By Karl Strom, editor
Best practices in hearing healthcare have become a big issue. The reason is best practices are highly correlated with better patient outcomes and high levels of customer satisfaction.
What is a “Best Practice”?
In medicine, best practice is essentially a “gold-standard” process for ensuring and improving effectiveness and efficiency in the healthcare system. Clinicians who adhere to these evidence-based processes—specific activities, tests, procedures, etc, that have been scientifically proven to improve patient outcomes—should create happier and healthier patients. (And save our healthcare system money!)
Similarly, for audiologists and hearing aid specialists, best practices in hearing healthcare have been shown to improve patient benefit and satisfaction with hearing aids, and it should save a lot of healthcare dollars. There are Best Practices established by their respective professional organizations (see details below). Members of those organizations are expected to adhere to these best practices, and numerous experts have contended that those who do not are violating ethical standards of the organization.
In short, a great hearing care professional ROUTINELY USES best practices on all new patients.
Audiologists and hearing aid specialists are two different disciplines but both dispense hearing aids. Therefore, they have their own sets of best practices. However, all of them share (at minimum) these best practices when performing a hearing aid fitting:†
1) Audiologic Evaluation
The aim of the Audiologic Evaluation (or Hearing Evaluation) is to obtain a comprehensive picture of your hearing status. It should include a questionnaire and intake interview about your overall health and anything that might help the hearing care professional understand your unique hearing needs and/or problems (eg, medical conditions, prescriptions, living/work situations, etc). The evaluation should also rule out any possible mental or physical problems that might warrant your referral to a physician or other professional (eg, “red flags”), and include otoscopy (examination of the ear canal). A variety of tests are usually administered during the hearing evaluation, and frankly this is where the difference between an audiologist and hearing aid specialist can be greatest. However, in either case, you should receive audiometric testing (air- and bone-conduction audiogram) in a soundproof booth to gauge how well you can hear at various frequencies, speech perception testing, and tympanometry/immittance testing to make sure your middle ear (and the tiny bones in it) is working properly. There are many other tests that may be applied, depending on the results of each test (and the capabilities and scope of practice of the professional), and may include evoked potentials, otoacoutic emissions, and more. You will also be asked questions about tinnitus (ringing in the ears) or any balance problems (vestibular or inner ear problems) you’re encountering. Because hearing loss is a medical condition and you may someday need the results of your test, it’s always a good idea to request a copy of the audiogram for yourself and have the results of the evaluation sent to your doctor.
2) Needs Assessment
As its name implies, this is where the clinician gains a practical understanding of your goals and needs relative to better hearing. There are many methods for doing this. Probably the most common is the Client Oriented Scale of Improvement (COSI) which helps define your objectives and key hearing needs. For example, you might want to hear better at work meetings or when your grandkids are visiting. Maybe you’re a bird watcher and want to hear bird songs. If the professional doesn’t know what your goals are, they’re unlikely to address them and make you happy! The needs assessment should also include an unaided speech-in-noise test to see how well you hear in noise prior to getting hearing help. If you have bothersome tinnitus, you may have a discussion about various strategies that can help, including special features within hearing aids (eg, masking and relaxation apps).
3) Hearing Aid Evaluation
If it’s determined you need hearing aids, the hearing aid evaluation zeros-in on the exact hearing aid style, earmold type, hearing aid features, accessories, etc, that will work best for you. All of the above test results help determine the professional’s recommendation. The goal here is to mutually agree on the specific hearing technologies and device(s) you need, which might include Bluetooth streaming from your phone/TV, remote microphones for communicating in noise places, captioned telephones (free for qualified people with hearing loss), telecoils for hearing in church or auditoriums/theaters, special smoke alarms, vibrating alarm clocks, etc. Although it has become less common, the professional or a clinician may take an impression of your ear canal if a custom earmold is indicated, and then they will order the hearing aid from the manufacturer. It’s usually also in the hearing aid evaluation that you discuss the cost of the device and services. Be frank about what you need and what you can afford (studies show good-quality low-cost hearings aid when fit with best practices can perform about as well as a top-of-the-line aids—they just don’t have as many cool features). Additionally, most practices offer low-interest or no-interest programs through third-party financing companies like CareCredit, Ally Lending, or others. These can come in very handy, particularly for folks on a fixed income.
Once the hearing aid is received, the professional or a technician at the practice will perform independent testing (often referred to as “coupler measurements”) to verify the hearing aids work according to the manufacturer’s specifications, including the performance of the directional microphones and its noise reduction features. If they are not “up to spec,” the hearing aids are sent back—protecting you from any “lemons” that might have crept through the hearing aid quality-control inspection process!
4) Hearing Aid Fitting
During the hearing aid fitting, the professional makes certain that your hearing aid is right for you in quiet, in noise, and for other goals you’ve set in the needs assessment. First, they take all the available information gathered to program your hearing aids as close as possible to a prescriptive algorithm like the NAL-NL2 (a computer program that has been scientifically validated to match the amplification to your hearing loss). They will also adjust various things to make sure the aids are physically comfortable, so that soft speech is soft but understandable, and that loud sounds are loud but not painful or uncomfortable. The NAL-NL2 is often called the “first fit” program, meaning it’s “good enough” for a large swath of people who have the same hearing loss as you. Unfortunately, some clinicians stop there. The problem is you’re not always like everyone else! In fact, probably 12-30% of people have small ear canals or have some other “outlier” attributes that make the NAL-NL2 “first fit” not an accurate match.* That’s why you must have at least two additional tests before leaving with your hearing aids:
- Real-ear measurement (REM). This verifies that the volume of the hearing aid exactly matches what it’s supposed to be inside the ear canal (ie, not just theoretically, but actual level of sound in the “real ear”) using what’s called a “probe-tube microphone.” The test has been highly correlated to customer satisfaction with hearing aids, but for various reasons, many (or most) clinicians continue not to perform REM!
- Aided speech-in-noise testing. When compared with your unaided speech-in-noise test, this allows you to see the difference the hearing aid makes in noisy situations. Sometimes this won’t seem like much, but don’t be fooled by the number; even a 1 dB signal-to-noise ratio (SNR) improvement can mean an 10% or better improvement in speech understanding.
The professional should also provide you with instruction about how to use and care for the hearing aids and the features or auxillary devices that go with it.
5) Validation Measures to Assess Benefit
Validation measures allow the clinician and the practice/facility they work for to assess benefit and satisfaction, and address any lingering problems/concerns you have. There are several standardized validation methods, and these are usually in the form of questionnaires. It gives you the opportunity to tell the clinician if they did a good job (or not), and it also helps pave the way for the practice to keep improving on its value to patients. The clinician or someone from the office should follow up to make sure you’re doing well.
On average, it takes 2-3 visits (and sometimes more) to get a hearing aid fitting right, so don’t be shy about calling and asking for an adjustment if you think it’s needed. You also need to take ownership of your hearing loss and commit yourself to using them—even when it’s hard to adjust to them at first. You will never have perfect hearing and there are some limitations that you will have to accept. But it’s very important you succeed in regaining your full communication abilities and getting back into the hearing world!
Conclusion: Best Practices Matter!
The reason you pay substantially more for a professionally fit hearing aid is because of all the training, skill, work, and special equipment required to perform the above services. In essence, if a professional is just hanging a hearing aid on your ear, pressing a “first fit” automatic programming button, and sending you out the door, you’re probably not getting your money’s worth—you can get a similar fitting from an online device. Your hearing care professional should be committed to using best practices. If they don’t, strongly consider moving to one who does!
It should be emphasized that the above is a brief overview of what I consider to be the most important components of Best Practices for both audiologists and hearing aid specialists. Indeed, there are a lot more procedures and services not covered here (eg, counseling on hearing strategies, tinnitus management, etc). If you’re interested in more specific details about Best Practices, here are the actual guidelines for professionals from their respective organizations:
Hearing Aid Specialists:
- International Hearing Society (IHS)
- National Board Certification for Hearing Instrument Specialists (NBC-HIS) credential
CONSUMER TIP: This also indicates that professional association membership/participation matters, and so does licensing and credentials! If your hearing care professional belongs to one of these professional organizations, there is a higher likelihood they will adhere to the tenets of that organization’s best practice guidelines (or at least should!)
† Note that some hearing care professionals might employ a particular test in a different phase of the process. For example, some clinicians perform speech-in-noise testing during the Audiologic Evaluation while others prefer to do it during the Hearing Aid Fitting. The exact order of the tests is much less important than how the test results are employed to create optimal outcomes.
*This is no knock against the NAL-NL2 formula. Considering all the variables in hearing loss, the NAL-NL2 remains an amazing audiological tool for fitting hearing aids, and it was painstakingly validated using a large population of people (ie, normative data) with different hearing impairments.
MORE (for Professionals): Offering Your Patients a Best-practice Outcome
About the author: Karl Strom is editor of The Hearing Review and has been reporting on hearing healthcare issues for over 25 years.