How Audiologists Make Hearing Aid Selection Decisions: Insights from New Research

Hello and welcome to another edition of This Week in Hearing. I’m your host this week, Brian Taylor. And today our topic is how audiologists make hearing aid selection decisions. And with me to discuss this topic and some of her recently published research is a PhD student at Northwestern University, Rachel Pennock. Rachel, welcome to This Week in Hearing. It’s great to have you here.

Thank you so much. So I know that you already have your AuD and you’re working on your PhD. And before we dive into the topic of how audiologists make hearing aid selection decisions, some of the research that you’ve done in that area, tell us a little bit about your background and what you got— what got you interested in this line of Research?

Oh, sure. So I got my AuD from the University of South Florida. I graduated in 2019, and I worked in a private practice in Columbus, Georgia, Columbus Speech and Hearing Center. And I worked with the whole range of patients from little tiny babies to older adults. And we did just about everything except for implantables. So I worked with a lot of hearing aids. We also did vestibular patients. We did lots of different, different practice areas. And it was wonderful, but I did start to feel a pull back to research, we’ll say, because I found that patients were asking me questions about why I was doing certain things or why I was recommending certain things, and I didn’t have very evidence-based responses for them. A lot of the responses that I could give were, oh, well, that’s what my clinical supervisors have shown me, or that makes logical sense. You know, I could give kind of hand-wavy answers. And then when I started to try to do some digging to find the answers, I didn’t find what I was looking for. So I decided, you know what, I’m going to find the answers. I’m going to go back. I’m going to go back to school and figure this out. And it turns out it’s really hard to find answers and it takes a really long time. So I understand a bit better why we’re missing some, some of the literature that that we ought to have.

Well, I think many of us are grateful that you did go back to, to get your PhD because there are 2 articles that you recently published. One was in JAAA earlier this year, and then just a few weeks ago in the American Journal of Audiology. And both of those articles are, they’re kind of companion pieces, I would say. And they get into this whole idea of when it comes to selecting hearing aids for the individual patient, I think many of us may or may not know that for decades, hearing aid manufacturers have kind of promoted 2 concepts. The first is the tiering approach. I think the good, better, best. We’ve seen that for many, many years, especially since the beginning of the digital era. And the second concept is that notion that the greater the listening demands of the individual, and this is what I want us to really get into today with your research, but the greater the listening demands of the patient, the greater the need to select devices that are the premium side of the technology tiering. So could you get maybe to kind of kick things off, you could tell us a little bit about this concept of hearing and about listening demands or what some people call auditory ecology and maybe why, what those concepts are, and then maybe a little bit about why manufacturers or how they promote that.

Sure. Yes. So absolutely. This is, What I’m really in the weeds of right now. It’s all I talk about. So it’s exactly as you’ve described, right? So audiologists and even long-term hearing aid users who’ve gone to enough appointments and worn enough hearing aids, they’re really familiar with this good, better, best model. So we’ve got hearing aids, most manufacturers, they’ve got 3 to 4 levels of technology, right? And compared to the more basic levels of technology, the sophisticated, the premium technology, it typically has stronger noise reduction, more nuanced microphone settings, more automatic features, more fine-tuning channels, or maybe even higher frequency fine-tuning channels. And so logically, it would make sense that if a patient is, describing or if the audiologist is picking up that the patient is in more complex listening environments, so they’re going to restaurants, they’re going to kids’ sporting events, they’re going to social clubs, then surely they, they would benefit from hearing aids that have better noise reduction capabilities. And we see that in some of the marketing documents that are provided by manufacturers or, or documents that are actually clinic-specific created by the clinics. They sort of mimic what the marketing materials from the big dogs look like. So they look visually, they can look in a few different ways, but a really common one is you’ll see 3 or 4 columns on a page and they’re separating their tech levels. And then in each column, they’ll list out different listening environments. So under the basic technology, they’ll have things like one-on-one conversations, at-home conversations in quiet, things like that. And then under the high-tech, the premium tech, they’ll have things like cocktail parties, restaurants, group conversations. And a lot of them, that’s all they say. They have these columns and they have this information. And so documents like that, handouts like that, they really invite this decision-making process where the audiologist, the patient, maybe together, they look They look at these different options and they say, oh, well, I kind of fit into this column the best, that seems most accurate. And so then that must be the technology level for them. Do you need good, better, or best? And that’s the question about if this is, if this is the right thing that we should be doing. We’ve got some beautiful marketing materials about it, but is it the right thing to be doing?

Well, that’s what I want us to get into in a minute, but Before we do, you know intuitively I think that makes a lot of sense, and I think it maybe made more sense at the early stages of digital when there were some really clear differentiators between maybe a one channel and a sixteen channel hearing aid, and it’s maybe a little tougher to do. But before we do that, I what clinical or peer-reviewed evidence do we have out there without getting into the weeds that would suggest that these tiering approaches matching listening demands are accurate or effective? What, what’s the evidence say about that, if you could kind of summarize it?

My gosh, yes. So when I first started digging into it, I found there is a fantastic series of papers that was put out by Cox and Johnson from University of Memphis. I want to give them their proper shout out. It was about 10 years ago, so it’s a little dated now because, you know, Hearing aid manufacturers, they pump out new platforms, new, new options, the, the best new thing. They’re pumping them out every 18 months or so. But back when they did this series of studies, they were looking at just a big group of participants and they were testing them on their basic, basic hearing aid outcomes and premium hearing aid outcomes. And they did tons of different outcomes. There were— Objective outcomes. So like what is their speech in noise performance with these different hearing aids? And they did subjective outcomes too, like what are their, what are their satisfaction levels with the different hearing aid tech levels? And when they did these studies and they’re looking at patients altogether, on the whole, premium hearing aids do not guarantee better outcomes than standard devices. And we’re, we’re definitely going to get into this, but I think it’s really important that I don’t want anyone to walk away thinking that premium hearing aids are not worth it. I think what it means instead is that we need to do a better job of finding out when they’re worth it or for whom they’re, they’re worth it. And so you may notice that I said that study is a big group of participants, and that’s because studies that actually split up participants based on listening environments to really examine that good, better, best model. The studies like that are very thin on the ground. And so the, the, the study that I keep coming back to, it was published by Plyler and colleagues, Patrick Plyler and his team from other side of Tennessee, University of Tennessee. Tennessee is doing great work, that state. And so they were also investigating participant performance with basic hearing aids and premium hearing aids. But then they broke down their analysis and they grouped participants into those that were in more demanding listening environments and less demanding listening environments. And they did that using data logging from the hearing aids themselves. And they were able to show not every measure was affected, but they were able to show that the participants who are in the more demanding listening environments they experienced improved noise tolerance when they were wearing the premium hearing aids that they didn’t experience with the basic hearing aids. And the participants that were in the less demanding listening environments, they didn’t show a difference regardless of the tech level that they’re using. So this is one, essentially the only study that I can really reference at this point that’s really pushing towards that question of is this good, better, best tier, what we should be doing because it really stands to be investigated a little bit.

Exactly. I think your studies kind of get at this in a way that’s clinically useful. And that’s what I want to get into next. So the first study I want to talk about of the 2 is the JAAA study that you did, published, I believe, maybe earlier this year, I’ll say. My first question about that JAAA study is, Tell us what question or questions were you trying to address with the study?

Yes. So this, this good, better, best decision practice approach that I described, it is a familiar story to me. I think to you as well. Anybody that’s been in audiology for the last 25 years. Right. Exactly. Anyone who’s really been in it, it’s exactly how I practiced when I was in practice. And when I went to start really writing about it, it wasn’t very well documented. It’s one of these phenomenons where we, we all kind of know that it’s what’s happening, but you can’t put a citation on it. You can’t say, oh well, this study back from 30 years ago when this phenomenon started happening, this is, this is how audiologists have started to practice. So the first step that we really had to do with this study was just establish how are audiologists selecting technology level for patients, and are they evaluating patient listening environments? How are they doing that? And then if, if they’re considering that, how are they applying that information to their hearing aid selection? So things that we thought that we knew, we’re pretty confident about, but you have to be able to, to show it before you can say it.

And so the study was really a survey, right? Elegantly simple. Yes. Yeah. So tell— yeah, but it gave— I think there’s some really meaningful information in it. So tell us a little bit about the survey, who— the, the, the methodology, the way that you analyzed it, and then what you found.

Yeah. So we just, like I said, we wanted to just establish some of the basics. So we just asked, right? We asked audiologists. We sent the survey out through several different channels. If, if you’re in some of the social media groups, you might have seen some posts in there asking if people would participate. And we really wanted to try to capture a good, a good number of audiologists and also a nice range of audiologists. We didn’t just want my old coworkers and my classmates to participate. So we were able to analyze 185 surveys. So we got a pretty good, pretty good response. It was pretty brief. 20 or so questions. If you did it in one sitting, it maybe took about 10 minutes. Of course, there was some boilerplate demographic stuff that we asked about just to ensure that nice range that we were getting. But the substance of the survey was asking about the hearing aid selection process. So we asked about any of the factors that audiologists could be considering when selecting tech level. So I’ve talked a lot about listening environments. It’s what I’m really interested in and what I think is really important. But there are other factors to consider. So we wanted to know, are you, what are you prioritizing in this decision-making process? Are you thinking about clinical results, finances, insurance coverage, previous tech level, the patient experience with hearing aids? And then we asked the participants, the audiologists, How are they using information about listening environments? How are they learning about that information? Are they interviewing? Are they using questionnaires like the COSI, for example? Are they using those marketing tools from manufacturers, or does their clinic have something that they use? And then what we were really able to dig into was we had 2 very narrow hypothetical scenarios, very narrow sort of patient profiles where we said, if the only information that I’m giving you is about their listening environments, what’s the technology level recommendation? So what do you recommend for a patient who you believe is in a lot of diverse or noisy listening environments? And what do you recommend for a patient who’s in those more simple or calm listening environments?

 

And what did you find?

So the majority of participants reported that those listening environments, and that’s the most important thing to consider. So this was not just some idiosyncratic practice method that I picked up somehow. This is really what’s happening when you look across the board at audiologists. The majority of us are gathering information about listening environments. Most of us are doing that by interviewing the patient, which means that even if we’re all using that same method, we’re probably all doing it a little bit differently. Everyone’s got their different clinical interview style. Everyone’s got a different amount of time they can spend with the patient, different connections that they’re building with their patients. That’s another can of worms we can get into. But So most of us are asking about listening environments. Most of us are doing that with interviews. And then we are doing this good, better, best approach. By and large, that’s what’s happening. So if a patient is described as being in complex listening environments, and that’s the only factor that we’re really thinking about, we are more likely as a group to recommend higher-tier technology. And if they’re in calmer listening environments, we’re going to recommend more basic technology. And that’s why I could confidently describe that good, better, best question. I probably would have hedged it a little bit more a year or so ago, but now that I can cite myself, I can better sort of quantify that in a way that that survey helps us to, helps us to say with confidence.

Well, and I thought it was really interesting and not surprising, but still interesting is that I don’t know, something like 80% of the respondents relied on the interview to make the decision, right? And very few used any sort of a formal questionnaire, any kind of a validated self-report or anything like that. Do I have that about right?

It was a really high number. It was very high. I’d have to pull it back up to verify, but it was a very high number. And actually, when you dug into what surveys they were using, that was a follow-up question that we asked, one of the few open-ended questions. If they said they used a survey, what questionnaire are you using? Most of the questionnaires that they talked about were like COSI, HHI, much broader questionnaires. And I would even argue that a questionnaire like the HHI, HHIA, HHIE, HHIR, whichever version you’re using, that’s— it is asking questions about hearing loss. It’s not really targeting listening environments. So there are, 2 questionnaires that are really designed to dig into listening environments and no one mentioned them. So it’s the ALDQ and the Hearly Q. And those have not, they don’t seem to have broadly penetrated into clinical practice yet. Exactly. So people are using surveys, but they’re maybe not use, maybe they reported that because they wanted to say, hey, oh, I am using surveys, I’m using these validated tools. And that’s fantastic, and it gives great information. But I’m not sure that it’s giving enough information about this specific patient characteristic.

Yeah, and I think the other part that’s really interesting is, and I think you allude to it in the in the discussion part of the article, is that the interview process, just by its nature, is really everybody does it differently. It’s kind of inconsistent, and that can be somewhat. of a challenge too.

It can be a really big challenge when you think about, like I said, you know, the difference in time that we can spend with patients. Some clinics are very, very busy and you don’t have a lot of time. You’ve got 2 minutes that you listen to your patient and then you walk away with a conclusion about that patient. And that very same patient could walk into another clinic 20 minutes down the road and have a very different conversation with a different audiologist. And that audiologist could walk away thinking something totally different about that patient. Yeah. I would be, I’d be surprised if people walk away with opposite impressions. You know, I don’t, I would hope that we’re not walking away with vastly different information, but there’s, there’s nuance and there’s information that certainly some Some practitioners are gathering and others are missing. And so— So there’s a lot of variability. Lots of variability. Yeah. Even though we’re all kind of saying we’re doing the same thing, inside of that, there’s a lot of variability. The nature of interviews and the nature of working with humans. Right, exactly. Exactly.

That brings me to the second study published within the last month or so in AJA, a little bit of a like I said, it’s a companion piece. This is a little bit more qualitative in nature. I think you only— you interview something like 10 audiologists and try to get at how they make selection decisions. Am I— do I have that right?

That’s exactly right. So this was my first my first foray into qualitative research. And after doing the survey— the survey is great, it had a lot of closed-ended questions because we really wanted to have some sort of solid data that we could analyze. But there’s so much more to dig into, you know? And some of the closed-ended questions, they were forced responses. We forced people to rank things and pick things like they had to make a decision. But once you get to talking to someone, you can really find out more about what are you really doing? What are you really talking about here? And so we wanted to let audiologists more fully explain their decision-making process and see what other insights we could learn about it. And absolutely, these were companion pieces. And they were actually proposed at about the same time. They were published quite far apart from each other, but they were always meant to be very complementary so that we could really try to learn about what is happening in the clinic.

Yeah, so take us through the qualitative piece. How did you conduct the interviews? What kind of questions did you ask? How did you analyze the responses, those kind of things, if you could kind of highlight that?

Absolutely. So it was Dr. Souza and then also Dr. Amelia Van Pelt, who’s at Northwestern. She’s in the implementation sciences area. And so she’s got a lot of experience with qualitative research. And we tried to really flip the script from the survey. So instead of closed-ended questions, we really tried to ask very open-ended questions that let the audiologists speak about their experiences as much as they wanted to, as much detail as they wanted to. Started very open-ended, and then we did come up with a series of interview prompts so that we would make sure, okay, so I let them speak for a few minutes and I’m taking notes, but they didn’t talk about this and I want to make sure that we get back to that. So we did have some prepared prompts. to make sure that if their sort of natural narrative didn’t dig into things that we could touch on that. And so I asked them to share about what do you do when you’re picking hearing aids for patients? How are you doing that? How are you making that decision? What factors are drawing you to premium devices over basic devices? And I was also really curious about how they learned that practice because I know how I learned and it was mostly from, watching other people, but I want to know how other people learned. I went to one school, right? And a lot of the people that I worked with after graduating, they went to a different school, but the same school. So, you know, there were— I’m looking at a lot of clinicians that are from 2 AUD programs, and that’s not every AUD program. So I wanted to know how are we training our up-and-coming clinicians And how have clinicians been trained in the past? And what did you find?

Well, first of all, it was And it was really lovely to speak with so many different clinicians, and they all spoke so passionately about their patients and their practice, and you could really hear from them how, how much they want their patients to do well. And the results were fascinating. We, we used what’s called an iterative inductive data analysis approach, which is— A technical term, and I don’t, I don’t want to bore any listeners, but I’m happy to talk about it more. But essentially what we did is we took these interview transcripts and we tried to find, after going over and over and over them, what themes kept reappearing among the different audiologists, what topics were brought up, what topics were brought up together, and how were they related to each other. And so in doing that, we were able to— again, we confirmed the majority of these audiologists, they’re using that good, better, best listening environment approach. But it’s more than that because they were allowed to speak about it a little bit more. They are using a set of patient characteristics. It’s not like that hypothetical survey question where you only have one piece of information about the patient. You have lots of information. So what— What pieces are you choosing to inform that tech level recommendation? All of them talked about listening environments. The majority of them who did this good, better, best approach, if they— they described in different ways, but they were all talking around this idea that if you have demanding listening environments, higher tech, less demanding listening environments, lower tech. But they brought up patient characteristics like speech audiometry. So some of them spoke about how if a patient has lower speech audiometry performance, higher tech. They also brought up factors like patient age, patient occupation or occupation status, are they working or not working? And then what are they doing within that? Patient preference, you know, they might talk to a patient, they learn that that patient is in a lot of quiet, simple environments, but the patient wants premium hearing aids. Okay, that’s what the patient wants, you know, that’s what we can do. So the majority are following this narrative that, that we’ve spoke a lot about. Then we also got to talk to the non-majority, and that was 2, 2 of the 8 audiologists, and they each described premium for all. That’s, that’s how— that’s the, the subtitle that I gave it, right? So for, for these audiologists, regardless of listening environments, regardless of speech scores, age, occupation, they are recommending premium hearing aids 100% of the time. And they both did give the caveat that in the event of financial restrictions, they would fit less than premium. It’s not that they fit 100% premium, but when they’re recommending to the patient what to get, it is always premium for those participants or for those audiologists.

Yeah. So it’s interesting, 20% or so. I mean, it’s a small number of people, but it’s fair to say 20% of the group you interviewed premium only, or they— that’s the kind of the default. And then 80% use the listening demands, auditory ecology kind of framework. Is that right?

I think that’s what the— that’s what we found. You’re right, it is a small sample. Qualitative studies tend to be smaller in sample size. So we might cannot expand that to all audiologists, but I think I’m very comfortable with saying majority-minority. Majority are following this good, better, best auditory ecology process, and— but there is a smaller group that are following a different process, and one of those processes might be premium for all.

Exactly. That’s really interesting. And what do you make of that?

It’s such a good question. I— and like I said, it was such a joy to speak to all of these clinicians. And when you’re speaking to them, they are so passionate and they’re so confident about what they’re describing. And they’re really describing— a lot of them would give individual stories and clinical experiences of, oh, well, I saw a patient this one time and this happened. And then this happened. And I think about that all the time. Great story. Fabulous. That’s one case study. So I think that when the field doesn’t have a great base of evidence, research-based evidence to fall back on, that sort of forces clinicians to live in the world of clinical experience and their own personal logic. So there’s really nothing else that we could expect from these clinicians other than to do what they think is best and what they have experienced and what their clinical preceptors have taught them. And I didn’t dig into this too much with my most recent monologue, but very few of them referenced research as the guiding principle behind these clinical decisions. So a lot of them cited, this is what I saw my clinical preceptors doing, or this was my clinical experience. And sometimes if we got onto the topic of research, I can recall one of them even said, I know that the research has shown there’s not a difference in tech level. So they probably had read the Cox and Johnson studies maybe when they were in school. Mm-hmm. And so they know sort of some of the research that’s out there. And even though it’s out there, they’re not necessarily following it. So it’s, it’s such a tricky, it’s such a tricky spot to be in. And audiologists can’t wait. They are practicing right now. They can’t wait for the research to come out. Exactly. They’re practicing right now. They have to pick a tech level today for a patient who’s struggling today.

Right. And I find it really interesting because, I mean, I think there is research out there. You mentioned it. There is a handful of studies, the really well-designed studies that kind of give us, you know, some insight into the question. But at the same time, there’s this commercial aspect where their manufacturers are launching a new product every 12 to 18 months. So, you know, in order for that to kind of make sense, you have to frame it in a way that Looks like good, better, best technology, the tiers, and listening lifestyle and auditory ecology is a really intuitive way to kind of think about how to apply those tiers. So I guess my final question to you, Rachel, is based on what you found so far and maybe what you’re looking at doing in the future with research, what are some alternatives to this current approach involving tiers and listening lifestyles? Is there an alternative? Is this the best we can do?

That’s such a good question. It’s such a good question. And I love the word you just used. You said intuitive. And I think that that’s what I’ve been trying to say with saying that it’s sort of logical. It’s intuitive. It makes sense if you think about it. You think about what the tech is saying, what the tech does, and you think about what the patient is saying, and they, they really seem to line up well. As far as an alternative or a recommendation on you know, how audiologists should be practicing. What I have done so far— so these 2 studies, which are great, they are really just establishing what are we doing, you know, what are we doing so that we can, we can reference this in the literature now and see the landscape and say this is, this is what audiologists are doing. And now the next step, and what I’m, I’m was doing writing today on my dissertation proposal. So the next step is going to be testing the theory more, expanding on the few studies that are out there, like the Plyler study that’s out there. I want to really put this to the test and see what is, is the intuitive nature, does it actually pan out in the research? So I definitely, I’m not comfortable yet to say to audiologists that they should or should not be practicing in this Good, better, best model. But I think it’s really important, and I hope that in some ways the results of these two studies—in some ways the results are not that interesting, right? Because we—we all knew that this is what we were doing. But what I—what I hope they’re contributing to is the narrative in those papers before and after the actual results section—is this narrative that we are. Healthcare providers, and we need to be practicing with evidence-based research behind us. And so I’m hoping that audiologists will recognize that and keep their eyes on the journals in the next couple of years, because I’m really hoping to put out some strong studies that can answer the question of, is this the right thing? And if it’s not, I will be digging into what the, what the best alternative is. So we can have a follow-up interview in a few years and I’ll have a better answer for you.

Exactly. Well, we’re setting the stage for this. You’ve documented where we are today and you set the stage. So we’ll have you— we look forward to having you back in a few years when you get that under your belt. Yes, I’m, I’m really looking forward to it. Yeah.

And there’s another audiologist who is not getting his PhD. He’s a practicing audiologist in California by the name of Bill Miller, who I plan to have on an interview. He’s done some really interesting work and written a few papers on something he calls minimal clinical need. And it tries to get away from the, the, the tiering approach and the lifestyle approach that we’ve been talking about. So he’s got some theories on that. We’ll have him on the broadcast and his papers are gonna be in the show notes and I can send those to you too as well, Rachel. But he’s written some really insightful papers, you know, really not any research that he’s done, but just more along the lines of a, you know, like a manifesto of what What needs to change in the profession to kind of move things along and make it more evidence-based.

Oh, I love that. I love that idea. Minimal, minimal clinical need. That’s what you said. Mm-hmm. Yes. I just, as a phrase, I love that idea because I think that’s, we need to get away from what intuitively makes sense and find out what actually makes a difference. For our patients. For the patient. Exactly.

So I will send you those papers that he wrote in Audiology Practices. You might find that to be interesting reading. And I want to thank you, Rachel, for being on This Week in Hearing. This has been a fabulous interview, and we look forward to having you on in a couple more years.