Editor's Note: The hearing aid selection process can be a challenging process. This is not only due to the ever-evolving complexity of hearing aids, but the varied needs of our hearing aid patients. Drs. Sandridge and Newman are expert researcher/clinicians and in this article they have provided a simple and quick 9-item questionnaire that they use on a regular basis in the Cleveland Clinic to help with the selection process. A downloadable version of this tool is provided at the end of this article for distribution and use in your clinic/practice.
- Paul Dybala, Ph.D. - President and Editor, Audiology Online.
A major challenge faced by audiologists working in a busy hearing aid dispensing practice is the selection of the most appropriate amplification system for a given patient in a time-efficient manner. That is, in one-hour or less, we must determine which set of hearing aid (HA) fitting options (e.g., monaural versus binaural, device style, earmold configuration) and technologies (e.g., directionality, fitting algorithm, number of programs) most closely meet the needs of our patient. Within that hour, we must not only determine the audiologic needs but also the non-audiologic variables such as vision, aging effects, physical function, cognitive ability, HA expectations, level of motivation, life-style issues, education, and support system (Gatehouse, 1994; Gatehouse, Naylor & Elberling, 2003; Kricos, 2000) that may affect the fitting outcome. Therefore, the question remains "How do you effectively counsel the patient regarding amplification options, ascertain his or her wants and needs, recommend specific devices, and take earmold impressions in one hour?" The purpose of this article is to provide the reader with some practical suggestions that help address the latter question. We also describe measures that can be utilized at the "front-end" of the hearing needs assessment (i.e., HA evaluation) to guide the clinician in the selection of the most appropriate devices.
Using A More Prescriptive Approach To HA Selection And Recommendation
Recently, we have adopted the philosophy to become more prescriptive with our HA recommendations. In this article, we are not referring to prescriptive techniques that utilize specified frequency response and gain characteristics (e.g., NAL-R, DSL). Rather, we are referring to the coupling of the audiologist's expertise and knowledge about current HA technology with the patient's prefitting perceptions, belief systems and needs. Using this prescriptive approach, the clinician selects the "ideal" style and level of technology with the appropriate electroacoustic features, and presents this to the patient as the recommend HA of choice. This is in direct contrast to our earlier counseling strategy. Previously, we believed that it was important to present the patient with all their options allowing them to make an informed decision. Not only did we find this approach time-consuming, it caused considerable confusion to the patients as they suffered from information overload. Many times the end result was a "I'll think about it" response. In most cases (with the exception of those "engineering-types"), patients are not that concerned or interested in such technological concepts as bands/channel, dual-microphone technology, noise reduction algorithms, compression strategies, etc. They are, however, interested in obtaining HA/s that meet their particular communication needs, lifestyle and financial resources.
What Are The Differences Between "Outcomes" And "Incomes" Measurement?
With today's emphasis on evidence-based practice in audiology (Cox, 2005), it is imperative to document the outcome of our service. A variety of HA outcomes measures (for a complete review of available instruments, see Johnson and Danhauer, 2002) exists that are helpful when addressing such questions of treatment effectiveness (e.g., Do HA/s improve the user's quality-of-life?), treatment efficiency (e.g., Does adaptive directionality improve performance in background noise compared to fixed directionality?), and cost-effectiveness (e.g., Does mid-level digital signal processing technology improve communication performance in relation to the purchase price of high-end technology?). Likewise, several self-report instruments have been developed for the expressed purpose of: (1) quantifying HA benefit when used in a pre- versus postfitting administration format, such as the Abbreviated Profile of Hearing Aid Benefit (APHAB; Cox & Alexander, 1995); Client Oriented Scale of Improvement (COSI; Dillon, James, & Ginis, 1997) and the Hearing Handicap Inventory for the Elderly/Adult (HHIE; Ventry & Weinsten, 1982; HHIA; Newman, Weinstein, Jacobson, & Hug, 1990); or (2) for documenting HA satisfaction such as the Satisfaction with Amplification in Daily Life (SADL; Cox & Alexander, 1999) at specified time intervals following the provision of amplification. Yet, neither benefit or satisfaction outcome measures provide a systematic method for assisting in the selection of the "best" HA at the outset (e.g., style, technology level and options).
What is needed is a method to quantify the audiologic and non-audiologic characteristics that may influence HA use. An 'income' tool would provide a means to determine which devices may be optimal. As suggested by Johnson and Danhauer (2002), attention to income measurement variables at the beginning of the HA fitting process ultimately results in better patient outcomes. Tools such as the Hearing Aid Needs Assessment (HANA; Schum, 1999) and the Expected Consequences of Hearing Aid Ownership (ECHO; Cox & Alexander, 2000) provide information about how the patient's perceived communication needs and expectations influence outcome; yet, neither instrument assists in the selection of specific devices. In response to this need, Jacobson, Newman, Fabry, and Sandridge (2001) developed The Three-Clinic Hearing Aid Selection Profile (HASP) to assess patient's perceptions and attitudes about issues related to both HA and non-HA use in an attempt to direct the clinician to the most appropriate class of devices (e.g., style, level of technology).
The HASP consists of 40 statements. The patient indicates level of agreement to each statement using a 5-point Likert scale ranging from "strongly agree" (4-points) to "strongly disagree" (0 points). The 40 statements are divided into 8 subscales (5 statements each subscale). Three subscales address issues directly related to HA/s. They are:
- motivation to wear HA (e.g., I want to wear a hearing aid even if I have difficulty in some situations);
- expectations about HA performance (e.g., A hearing aid will restore my hearing to normal just as eyeglasses restore vision to normal); and
- communication needs (e.g., It is very important for me to hear conversations when I am in a larger group, for example at a party);
The remaining 5 subscales contain items that assess a patient's perceptions and attitudes about issues not related to HA/s specifically. They are:
- importance of physical appearance to others (e.g., There is nothing wrong with using plastic surgery to improve one's appearance, this subscale is reversed scored);
- attitude toward cost of commercial goods and services (e.g., I don't think that I need the best money can buy; this subscale is reversed scored).
- attitude toward technology (e.g., I feel that new technology has improved our lives);
- physical functioning and manual dexterity (e.g., It is easy for me to use small objects such as paper clips, coins, small buttons, and/or zippers); and
- lifestyle (e.g., I consider myself to be an active, busy, "on-the-go" kind of person).
A maximum score for each of the subscales is 20 points (5 items per subscale times a maximum score of 4 points for each item). From a clinical perspective, a greater subscale score is generally considered more favorable (e.g., realistic HA expectations) whereas a lower subscale score is generally considered less favorable (e.g., inadequate physical functioning and manual dexterity). The individual scores are plotted on a multifactorial matrix (developed from the normative data) providing a visual representation of where the individual falls with reference to the normative percentiles. In addition to its use in counseling the patient, the matrix is useful in selecting the style and level of technology for an individual patient. For example, the patient's profile in Figure 1 shows that he is motivated, has high expectations (which may not be appropriate and may necessitate some counseling regarding realistic expectations from amplification), is extremely appearance conscious, is not concerned about the cost of goods and services, is comfortable with high technology, does not have any significant physical limitations, has high communication needs, and has an active lifestyle. Based on this profile, high-end, micro/mini BTE hearing aids that match the patient's hair color and an open-ear fit (given appropriate audiometric data) would be an appropriate "first choice" recommendation.
Characteristics of Amplification Tool (COAT)
While the HASP has documented psychometric adequacy and clinical usefulness (Jacobson et al., 2001), it is not the most time-efficient tool, limiting its application in a busy clinical practice. Therefore, we set out to design a questionnaire that would meet the following criteria:
- similar constructs to the HASP;
- short in length so that it could be completed in 10 minutes or less;
- easy to administer and interpret;
- obtain the critical non-audiologic information useful in determining the style and level of technology required by the patient;
- function as a basis for counseling during the HA selection appointment;
- serve as a measure for clinician accountability in this era of evidence-based practice; and
- useful as a teaching tool for student externs.
Based on these criteria, we developed a 9-item instrument known as the Characteristics of Amplification Tool (COAT). The main point of each item is listed below, accompanied by an explanation of the rationale for inclusion and the item's intent.
A copy of COAT in Microsoft Word format can be downloaded here.
Feel free to take this form and update it with your practice name and/or logo.
Item 1: Please list the top three situations where you would most like to hear better.
The best way to determine the circumstances in which the patient needs to hear better is simply to ask. Accordingly, the patient is requested to provide three specific difficult listening situations encountered in daily life, a format similar to the COSI. Structured self-report measures such as the HHIE/A or the APHAB, contain fixed items that may have little to no relevance to the patient. By allowing the patient to indicate areas of desired improvement, they play a more active role in selecting the HA that will meet their individual needs.
Item 2: How important is it for you to hear better?
The importance of hearing better is addressed in this item. Because it is not situation specific, this item assesses the patient's global priority of hearing. For example, the retired individual whose primary activity is reading may not place as much importance on hearing as the individual involved in a variety of social activities.
Item 3: How motivated are you to wear and use hearing aids?
Jacobson, Newman, Sandridge, and McCaslin (2002) reported that one of the key factors for HA/s returned for credit in their study was motivation, or more precisely, lack of motivation. A patient without motivation to use HA/s sets the stage for failure; therefore, it is critical to assess motivation levels.
Item 4: How well do you think hearing aids will improve your hearing?
Unrealistically high or low expectations of HA performance will likely lead to poor outcome. In fact, unrealistic expectations can result in decreased satisfaction with, or complete rejection of the devices.
Item 5: What is your most important consideration regarding hearing aids?
Four important considerations when selecting HA/s are ranked ordered by the patient. These include: cosmesis (Hearing aid size and the ability of others not to see the hearing aids); audibility of speech (Improved ability to hear and understand speech); listening in background noise (Improved ability to understand speech in noisy situations such as restaurants/parties); and finance (Cost of the hearing aids).
Item 6: Do you prefer hearing aids that: are totally automatic; allow you to adjust the volume and change listening programs; or no preference?
This question provides insight into the patient's locus of control regarding HA functionality.
Item 7: Indicate which hearing aid style(s) you would NOT be willing to use.
Pictures illustrating six styles of hearing aids are displayed. The six styles include: traditional BTE, mini BTE with open ear tubing, full-shell ITE, half-shell ITE, ITC and CIC. The patient is asked to indicate which style(s) of HA/s is not acceptable. Based upon the patient's preferences, the appropriateness and/or inappropriateness of the various styles can be discussed.
Item 8: How confident are you that you will be a successful hearing aid user?
According to Kricos (2006), determining the degree of self-efficacy (i.e., domain-specific belief that one can successful complete a task) is a predictor of successful HA use. A patient indicating low self-efficacy (i.e., lack of confidence) will alert the clinician to explore what concerns the patient has in using amplification. For example, the patient may have concerns about manipulating small objects due to arthritis. In this case, an automatic ITE with a removal cord might be most appropriate.
Item 9. Select the cost category that represents the maximum amount you are will to spend.
The last item focuses on the patient's willingness to pay, guiding the clinician to select a level of technology consistent with the patient's desired financial investment.
In addition to the 9 items requesting patient responses, several other non-audiologic variables should be evaluated in the selection process. The following is a brief overview of these considerations. The reader is referred to Kricos (2000, 2006) for further elaboration of these non-audiologic factors and suggested methods for minimizing their effects.
- Gender: Women are more likely to seek assistance (Jacobson et al., 2002) and place greater importance of communication than men (Garstecki & Erler, 1998; Kricos, 2006). Women also report less difficulty in noisy environments than men (Cox, Alexander, & Gray, 1999) suggesting greater acceptance of HA/s in the least successful listening environments. Yet, women have been shown to have greater difficulty in manipulating HA controls (Wilson & Stevens, 2003).
- Age: With increased age, there are a number of cognitive functions that may become compromised. If there are any concerns, clinicians are encouraged to screen for cognitive decline utilizing the Mini Mental Status Examination (MMSE; Folstein, Folstein, & McHugh (1975) or the Short Portable Mental Status Questionnaire (Pfeiffer, 1975).
- Fine motor skills: Jacobson et al. (2002) found that rejection of amplification was associated with manual dexterity problems. Kumar, Hickey, and Shaw (2000) reported a significant positive correlation (r=0.80) between manual dexterity and hearing aid satisfaction. A review of the patient's handwriting may cue the clinician into potential fine motor skill difficulties.
Utilizing the COAT - A Clinical Example
CS is a 59 year-old male who is being seen for a Hearing Needs Assessment appointment. His audiometric results indicate a mild to moderate sensorineural hearing loss, bilaterally. Upon review of his responses on the COAT, the following is noted:
- wants to hear his customers in restaurants, his grandchildren at family gatherings, and co-workers at company social functions (Item 1)
- hearing better is very important to him (Item 2), he is very motivated to use HA/s (Item 3); and he expects that they will greatly improve his hearing (Item 4)
- rates HA size as the most important consideration followed by cost, understanding in background noise, and improved ability to hear speech (Item 5)
- prefers HA/s that are automatic (Item 6)
- unwilling to use any style of HA/s except CICs (Item 7)
- indicates high level of confidence for successful HA use (Item 8)
- did not complete the cost item (Item 9).
Combining all factors (age, hearing loss, responses on the COAT), a mini-BTE would be recommended with open ear fitting. He is initially uncomfortable with this recommendation because of the cosmetics. The advantages and disadvantages of an open-ear fitting over the CIC are discussed and he agrees to try the recommended style of device. The level of technology is discussed. He needs devices that have multiple microphone technology and noise-reduction processing to provide him better hearing in restaurants and social events. This increases the level of technology needed, and hence the device cost. He is not willing to commit to the recommended level of technology. Lower-end devices are chosen with the understanding that his hearing in background noise may be compromised to a certain degree. He understands that and wishes to proceed with the devices that fall within his budget.
We are advocating the use of income measurements in the HA selection process. Specifically, we have developed a self-report prefitting tool, namely the COAT, with the following characteristics: (1) it is brief and easy to complete either at home or in the office; (2) it serves as a springboard for patient counseling; (3) it promotes accountability for both the patient and clinician; and most importantly, (4) provides guidance in the selection of specific devices by assessing a broad range of non-audiologic variables that have been shown to influence HA success.
A copy of COAT in Microsoft Word format can be downloaded here.
Feel free to take this form and update it with your practice name and/or logo.
Cox, R.M. (2005). Evidence-based practice in provision of amplification. Journal of the American Academy of Audiology, 16, 419-439.
Cox, R.M, & Alexander, G.C. (1995). The Abbreviated Profile of Hearing Aid Benefit. Ear & Hearing, 16, 176-183.
Cox, R.M., & Alexander, G.C. (1999). Measuring satisfaction and amplification in daily life: The SADL Scale. Ear & Hearing, 20, 306-320.
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.M., Alexander, G.C., & Gray, G. (1999). Personality and the subjective assessment of hearing aids. Journal of the American Academy of Audiology, 10, 1-13.
Dillon, H., James, A., & Ginis, J. (1997). 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.
Folstein, M.D., Folstein, S.E., & McHugh, P.R. (1975). "Mini-mental state": A practical method for grading cognitive state of patients for the clinician. Journal of Psychiatric Research, 12, 180-198.
Garstecki, D.C., & Erler, S.F. (1998). Hearing loss, control, and demographic factors influencing hearing aid use among older adults. Journal of Speech-Language-Hearing Research, 41, 527-537.
Gatehouse, S. (1994). Components and determinants of hearing aid benefit. Ear & Hearing, 15, 30-49.
Gatehouse, S; Naylor, G; Elberling, C (2003). Benefits from hearing aids in relation to the interaction between the user and the environment. International Journal of Audiology, Supplement 1,42, S77-86.
Jacobson, G.P., Newman, C.W., Fabry, D.A., & Sandridge, S.A. (2001). Development of the Three-Clinic Hearing Aid Selection Profile (HASP). Journal of the American Academy of Audiology, 12, 128-141.
Jacobson, G.P., Newman, C.W., Sandridge, S.A., McCaslin, D. (2002). Using the Hearing Aid Selection Profile to identify factors in hearing aid returns. The Hearing Journal, 55(2), 30-33.
Johnson, C.E., & Danhauer, J.L. (2002). Handbook of outcomes measurement in audiology. Clifton Park, NY: Delmar Learning.
Kricos, P.B. (2000). Influence of nonaudiological variables on audiological rehabilitation outcomes. Ear & Hearing, 21, 75-155.
Kricos, P.B. (2006, January 16). Minimizing the effects of non-audiological variables on hearing aid outcomes. Audiology Online, Article 1527. Retrieved February 10, 2006 from the Article Archives on www.audiologyonline.com
Kumar, M., Hickey, S., Shaw, S. (2000). Manual dexterity and successful hearing aid use. Journal of Laryngology and Otology, 114, 593-597.
Newman, C.W., Weinstein, B.E., Jacobson, G.P., & Hug, G.A. (1990). The Hearing Handicap Inventory for Adults: Psychometric adequacy and audiometric correlates. Ear & Hearing, 11, 430-433.
Pfeiffer, E. (1975). A short portable mental status questionnaire for the assessment of organic brain deficit in elderly patients. Journal of the American Geriatrics Society, 23, 433-441.
Schum, D.J. (1999). Perceived hearing aid benefit in relation to perceived needs. Journal of the American Academy of Audiology, 10, 40-45.
Ventry, I.M., & Weinstein, B.E. (1982). The Hearing Handicap Inventory for the Elderly: A new tool. Ear & Hearing, 3, 128-134.
Wilson, C., & Stephens, D. (2003). Reasons for referral and attitudes toward hearing aids: Do they affect outcomes? Clinical Otolaryngology, 28, 81-84.