by Wayne M. Garrison* and Joseph H. Bochner**
Editor Note: With legalized OTC (over-the-counter) hearing aids sales expected as a hearing-impaired consumer option, a previous post asked if it was possible to predict hearing level without an audiogram? This question was raised because essentially every argument against OTC hearing aid sales states that an audiogram is necessary, but is that factual? In response to the question asked, Garrison and Bochner of NTID (National Technical Institute for the Deaf) responded, citing their extensive research stating that hearing level can be predicted without an audiogram. They were asked if they could provide a shortened summary of their work. They provided the article this week, and one to follow next week, that provides information on a consumer self-administered test that predicts hearing level with a high degree of accuracy. Readers are encouraged to take the self-administered online test https://apps.ntid.rit.edu/NSRT/.
Accommodating the OTC Hearing Aid Discussion: Hearing Screening in the Absence of Audiometry
From retail politics to humanitarian outreach efforts to expand delivery of hearing healthcare services, the OTC Hearing Aid Act of 2017, introduced in the 115th Congress of the USA on March 21st of this year, garners reactions ranging from anxiety to excitement. Chief among the concerns expressed by audiologists is the obvious absence of policy around the requirement in the OTC discussion for an audiogram to guide consumers in the purchase of an appropriate hearing aid. Policymakers are, nonetheless, spurred on by the need to expand the market of those not currently served with hearing aids, pointing to accessibility and affordability as major barriers. Is there a middle ground within which the interests of policymakers, audiologists and consumers might be better served? In this article, we introduce an online hearing screening test intended to accomplish that end, in essence bringing a potential profession/legislative divide together through an individualized assessment component that ultimately benefits the end user, a person with hearing loss.
Self-Testing of Hearing
Contemporary approaches to automated hearing screening in adults typically involve some form of self-administered test, with stimuli often presented under variable and uncontrolled listening conditions. The tests typically are delivered to individuals via land-line or cellular telephones, the internet, or hand-held consumer electronic devices such as smartphones and tablet computers. Although software applications have been developed for determining hearing thresholds and screening with the use of pure tones, they have proven problematic for even the most promising automated tests.
Partly because calibration problems make it difficult to deliver pure-tone tests over the Internet and on wireless devices, stimulus materials consisting of speech, more often speech in noise, are used in some of the newer hearing screening tests. Speech recognition testing has a long history involving a variety of tests, stimulus materials and administration protocols. Speech-in-noise screening tests provide a good measure of functional hearing capabilities, but their relationship to pure-tone testing results, until now, has been quite limited. Seeking to reverse that trend, recent research at the National Technical Institute for the Deaf1,2 (NTID) has resulted in the development of a self-administered automated speech-based hearing screening test (NSRT®) enabling the prediction of hearing thresholds with impressive accuracy.
Self-Administered Automated Speech-Based Hearing Screening Test (NSRT®)
Data obtained from the NSRT® testing experience are used to construct a pseudo audiogram. In their work the researchers report that, when predicted hearing thresholds are compared with conventional, clinical pure-tone measures, the sensitivity and specificity of the NSRT® screening measure have been found to be 95% and 87%, respectively; diagnostic accuracy is 91%. These statistics reinforce the argument for OTC hearing aid sales suggesting that, in addition to self-fitting, self-assessment may be a viable way to manage the market of those individuals not served by current audiological practice.
The NTID Speech Recognition Test (NSRT®) Described
The NSRT® is a computerized, adaptive hearing screening test. It is composed of sentence-length stimulus materials containing phonetic contrasts, primarily minimal pairs. The test simply requires respondents to determine whether sentences printed on a computer screen are the same or different from sentences delivered as auditory stimuli through the computer sound card. Respondents are encouraged to take the test using headphones.
As test takers respond to tasks presented in an adaptive test, the test adjusts itself by selecting the next stimuli to be presented on the basis of performance on preceding tasks. For example, in the assessment of academic performance in a given domain, if a test taker performs well on a set of intermediate-level tasks, more difficult tasks are presented. Conversely, if a respondent performs poorly on intermediate-level tasks, tasks of lesser complexity are presented. In an adaptive testing situation, testing terminates when the performance of a test taker on a trait or construct reaches its highest sustainable level or threshold.
In adaptive testing, test takers respond to tests composed of different stimulus materials. The psychometric technology that allows equitable measures to be determined across differing configurations of stimulus test materials is item response theory or IRT, the preferred methodology in the field of psychometrics for optimizing statistical information yield available for test takers.
Like the stimuli used in other psychophysical procedures, the stimuli used in the NSRT® are scaled along a continuum extending from low to high degrees of magnitude. However, rather than representing a physical construct such as the intensity of a sound, the continuum in this instance represents a domain of human performance, speech recognition ability. The scale values separating the NSRT® stimulus materials are the product of previous research undertaken by the authors but, briefly explained, represent differences in the complexity of discerning linguistic contrasts between stimuli in the testing protocol (minimal pairs), which are themselves associated with variation in the phonetic and acoustic properties of speech.
The Hearing Screening Interface
To access the NSRT® hearing screening test, go to https://apps.ntid.rit.edu/NSRT/. There is no cost to take the test; it is freely available. All of the information provided by individual users is confidential and will not be shared for any purposes, commercial or otherwise.
Initially, individuals who wish to take the hearing screening test are prompted to create an account. This is accomplished by providing an email address and a password of one’s own choosing. Individuals who have previously been tested are simply asked to log on to access earlier test results or to re-test under the same/different condition (i.e., quiet vs. noise).
Figure 1. An NSRT® practice item. Was what you heard the same or different from what is written? The person taking the test uses the mouse to click on “same” or “different.” If the person taking the test does not believe the test stimuli is loud enough, they are encouraged to adjust the computer’s volume control.
Users are next asked to respond to a brief set of questionnaire items (7) intended to gauge their perception whether they suffer from hearing impairment. They are next instructed how to adjust the listening level of their computer for administration of the hearing screening test. A practice test, which returning users can bypass, is provided to familiarize respondents with the nature of the stimulus materials and testing procedure. An example frame corresponding to the presentation of a practice item is shown in Figure 1.
Responses to the discrimination tasks in the practice sequence include feedback (i.e., correct/incorrect). Users can adjust the volume of auditory signals during the practice session as well. The icon in the upper right corner of Figure 1 alerts respondents that auditory signals (i.e., spoken sentences) are being presented.
Individuals visiting the assessment site who are unable to correctly discern whether the printed and auditory stimuli are the same/different on fewer than half of the practice items (i.e., relatively “easy” discrimination tasks) are not advanced to the formal testing stage. They are advised that, given the data that they have provided to this point, further testing would likely provide questionable results. These individuals have hearing sensitivity outside the area targeted by the NSRT®. This is further corroborated by analysis of responses to the questionnaire items. Individuals who “pass” the practice test advance to the formal hearing screening test.
Summary
To summarize, persons visiting the hearing screening test site are asked to: (1) create an account; (2) provide some background information via a brief questionnaire; (3) set the volume of their computer or wireless electronic device to MCL; (4) take a brief practice test to familiarize them with the nature of the assessment task; and (5) take a hearing screening test, the results of which are used to create a pseudo audiogram. Thereafter, respondents are provided with a variety of informative reports regarding their test performance.
Continuation: The information reports and interpretation resulting from this testing will be provided in next week’s post. Readers are encouraged to take this online test at https://apps.ntid.rit.edu/NSRT/ to more fully understand and appreciate this self-test of hearing.
References
- Bochner, J. H., Garrison, W. M. and Doherty, K. A. (2015). The NTID Speech Recognition Test: NSRT®. International Journal of Audiology, 54, 490-498.
- Garrison, W. M. and Bochner, J. H. (2015). Applications of the NTID Speech Recognition Test (NSRT®). International Journal of Audiology, 54, 828-837.
*Dr. Wayne Garrison is a Research Professor at the National Technical Institute for the Deaf on the Rochester Institute of Technology campus in Rochester, New York. He is a psychologist by training, with a broad range of R/D experience in statistics, psychometrics and software design.
**Joe Bochner is a professor and department chair at RIT/NTID. He has been involved in the language sciences, deafness and higher education for four decades, conducting research on the acquisition of English language and literacy skills, speech perception and production, and American Sign Language.
The test nailed me within +/- 5 db except at 500Hz, binaurally, sound field. Unbelievable.
My results from the test were right in line with my calibrated audiometer test thresholds.
OTC Op-Ed
OTC Hearing Aid Bill Poses Significant
Risks for Hearing-Impaired Consumers
Max Stanley Chartrand, Ph.D.
Hearing loss treatment as a consumer electronics company opportunity? It will be if the Over-the-Counter Hearing Aid Act passes, and the rest of us will lose.
The OTC proposal pending before Congress, in a nutshell, will mean that one-size-fits-all hearing aids will become available at one’s corner drug store, hardware store, and/or, conceivably, at the local 7-11—presumably next to the OTC reading glasses.
And it will affect up to 85% of the hearing impaired market, shutting out most of licensed professionals now serving the hearing impaired. In one fell swoop, the OTC proposal will effectively sweep aside fifty state licensing boards and their attendant rules and regulations. There will be no hearing evaluations nor otoscopy inspections or measurements taken of the ear canal, nor any other vital service provided by virtual army of untrained, unlicensed, and utterly unqualified sales clerks that will be unleashed onto an unsuspecting public.
Proponents argue that increased competition will increase accessibility and lower cost – both cited as significant issues in the United States. Not so. Every recent survey indicates that hearing aid services are available in virtually every nook and cranny of the United States. Nearly every practitioner has available a wide array of prices for instrumentation for as low as $500 per ear up to several times that, depending on the technology and peripherals desired. Many practices also offer low or no cost care to those who really need it and want it but cannot afford it. OTC devices, on the other hand, are projected to sell in the range of $500-$800 each. Where is the savings there? Plus, the competitive claim is a ruse: trained and licensed dispensers will be expected to abide by hundreds of pages of rules while their unlicensed competitors will not.
More pertinent, however, is the fact that cost never has been a real barrier to receiving hearing correction in the US. Rather, the real barriers to obtaining hearing care involve psychosocial barriers, such as denial of even having a hearing loss, or at least one bad enough to need amplification. Other barriers are lack of internal reference, abnormal loudness growth, signal-to-noise challenges, and cosmetics, dexterity, and lack of awareness of available options.
Meanwhile, one of the most critical consequences of the OTC proposal is the doing away with the consumer safety net imbedded in FDA red flag and medical clearance regulation. The US is known for its vast, voluntary network of community hearing healthcare teams, involving ear physicians, hearing aid specialists, audiologists, speech pathologists, and deaf educators.
These teams, formed in every community of the nation, assure that the 13.33% of hearing impaired individuals who have potentially life threatening conditions are connected with the medical services they need for timely life-saving treatment. A partial list of the serious conditions often encountered and referred are: cholesteatomas, keratosis obturans, glomus tumors, acoustic neuromas, vestibular Schwannomas, Meniere’s disease, cochlear stoke, sudden hearing loss, and a host of other conditions.
Hence, we will find that this “feel good” legislative proposal is really a veritable Trojan Horse hiding an unpleasant truth: consumers will no longer be assured a thorough and searching auditory evaluation, case history, and a medical clearance before purchasing a hearing aid. Furthermore, the crucial services for earmolds, programming, verification, and aftercare services that are generously provided now will also disappear under the new delivery model.
Make no mistake about it: there are no similarities between the vastly complex parameters involved in appropriate correction of hearing loss and the more straightforward, less complicated treatment of visual conditions. There is no instrumentation in hearing healthcare that compares to “reading glasses.” Yet Congress is considering a model that goes well beyond the eyeglass and contact lens model, which still requires a prescription within six months from a licensed provider. Clearly this requirement hasn’t hindered online sales in the vision market.
Experience tells us that a steady drumbeat of consumer education will improve penetration much more than unleashing a flood of cheap hearing aids and untrained salespeople onto the population ever could.
This proposal is not good for consumers; it will effectively dissolve decades of technology advancements and consumer protections. A hearing aid not fitted appropriately to a given individual’s specific needs, at any price, is a hearing aid that costs too much.
Dr. Chartrand is a professor of behavioral medicine and a well-known professional educator in the healthcare field. He is also profoundly deaf and a lifelong user of hearing technology. Contact: [email protected].
What about glomus tumors, cholesteatomas, keratosis obturans, acoustic neuromas, vestibular Schwannomas, sudden hearing loss, Meniere’s, and a long, long list one would need to see a trained professional? Or conductive vs sensorineural? This and just about every article supporting OTCs is absent of the reasons hearing healthcare cannot be delivered by untrained, unlicensed individuals. But how does the unsuspecting public know that? They trust the “experts” that tell them that cost and access are the top barriers (instead of the real barriers, like denial, lack of internal reference, etc.) and that all they need is a hearing aid, any hearing aid…what about couplers, own voice complaints, neurophysiological considerations? Really, OTCs and the dissolution of the consumer protections needed to direct them to the right resources is NOT the answer. It a contrivance that will take the most satisfying and lowest cost private program in the world and reduce them to the low levels of user like we see elsewhere and destroy the thousands of dispensing practices that have already staggered under the malfeasance of VA, online, and mail order sales. OTC–for >85% of the hearing impaired population–will bring the deathknell to a once great delivery system.
Since when is +/- 5dB considered “nailed it!”?