Postfitting Rehabilitation
July 2011
Harvey B. Abrams, PhD, CCC-A
Dr. AuD: "So, Mrs. Smith, how are you doing with your new hearing aids?"
Mrs. Smith: "Well, Dr. AuD, the hearing aids work pretty well when things are quiet, but when other people are talking, I still have problems understanding what everyone is saying."
Dr. AuD: "Well, remember I said that it would take you time to get adjusted to your hearing aids?"
Mrs. Smith: "Yes, I remember, and I wear my hearing aids all the time, but I just can't seem to hear what I want to hear. Isn't there something else that can help? Maybe a different type of hearing aid?"
Dr. AuD: "I don't think so, Mrs. Smith. We fit you with the best hearing aids on the market with many advanced features. It's just going to take you a bit more time."
Mrs. Smith: "Well, OK. I'll keep trying."
Dr. AuD: "That's great. And remember, you can call me anytime if you have questions."
Sound familiar? This scenario is not an uncommon one in many clinical settings. Could Dr. AuD have offered additional postfitting services, such as aural rehabilitation (AR), instead of simply suggesting that it would take more time for Mrs. Smith to adapt to her hearing aids? The study of AR is a component of just about every audiology doctorate (AuD) training program; scores of articles, book chapters, and entire textbooks are devoted to the topic; a recently published MarkeTrak survey (Kochkin et al., 2010) suggested that the inclusion of postfitting services to include auditory training (AT) and AR groups may positively affect treatment outcomes. Yet, when I query groups of conference attendees and students enrolled in distance learning AuD programs (many of whom are practicing clinicians), very few claim to offer any type of structured AR program to their patients. When I ask, why not, the responses include the lack of reimbursement, a lack of time, and a lack of confidence that such services are, in fact, effective.
In 2005, the Journal of the American Academy of Audiology (JAAA) devoted an entire issue to the topic of evidence-based practice in audiology. This special issue, edited by Robyn Cox (Cox, 2005), included two systematic reviews of the evidence relating to AR. Sweetow and Palmer (2005) reviewed the evidence concerning the efficacy of individual AT in adults, and Hawkins (2005) performed a similar review on the effectiveness of counseling-based adult group AR programs. In their review, Sweetow and Palmer identified six studies (out of 213 potentially relevant studies identified by a key word search) that met their inclusion criteria for adequate evidence, appropriate intervention, and sufficient detail for the authors to adequately analyze the study. Clinical outcomes improved among participants receiving AT in each of these studies, but the authors expressed concern about the quality of even these six studies—specifically, a lack of information concerning any blinding of the subjects or experimenters, a lack of a power calculation (justifying the number of subjects), the small number of subjects in five of the six studies, and large variability in the measured outcomes among subjects in several of the studies. Given these limitations, the authors concluded that the evidence did not provide convincing support for the effectiveness of individual AT; however, they did find encouraging trends in the data to suggest that certain types of AT can assist hearing impaired individuals to improve their listening skills as well as speech recognition in noise.
In his systematic review of the adult group AR program literature, Hawkins (2005) identified 13 articles that met his inclusion criteria for type of intervention and study quality. Similar to the conclusions reached by Sweetow and Palmer (2005), Hawkins noted that very few of the studies on adult group AR published in the last few decades were scientifically well-controlled or had adequate numbers of subjects. As a result of these limitations, a positive statement regarding the benefit of group AR could not be made. However, Hawkins did note two studies with an adequate design and a large number of subjects (Abrams, Chisolm, & McArdle, 2002; Chisolm, Abrams, & McArdle, 2004). On the basis of these studies, the author suggested that participation in adult AR groups was likely to result in at least short-term benefit as manifested by reduction in self-perceived hearing handicap, improved self-perceived health-related quality of life, and better use of communication strategies.
There have been several studies published in the areas of AT and group AR since JAAA's 2005 special issue that add to the evidence regarding effectiveness of postfitting AR. Sweetow and Sabes (2006), for example, reported on the results of a study evaluating the Listening and Communication Enhancement (LACE) home-based AT program. . The online training regimen (also available on DVD) involves 30 minutes of training per day, 5 days per week for 4 weeks, and is designed to improve speech understanding in noise, speed of processing, and working memory. The authors compared the outcomes of 38 participants who were randomized to start the LACE program immediately with 27 participants randomized to the control (delayed treatment) group. The participants in the immediate treatment group had significantly better scores on the Quick Speech-in-Noise Test (Killion, Niquette, Gudmundsen, Revit, & Banerjee, 2004), the Hearing Handicap Inventory for the Elderly (Ventry &Weinstein, 1982), and the Communication Scale for Older Adults (Kaplan, Bally, Brandt, Busacco, & Pray, 1997).
A recent study that adds to the literature concerning adult AR group programs was conducted by Hickson, Worrall, and Scarinci (2007). This randomized controlled study compared the outcomes of a large number of adults who participated in an Active Communication Education (ACE) program with a control group who received an equivalent amount of social contact. The data revealed that the individuals who participated in the ACE program, when compared to the control group, demonstrated significantly improved scores on several outcome measures including the Hearing Handicap Questionnaire (Gatehouse & Noble, 2004), the Quantified Denver Scale of Communicative Function (Alpiner, Chevrette, Glascoe, Metz, & Olsen, 1974), the Self-Assessment of Communication (Schow & Nerbonne, 1982), and the Ryff Scales of Psychological Well-Being (Ryff & Keyes, 1995). A particularly important finding was that the benefits of the ACE program were maintained for at least 6 months.
As noted earlier, many of the studies that have examined the effectiveness of AT or group AR, with few notable exceptions, suffer from small sample sizes. Fortunately, there is a statistical treatment, meta-analysis, that allows researchers to combine these smaller studies into a single analysis. Meta-analyses often reveal clinically significant findings that may not be apparent when these studies are analyzed individually. Chisolm and Arnold (in press) conducted a meta-analysis on the studies reviewed in both the Sweetow and Palmer (2005) and Hawkins (2005) systematic reviews. Figure 1 [PDF] illustrates the result of a meta-analysis on the studies included in the Sweetow and Palmer systematic review plus the addition of a more recent study by Humes, Burk, Strauser, and Kinney (2009) that examined the effects of AT on sentence recognition. On the vertical axis of the figure are the individual studies included in the systematic review along with their respective 95% confidence interval (the horizontal lines next to each study). The wider the confidence interval, the less "confident" we can be that, if repeated, the study will yield the same result. If the horizontal line crosses 0, the data failed to reach statistical significance. The box on the confidence interval represents the standard difference in the means, or effect size, which is a measure of clinical significance. The greater the effect size, the greater the clinical effect the intervention is likely to have. As we can see, there is a considerable spread of confidence intervals (most crossing 0) and effect sizes among the six studies included in the analysis (some studies are analyzed more than once as they report data on different outcome measures). However, when all of these studies are statistically combined in a meta-analysis (represented by the "Total" data), the results suggest that individual AT provides a reliable, although small, effect in terms of improving speech understanding.
Figure 2 [PDF] illustrates the result of a meta-analysis performed by Chisolm and Arnold (in press) on selected studies from the Hawkins (2005) systematic review plus more recent studies on the effectiveness of adult group AR (Hickson et al., 2007; Preminger & Yoo, 2010). Similar to the AT literature, there is considerable variability in the data among the separate group AR studies. When subjected to meta-analysis, however, the combined data suggest that, as with individualized AT, participation in an adult group AR provides a small but reliable treatment effect.
In addition to concerns about the effectiveness of postfitting AR, clinicians express reluctance to provide AR because their patients are unlikely to pay for these professional services, and audiologists rarely get reimbursed by third-party payers for providing AR. Reimbursement (direct or through third-party payers) is only one way of looking at revenue; the other is loss avoidance—as a result of hearing aid returns for credit (RFC). There is evidence that postfitting AR may reduce RFC. Northern and Beyer (1999) compared the RFC among private practice offices that offered a postfitting hearing education and listening program (HELP) with those that did not. Of the 7,178 patients followed in their study, 42% elected to participate in the HELP program. The RFC rate among the HELP participants was 3% compared to the 9% RFC rate among nonparticipants. We can reasonably estimate that just a few pairs of hearing instruments not returned for credit will pay for many group AR sessions (not to mention the free word-of-mouth advertising that clinicians who provide these services will likely earn). Audiologists need to stop thinking of AR as a paid service; hearing aids that are paid for and patients who are pleased represent a much greater potential source of revenue.
Finally, a commonly stated reason for not providing postfitting AR is the lack of time. It could be argued, however, that, just as group AR reduces RFC, these same programs reduce return visits for adjustments (leading in many cases, to RFC). Not only are multiple return visits for hearing aid adjustments non-income-producing, but the more time the audiologist spends with an existing patient, the less time is available for new patients (and new hearing aid fittings).
Dr. AuD: "So, Mrs. Smith, how are you doing with your new hearing aids?"
Mrs. Smith: "Well, Dr. AuD, the hearing aids work pretty well when things are quiet."
Dr. AuD: "How about in noisy situations?"
Mrs. Smith: "With the information you provided to me in your rehabilitation program plus the work I'm doing at home with the program you gave me, I'm beginning to do better in noisy environments."
Dr. AuD: "That's great. And remember, you can call me anytime if you have questions."
Postfitting AR services are clinically effective, economically sensible, and potentially time-saving. As clinicians, we should find the time and resources to expand our treatment plan and provide these valuable services.
About the Author
Harvey B. Abrams is the Director of Audiology Research at Starkey Laboratories. Prior to joining Starkey, Dr. Abrams served in a number of clinical, research, and administrative capacities with the Department of Veterans Affairs and the Department of Defense. His research has focused on treatment efficacy and improved quality of life associated with audiologic intervention. In 2010, Dr. Abrams received The ASHA Leader Outstanding Contribution Award in Audiology for his feature article "Audiologic Management of the Older Patient" (Sept. 1, 2009). Contact him at Harvey_Abrams@starkey.com.
References
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Alpiner, J. G., Chevrette, W., Glascoe, G., Metz, M., & Olsen, B. (1974). The Denver Scale of Communicative Function.Denver, CO: University of Denver.
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Chisolm, T., & Arnold, M. (in press). Evidence about effectiveness of aural rehabilitation programs for adults. In L. Wong & L. Hickson (Eds.), Evidence-based practice in audiology: Evaluating interventions for children and adults with hearing impairment. San Diego, CA: Plural.
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