearing aids and had outcomes measured at a fourth appointment).
At the end of the self-fitting process, the achieved results were evaluated with 2 cc coupler analysis. Coupler data was used to ensure that hearing aid output was not causing harm to the patient due to excessive output, not to assess a matched prescriptive target. (None of the self-fitted devices were determined to be unsafe due to high outputs).
A variety of outcomes were gathered following the 12-week field trial, including coupler measures that assessed user gain and output at 50, 65 and 80dB SPL, speech recognition in noise, activity limitations using the APHAB, participation restrictions using the HHIE, and self-reported hearing aid satisfaction using the SADL. Outcome data was collected on 52 of the study participants, 38 of which were in the user-driven and 14 in the clinician-driven fitting groups, respectively.
Among the outcome differences between the user-driven and clinician-driven groups were participants who self-fitted generally had more low frequency gain according to coupler measures, likely resulting from a poorly sealing ear tip. Even though some in the user-driven group had more low frequency gain, there was no difference in the speech recognition scores compared to the clinician-driven group. User-driven participants also reported lower satisfaction scores on the personal image subscale of the SADL. This lower score is probably due to the large, somewhat clunky appearance of the SFHA used in this study.
Overall, however, after controlling for degree of hearing loss and cognitive ability, there were no significant differences in outcome between the user-driven and clinician-driven groups in coupler gain, speech understanding in noise, or self-reported hearing aid benefit and satisfaction.
As the authors surmise, the factors that influenced outcomes with SFHAs in their study are likely a result of the physical design and implementation of the particular SFHA used in this study, not the fact that the hearing aids had been self-fitted. The outcome differences between the experienced & new groups and the user-driven & clinician-driven groups are due to the appearance and features, not the self-fitting nature of the devices themselves. And, it is almost a sure bet that as the appearance of SFHAs becomes more cosmetically appealing, and as the user-friendly interface to program and adjust the product evolves, SFHAs are likely to become a worthwhile option for a growing segment of the market in need of hearing improvement.
Challenging Entrenched Ideas
Assuming SFHAs will continue to evolve, especially in light of the study’s findings, audiologists ought to embrace the self-fitting concept as an option for patients who are able to self-direct their care. To do so, however, will require audiologists rethink their role in the service delivery process.
Much like buying furniture from IKEA, taking it home, unboxing it and assembling it, the SFHA experience could be similar. Many purchasers of IKEA furniture end up with some unused bolts, a broken slat or some other unfortunate DIY mishap that gets in the way of an otherwise “good deal.” Invariably, a similar fate will occur for some SFHA purchasers. But as the study cited above indicates, with well-trained assistants accessible via easy-to-use remote technology, and carefully crafted instructional videos available on a smartphone app or website, many of the nuisances associated with hearing aid orientation and adjustment could be addressed quite effectively for many patients.
If the Keidser and Convery study is reflective of SFHA use in the real world, it tells us about 25% of adults will be able to independently complete the entire multi-step, self- fitting process. The other three-quarters of patients will need some level of personal support, but as their study shows, much of that support can be provided remotely via the web by a trained assistant.
The advent of SFHA technology (and data supporting its efficacy and effectiveness) demonstrates that some entrenched ideas, like an audiologist personally involved in all facets of the selection and fitting process for every patient, could be discredited or debunked.
In addition to the obvious need to unbundle for the provision of services, hearing care professionals working in a marketplace where consumers can purchase SFHAs will need to emphasize a different set of professional skills: Keen insights on the application of the transtheoretical model of behavior change to hearing care, personal adjustment counseling based on the ICF framework, and the ability to quickly & accurately assess non-audiologic factors, such as cognitive ability & self-efficacy, which routinely go unchecked in hearing aids centers today, These skills will be valued in a world with high quality SFHAs.
Like that inexpensive IKEA bookshelf, with the right instruction and support, a lot of people now have another option to address their hearing problem. Unlike purchasing IKEA furniture, however, the emotional, social, cognitive and physical consequences of hearing loss that afflict some individuals require the support of another human. Does that human need to have an advanced degree or deliver care face-to-face are questions the profession and consumers need to sort out.
In the meantime, the good news for people with hearing loss, and those serving them, is that life is filled with a growing number of choices. An abundance of choices is good; making the right one can be tough.
Brian Taylor, AuD, is the director of clinical audiology for the Fuel Medical Group. He also serves as the editor of Audiology Practices, the quarterly journal of the Academy of Doctors of Audiology, and editor-in-chief of Hearing News Watch for HHTM. Brian has held a variety of positions within the industry, including stints with Amplifon (1999-2008) and Unitron (2008-2015). Dr. Taylor has more than 25 years of clinical, teaching and practice management experience. He has written and edited six textbooks, including the third edition of Audiology Practice Management, recently published by Thieme Press. He lives in Minneapolis, MN and can be reached at firstname.lastname@example.org