Task Force Members
In 2003, Angela Loavenbruck, then President of the American Academy of Audiology (AAA), asked the author to consider chairing a new Task Force whose goal was to develop a national guideline for fitting hearing aids to adults. At that time, AAA would soon release a guideline for fitting hearing aids to children, and AAA felt a separate guideline was needed for adults. For the adult population, the American Speech-Language-Hearing Association (ASHA) maintained the most recent national guideline that was released in 1998, and Angela felt a new guideline was necessary because a) the AAA guideline for children was about to be published; b) as the national organization for audiologists, AAA needed to formulate its own guideline; and c) numerous advances have been made in technology since the ASHA guideline was published. Angela informed the author that the current Task Force members included Harvey Abrams, Dennis Hampton, Todd Ricketts, and Robert Sweetow. Soon after assuming the chair, I asked Theresa Hnath-Chisolm, Darcy Benson, David Citron, and Helena Solodar to join. Please see Appendix A for a list of the members of the Task Force. It is important to note that of the ten members of the Task Force, five are in private practice (Darcy, David, Dennis, Angela, and Helena), one is involved in full-time research and teaching (Todd) and the others (Harvey, Theresa, Robert, and I) have combined administrative, patient care, research, and teaching responsibilities. As chair, I felt it was imperative to have a significant presence of clinicians as members of the Task Force so the content of the guideline would have relevance to the clinicians who would be asked to implement its contents. What followed was a three-year journey to develop the guideline. During that journey, there were numerous hurricanes, several crashed hard drives, lost files, thousands of e-mails and phone calls, some illnesses, and two face-to-face meetings (Tampa Bay and Washington, D.C.).
Why a New Guideline?
The reader might ask, "Why a new guideline?" There are several answers to this important question. First, as mentioned earlier, the last guideline was published by ASHA (Valente et al., 1998). Since 1998, there have been numerous advances in hearing aid technology as well as the methods used to verify and validate hearing aid fittings. Thus, the current standard needed to be updated to accommodate these advances. Second, there is increased interest in other professions in using evidence-based principles (EBP) when developing a new guideline. It was felt that in order for this guideline to have relevance, it too must use EBP to reinforce its recommendations. Third, AAA published a pediatric guideline (2004) and felt an adult guideline was also necessary. Fourth, there is considerable concern regarding the manner in which hearing aids are dispensed by audiologists (Mueller, 2003; Kochkin, 2002). That is, current clinical practices implemented "in the field" may do little to differentiate how hearing aids are dispensed by audiologists and others and therefore would not be in line with AAA's goal for professional autonomy.
Goals for Developing the Guideline
After recruiting the members, it was decided that a primary goal would be to use EBP to support whatever recommendations were developed. Initially, the decision to incorporate EBP into the guideline was not unanimously supported by the Chair and several members of the committee. Initially, the Chair felt the Task Force would make a major contribution by taking the current guideline and updating its contents. Harvey and Theresa, however, very diplomatically argued that using EBP to support guideline recommendations would be even a greater contribution to our profession. Because using EBP to support guideline recommendations had never been done in past or current Audiology-related guidelines, Harvey and Theresa persisted that the final guideline must be supported using EBP. Also, other than Harvey and Theresa, few members of the Task Force were exposed or knowledgeable about implementing EBP. To become more knowledgeable, each member was provided Law's (2002) textbook on EBP. For several weeks, little was accomplished until the members became more comfortable and knowledgeable about EBP. The author believes it fair to state that if Harvey and Theresa were not members of the Task Force, then the final version of the guideline would bear little resemblance to the version currently available on www.audiology.org and approved by the Executive Board of AAA.
A second goal was that the guideline must be patient-centered by incorporating a section on auditory and non-auditory needs-assessment. Finally, it was felt that if the "spirit" of the guideline (i.e., not every recommendation needs to be implemented; recommendations do not need to be implemented precisely as stated within the guideline) were followed then its implementation by audiologists would:
- Promote uniformity of care,
- Decrease variability of outcomes,
- Promote better fitting practices,
- Elevate the clinical care to our patients as well as elevate our profession,
- Provide greater patient satisfaction, and,
- Reduce the hearing aid return rate.
The content and organization of this guideline differs significantly from the previously published ASHA guideline in several ways. First, it is the only guideline thus far to include a section specifically on auditory and non-auditory needs assessment. Second, it is the first to use EBP to support its recommendations. Within the guideline, EPB is also used to point out areas where the evidence may not be sufficient to support implementing some recommendations of the guideline. Finally, it is emphasized that a guideline is not static and needs to be re-evaluated every five years to assess the need for revisions as technology and the evidence changes.
How Did the Members Organize the Guideline and Review the Evidence?
First, the group divided the guideline into five major divisions (Introduction; Assessment; Technical Aspects of Intervention; Instruction, Orientation, Counseling and Follow-Up Audiologic Rehabilitation; Assessing Outcomes). These divisions follow the sequence patients typically follow when pursuing amplification. The five divisions were divided into nine sections. The numbers appearing below in parentheses indicate the number of specific recommendations for each section:
- Assessment: auditory assessment (0), auditory-needs assessment (3), and non-auditory needs assessment (6).
- Technical Aspects of Intervention: hearing aid evaluation (13), quality control (2), fitting and verification (7), and hearing assistive technology (4).
- Instruction, Orientation, Counseling and Follow-Up Audiologic Rehabilitation: hearing aid orientation (2), and counseling and follow-up audiologic rehabilitation (6).
- Assessing Outcomes (0)
Then a systematic search of the literature was conducted using EBP to support each of the 43 recommendations. The search focused on seeking the best available evidence to address each recommendation and ensure maximum coverage of studies at the top of the hierarchy of study types (Levels 1-2, see Table 1). Once definitive studies providing relevant information were identified at this level, the search stopped. The search extended to studies or reports of lower quality (Levels 3-6) only if higher quality studies (Levels 1 or 2) could not be found.
Table 1. Levels of Evidence
- Systematic reviews and meta-analysis of randomized controlled
trials (RCT) or other high-quality studies
- Well designed RCT
- Non-randomized intervention studies
- Cohort studies, case-control studies, cross-sectional
surveys or uncontrolled experiment
- Case report
- Expert opinion
Table 2. Grade of Recommendation
- Level 1- 2 with consistent conclusions.
- Level 3- 4 studies; extrapolated evidence (generalized to a situation
where it is not fully relevant from Level 1 - 2).
- Level 5 studies of extrapolated evidence from Level 3 - 4.
- Level 6 evidence; inconsistent or inconclusive studies of any level;
any study having a high risk of bias.
After retrieving the evidence using a wide variety of methods, the members reviewed and graded the evidence using Quality of Evidence Ratings (Levels 1-6; Table 1) and Grade of the Recommendation (A-D; Table 2). In addition, it was determined if the evidence was Effective (EV) or Efficacy (EF) - based where EV is evidence measured in the "real world" and EF is evidence measured under "laboratory or ideal" conditions.
Table 3 provides an example of a Table of Evidence taken from the guideline. In this example, the first column shows guideline recommendation number(s). The second column states the evidence to support the recommendation. On several occasions, more than one statement was presented to support a recommendation. Also, several recommendations could be presented to support one statement. Overall, the combined Tables of Evidence contained 108 statements to support the 43 recommendations. The third column cites the reference(s) used to support the statement of a recommendation (the number is the number of the reference cited to support the statement from the Reference section for that section of the guideline). The fourth column is the Level of the Evidence (1-6) and Grade (A-D). When reading the entire guideline, the reader will note that of the 108 statements supporting the key recommendations, 4.6%, 25.9%, 14.8%, 35.2%, 4.6%, and 14.8% were judged to have evidence at Level 1 through 6, respectively. It is clear that for most recommendations within the guideline, less than 1/3 were judged as Level 1-2. This finding should be a major concern because this suggests there may not be strong evidence to support many of the procedures audiologists typically complete when dispensing hearing aids to the adult patient! This finding also points to the need for future research to justify the manner in which audiologists provide services relative to the sections covered in this guideline.
Table 3. Example of Evidence Table
Organization of Each Section
Each section begins with an Objective that states the purpose for that particular section. This is followed by a Background detailing how the section fits within the guideline. The specific Recommendations then follow. Each section then ends with the Table of Evidence and References.
Specific Divisions and Sections of the Guideline
Within the "Introduction," the guideline provides several statements outlining some of the essential components. First, services must be provided by a licensed audiologist. Second, the combined efforts of the audiologist, patient, significant others, and/or caregivers are essential. Third, assessment must be viewed as a multi-faceted process that includes assessment of auditory function to determine the extent of impairment and assessment of activity limitations, as well as participation restrictions through self-report of communication needs and performance. Fourth, consideration should be given to assess the typical listening environments using tools such as datalogging or self-assessment. This assessment could be useful in helping make decisions regarding hearing aid style and features. A recent example of such a self-assessment tool is the "Characteristics of Amplification Tool (COAT)" that was recently introduced by Cleveland Clinic and published on Audiology Online (Sandridge & Newman, 2006). Washington University audiologists use this two-page questionnaire daily and have found it to be very beneficial in focusing upon the perceived listening environments of the patient, level of motivation for success with amplification, expectations, style, and cost of amplification. I urge readers to pursue this very helpful tool.
Also, consideration needs to be given to how these levels of assessment interact and reinforce each other to improve quality of life (QOL) of the patient. It was felt that as a result of the multi-faceted assessment, clear and realistic individualized goals for intervention could be set.
This section details the various components of the auditory assessment of the patient. Some of the specific components include:
- Comprehensive case history,
- Identifying type and magnitude of hearing loss via pure-tone and speech audiometry as well as immittance audiometry (tympanometry and acoustic reflexes),
- Measuring loudness discomfort levels (LDLs)
- Otoscopic inspection and cerumen management,
- Determine need for treatment/referral to physician or need for further tests (ABR; vestibular, etc),
- Counsel patient, family, caregiver on the results and recommendations,
- Assess candidacy and motivation toward amplification,
- Determine medical clearance as determined by FDA (1977).
This section details procedures to develop patient-specific communication needs. This includes providing realistic expectations and creating patient-specific fitting goals as the initial stage of the "validation" process. The importance of providing realistic expectations becomes increasingly more important as one reads the advertisements appearing in the local media. For example, the author lives in a major city where one major newspaper contains advertisements for hearing aids on a daily basis. One advertisement suggested an available hearing aid could "control the noise of 65,000 screaming football fans." Another advertisement used an excellent article on dead hair cells published in the Journal of the American Academy of Audiology (JAAA) as support that their hearing aid had the ability to "bypass dead cells" to improve speech understanding. It should be easy for the reader to see how advertisements such as these, and others, will create an atmosphere of unrealistic expectations and force a dispensing audiologist to dismiss these claims and provide his/her patient with more realistic expectations.
Also involved in this process is determining which hearing aid "features" may be appropriate for the patient. These features may include:
- Directional microphones
- Direct auditory input (DAI)
- Noise management
- Frequency Modulation (FM) devices
- Abbreviated Profile of Hearing Aid Benefit (APHAB) (Cox and Alexander, 1995).
- Client Oriented Scale of Improvement (COSI) (Dillon et al., 1997).
- Hearing Handicap Inventory for the Elderly (HHIE) (Ventry and Weinstein, 1982).
- Expected Consequence of Hearing Aid Ownership (ECHO) (Cox and Alexander, 2000)
- Glasgow Hearing aid Benefit Profile (GHABP) (Gatehouse, 2000)
- International Outcome Inventory-Hearing (Cox et al., 2003)
This section deals with the non-auditory aspects of the patient that may interact to determine success with amplification. These aspects may include cognition, patient expectations, motivation, willingness to take risks, assertiveness, manual dexterity, visual acuity, prior experience with amplification, general health, tinnitus, occupational demands, and the presence of support systems.
Technical Aspects of Intervention
Hearing Aid Selection
This section relates to the decisions needed to select the appropriate hearing aid(s) and hearing assistive technology (HAT) based on the results of the hearing assessment and the auditory and non-auditory needs assessment. The outcome of this process is an attempt to match the appropriate style and features to the patient. These decisions may include:
- Style (CIC ; ITE ; ITC ; BTE)
- Occlusion management
- Volume control
- Bilateral versus monaural
- Direct auditory input (DAI); telecoil (programmable)
- Type of signal processing
- Capacity for frequency shaping (number of bands)
- Selection of output and SSPL90
- Number of memories
- Number of channels of compression and feedback management
- Digital noise reduction
- Switchable or adaptive directional/omnidirectional microphones
- Frequency compression or transposition
- Bone anchored devices
- CROS/BICROS/Transcranial CROS
The objective of this section is to ensure that hearing aids meet reasonable and expected quality standards prior to scheduling for hearing aid fitting and verification. A small percentage of instruments and earmolds may be defective upon receipt. In addition, hearing aids and earmolds may arrive in good working order, but with the incorrect configuration/features. Quality control (QC) measures are necessary to limit patient and clinician frustration and inconvenience. Examples of QC may be:
- Verification of directional microphone performance using either coupler or real-ear measurement
- Electroacoustic analysis of new and repaired aids to ensure compliance to national standards and clinician satisfaction
- Electroacoustic analysis at final fit to provide base for measures at semi-annual or annual checks
- Verification of features to include confirmation of earmold/shell style, vent, color, type, processing (memories, automatic switches, etc.) and mechanical (directional microphones, t-coil, integrated FM, etc) features,
- Listening check for features not verifiable through physical examination or electroacoustic analysis. These may include operation of the volume control, directional microphones, FM, t-coil, etc.
The objective of this section is to assure the fitting and verification procedure is viewed as a process that culminates in the optimal fitting. Verification procedures also serve as a benchmark against which future hearing aid changes can be compared.
Verification procedures should be based on validated hearing aid fitting rationales and are expected to yield a comfortable fit of hearing aids including all desired features. In the fitting and verification process a signal must be presented to the hearing aid whether in the test chamber or with a probe microphone in the real ear. The clinician must select signals ensuring accurate verification of prescriptive methods to target, which are based on speech inputs and therefore a speech-like signal should be used. Examples of aspects of the fitting requiring verification may include:
- A comfortable physical fit
- Gain/output using validated fitting rationales.
- Correction for monaural/bilateral conditions
- Correction for type of HL
- RESR90 measurement below the individually measured LDL using pure-tone signal, when possible.
- Aided sound-field thresholds for audibility of soft sounds.
- Function of features such as telecoil and directional microphone
- Absent or minimal occlusion effect
The objective of this section is to promote the use of Hearing Assistive Technology (HAT) to ensure communication needs are met as hearing aids alone may not address all the needs of the patient. HATs can either be used alone or combined with hearing aids to supplement performance in difficult listening conditions. HATs can address four communication needs:
- Face-to-face communication.
- Broadcast and other electronic media.
- Telephone conversation.
- Sensitivity to alerting signals and environmental stimuli.
- Personal FM system
- Induction loop
- Hardwired systems
- Telephone amplifier, telecoil, TDD (telecommunication device for the deaf)
- Situation specific devices (e.g., television)
- Alerting devices
Hearing Aid Orientation
The objective of this section is to ensure patients obtain the desired benefits from amplification as easily and efficiently as possible. The hearing aid orientation process begins with the initial hearing aid fitting and may continue over several visits. Hearing aid orientation is complete only when all appropriate information has been provided and the patient (or family member/caregiver) is competent to handle the instruments or declines further post-fitting care.
Orientation information can be device or patient-related. Device-related is specifically about the care and use of hearing instruments. Patient-related includes helping the patient understand the nature of hearing loss, adjust to amplification, have realistic expectations of the benefits and limitations of amplification, and take advantage of other sources of help (such as better communication strategies, HATs and speechreading). Topics addressed in orientation may include:
- Use and care of aids such as instrument features; insertion/removal; battery use; care and cleaning; comfort; feedback, use with telephone; warranty.
- Wearing schedule; goals and expectations; adjustment to amplification; speechreading; post-fitting.
The objective of this section is to provide patients who have received hearing aids a comprehensive understanding concerning the effects of hearing impairment and the implementation of strategies to mitigate those effects. The members view the fitting of hearing aids as the beginning of the treatment process. Successful management requires comprehensive counseling to help the patient adjust to his/her hearing aids, as well as instruction the patient and his/her primary communication partners concerning the development of appropriate communication strategies to maximize and augment the assistance he/she receive from the hearing aids. Counseling is often required to help the patient learn new strategies to help ensure success. In addition, emotional factors concerning hearing loss must be addressed in a comprehensive audiologic rehabilitation program. Counseling can be provided on an individual basis, but is often delivered in small group settings.
Topics addressed in these sessions should include:
- Anatomy and physiology of hearing process
- Understanding the audiogram
- Problems associated with understanding speech in noise
- Appropriate/inappropriate communication behaviors
- Communication strategies
- Listening and repair strategies
- Ways in which to control the environment
- Assertiveness training
- Realistic expectations from amplification
- Stress management
- Speechreading skills
- Community resources
This is the part of the patient management process that assesses how well intervention reduced activity limitations, decreased participation restrictions, and improved QOL. This is referred to as validation. Validating the choices made as part of the assessment, selection, and fitting processes, to the extent that the patient's needs have been met, is accomplished through the administration of outcome measures. Many outcome measures, described in the auditory and non-auditory needs assessment section, have been developed to assess the impact of a hearing impairment on the individual in the areas of communication functioning, activity limitation and participation restrictions.
As critical as it is to measure the benefits of hearing aid intervention at the level of the patient, the measurement of treatment outcomes is assuming greater importance on the national health care stage. Through the routine use of clinically applied outcome measures and carefully controlled clinical trials, audiologists can build a foundation for evidence-based clinical practice guidelines. Clinical practice guidelines, in turn, minimize variability in outcome, maximize treatment efficacy, reduce risks, decrease waste, and improve patient satisfaction. In addition, the guideline should elevate the profession of Audiology among third party payers, other health care providers as well as current and future patients. As audiologists continue to compete in the health care marketplace, they must demonstrate that treatments reduce activity limitations, decrease participation restrictions, and improve health-related quality of life. Only by measuring the outcomes of treatment can audiologists be assured that interventions make a difference and patients have benefited from their care.
Personal Thoughts on Some Possible Limitations of EBP
Integrating EBP to develop this guideline and implying that clinicians should routinely use EBP to critically analyze the evidence (literature) to determine whether to include new procedures or treatments into the clinical care of their patients is a logical step. One would be hard pressed to argue against this. The author, however, believes that strict reliance on EBP to help clinicians make these decisions may not be without some problems and these potential problems need to be, at least, mentioned. This is not to minimize the importance of integrating EBP into the daily clinical practice of audiologists. Rather, this section serves to point out some concerns the author has about the reality of strict integration of EBP within the current clinical environment. These potential concerns include:
- Reviewing the evidence is subjective. Anyone experiencing the peer review process as either a reviewer or author knows of the rather common outcome of reviewers having significantly different views on the quality of the submitted manuscript. In fact, in the experience of the author, it is quite rare when the reviewers arrive at the same recommendation concerning acceptance/rejection or specific concerns about the quality of the submitted manuscript. Further, members of the Task Force, when using EBP, were not always in agreement as to whether a particular article was a Level 1 or Level 2 or some other level of evidence. Thus, if the "experts" are not in agreement, is it realistic to expect the "non-experts" among us to agree on the quality and level of the research he/she has just read? That is, the EBP process also appears to be a balance between art and science.
- The application of clinical care needs be a balance between art and science. That is, clinician experience/intuition should not simply be written off as having little or no value. Clinical experience does have significant value and this experience must be balanced with the conclusions a clinician might draw as he/she reads and analyzes the evidence. The clinician, for example, should be able to judge if the results of a published project have relevance to the "real world." For example, is a reported improvement of 6.5 dB obtained in a sound suite with noise arriving from a single loudspeaker from 180 degrees is going to result in the same magnitude of improvement in the real-world? No, and hopefully most clinicians would be able to make the connection between research completed in the laboratory and its application in real world experiences and expectations of their patients.
- This is extremely difficult for the author to state, but do most audiologists actually read the evidence? Unfortunately, my experience would suggest that the answer may be "no." Thus, if a profession relies on the use of EBP to advance the quality of care, is its value being maximized if the members of the profession do not routinely read the evidence?
- On a more positive note, the author believes there is a significant shift within the profession to embrace EBP. This shift is observed by the increased number of presentations on EBP at professional meetings. In fact, there are now entire conferences dedicated specifically to the implementation EBP in Audiology. Also, there are increased requests on the part of conference organizers asking presenters to use EBP in their presentations to support the ideas being expressed. Finally, a casual review of the curriculum of residential four year Au.D. programs appears to show a significant increase in courses pertaining to statistical analysis and research design that is required in order to be awarded the degree.
- It is also extremely difficult for the author to suggest that most audiologists are not typically trained to critically analyze the evidence. Thus, even if the evidence is being read, is the typical audiologist trained to critically analyze the merit of the evidence? Again, the author believes there is a significant shift in direction with the residential four year Au.D. programs offering courses on statistical analysis and research design. In addition, many programs appear to be mandating that students use EBP in the review of the literature and discussion sections of their Capstone Projects. It does appear as if the current graduates from Au.D. programs are being better trained in EBP. The hope, of course, is that this will continue in the years after graduation.
- Technology is rapidly changing and it may take more than two years from the time data collection and the peer-review process is completed before the benefits/risks of this new technology to appear in the literature. Can a clinician afford to wait more than two years before learning if a new treatment or procedure has greater benefit than a current treatment or procedure before implementing it into the daily clinical care for their patients? If clinicians followed this time line, with the current explosion in technology, the advances would pass their patients by and audiologists would remain stagnant.
- As noted earlier, there appears to be little Level 1 or Level 2 evidence to support the practices clinicians typically practice when dispensing hearing aids to adult patients on a daily basis. Hopefully, one of the greatest contributions of incorporating EBP to formulate this guideline is pointing out the "holes" or "weaknesses" in our collective research and "force" our profession to generate better research.
- Strict use of EBP would seem to minimize the contribution of information published in non-peer reviewed "trade" journals. The reader probably realizes that in an environment where technology is changing so rapidly, it may well be that the information contained within these journals may be the best source of current information on the capabilities and limitations of these new advances. The reader simply needs to be reminded of the obvious conflict of interest (bias) that may be contained within the information provided. The reader should be further reminded that some of the most often cited work in our field has been contained within the pages of these journals.
- Finally, and related to some of the previous points, there is some concern within our profession that the Au.D. may weaken the scientific base of our profession as more pursue the Au.D. rather than the Ph.D. This latter concern is less related to EBP, but to the dwindling number of Ph.D. candidates pursuing Audiology in graduate programs the United States. Audiology needs a strong scientific base to gain autonomy and remain vibrant in the years ahead. The strength of the scientific base is related to the number and quality of audiologists holding and using their Ph.D. to further the science of our profession.
This paper was written to offer some additional insight into the current AAA adult hearing aid fitting guideline and EBP. If the reader is interested to learn more about EBP, several websites may prove to be helpful. For example, ASHA (2006) developed a National Center for Evidence-Based Practice in Communications Disorders (N-CEP). This is a registry of evidence-based clinical practice guidelines and systematic reviews of topics related to audiology and speech pathology. This registry allows clinicians to find guidelines and reviews at a single location www.asha.org/members/ebp/registry. This registry was initially launched in 2005 with 90 guidelines. Members of N-CEP reportedly used the Assessment of Guidelines for Research and Evaluation (AGREE), which is the most prominent method to review clinical practice guidelines www.agreecollaboration.org. Other websites include Agency for Heathcare Research and Quality www.ahrq.gov and the National Guideline Clearinghouse www.guideline.gov.
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American Speech-Language-Hearing Association. (2006, June 13). Evidence-based practice tool available. ASHA Leader, 19.
Cox, R., & Alexander, G. (1995). The abbreviated profile of hearing aid benefit. Ear and Hearing, 16, 176-186.
Cox, R.M., & Alexander, G.C. (2000). Expectations about hearing aids and their relationship to fitting outcome. Journal of the American Academy of Audiology, 11, 368-382.
Cox, R., Alexander, G., & Beyer, C. (2003). Norms for the international inventory for hearing aids. Journal of the American Academy of Audiology, 14(8), 403-413.
Dillon, H., James, A., & Ginis, J. (1997). The client oriented scale of improvement (COSI) and its relationship to several other measures of benefit and satisfaction provided by hearing aids. Journal of the American Academy of Audiology, 8, 27-43.
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Kochkin, S. (2002). 10-year customer satisfaction trends in the US hearing instrument market. The Hearing Review, 9(10), 14-46.
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Mueller, G. (2003). Fitting test protocols are "more honored in the breach than the observance." The Hearing Journal, 56(10), 19-26.
Sandridge, S.A., & Newman, C.W. (2006, April 6). Improving the efficiency and accountability of the hearing aid selection process. Audiology Online, Article 1541. Retrieved August 16, 2006 from the Articles Archive on www.audiologyonline.com. Direct access URL located at: www.audiologyonline.com/articles/article_detail.asp?article_id=1541
Valente, M., Bentler, R., Seewald, R., Trine, T., & Van Vliet, D. (1998). Guidelines for hearing aid fitting for adults. American Journal of Audiology, 7, 5-13.
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Members of the Task Force
Washington University School of Medicine
St. Louis, Missouri
Veterans Administration Medical Center
Bay Pines, Florida
California Hearing Center
San Mateo, California
University of South Florida
South Shore Hearing Center
South Weymouth, Massachusetts
Westchester Audiology Center
White Plains, New York
New York, New York
Audiologic Consultants of Atlanta
University of California-San Francisco
San Francisco, California