"There is good evidence (both common sense and research) that shows that people can benefit even more from hearing aids it they are provided with a more intensive follow-up program."

Lately, some audiologists have displayed a great deal of interest in devising ways to document the efficacy of hearing aid "treatment." Not just because audiologists understandably need assurance that they are helping people as much as can reasonably be expected, but also because third-party payers of all kinds (insurance companies, health maintenance organizations, etc.) are asking for this kind of evidence before they will consider underwriting the purchase of hearing aids.

Traditionally, potential benefits of hearing aids have been formally assessed by comparing speech perception scores with and without hearing aids. More recently, many audiologists are also measuring the actual sound pressure generated in the ear canal by a hearing aid and comparing the results to specified "amplification targets." Either way, these procedures would be considered "objective" tests of hearing aid performance.

It is also traditional for hearing aid dispensers to elicit "subjective" impressions from their clients by asking them to compare how well they hear with and without the hearing aids. All subjective tests and impressions are premised on the fact that users are the best judge of their own performance with hearing aids. I would argue that spouses and adult children are sometimes even better judges!

As valuable as these subjective judgments may be, and because they are uncontrolled and unstandardized, it is impossible to determine just how much help a person receives and whether and how much this help varies in different types of situations. It is also important to compare subjective impressions with other individuals who use a different hearing aid technology or who receive a different type of rehabilitative treatment. To accomplish these purposes, it is necessary to employ comprehensive performance scales in which subjective judgments can be standardized. Just asking "How does this sound?" is no longer enough. The scales that have been developed require users to self-evaluate a number of dimensions of hearing aid performance, such as listening difficulties in various types of situations, how beneficial they perceive the hearing aids to be, whether they are satisfied with the aids, and the psychosocial impact of their [presumed] improved communication abilities.

The inclusion of these scales in routine hearing aid selection procedures is a commendable development in audiology. This development recognizes that people are different, that their needs, expectations and experiences vary, and that each person has to be approached on his or her own terms. At the same time, it helps audiologists determine whether the benefits achieved by their clients conform to their professional expectations (i.e., Is another type of technology required? Should the aid's characteristics be modified? Is there a need for more personalized counseling, etc.?)

Quite a few of these subjective tests have developed enough so that their number and diversity have challenged the capacity of audiologists to concoct new acronyms. Emerging from this alphabet thicket and entering routine clinical practice are:

1. Hearing Handicap Inventory for the Elderly (HHIE);
2. Abbreviated Profile of Hearing Aid Benefit (APHAB);
3. Hearing Aid Performance Inventory (HAPI);
4. Client-Oriented Scale of Improvement (COSI); and,
5. Hearing Aid Users Questionnaire (HAUQI).

Several additional scales, including perhaps the most comprehensive one to date - the Glasgow Hearing Aid Benefit Profile, (GHABP) were introduced in a recent article in the Journal of the American Academy or Audiology that was entirely devoted (as was the previous issue) to presenting and analyzing various subjective measures of hearing aid outcomes.

Even though there is some over lap, these scales generally focus on different aspects of the listening experience. Therefore, to get a well-rounded view of the need for, and the impact of amplification, it may be necessary to administer at least two of these scales. In my judgment, their inclusion in a clinical test battery is often as necessary as any "objective" test.

But, there is still one important ingredient missing: the routine provision of an adequate post-hearing aid follow up program. For the most part, in the studies on "outcome" measures, there is as implicit acceptance of the "outcome" as that achieved with traditional hearing aid fitting procedures. As practiced by the overwhelming majority of hearing aid dispensers, a routine procedure entails an audiological evaluation, a hearing aid selection procedure, several office visits within the 30-day trial period, and an admonition to "call if you have any problems." And, yes, most people do benefit from this service; they surely do much better with hearing aids than without them.

However, there is good evidence (both common sense and research) that shows that people can benefit even more from bearing aids if they are provided with a more intensive follow-up program, such as is recommended by SHHH in one of our position papers. Now that audiology is succeeding in quantifying "outcomes", it is time to focus on steps to improve these outcomes, by increasing hearing aid benefit, satisfaction, and use. As the first step, I would recommend that we de-emphasize the focus on hearing aids as a technological "product" and begin thinking of the hearing aid selection procedure as a rehabilitative "process", one that takes time to accomplish and that is concerned more with the total impact of the hearing loss than the hearing aid itself.

Hearing Loss May/June 1999