Core Outcome Set Implementation Toolkit
This toolkit supports clinical adoption of the core outcome set established by the 2025 NASEM Meaningful Outcome Measures report. Use these tools—alongside any others that you deem clinically appropriate—when assessing hearing health interventions in adults.
Unlike during diagnostic use, you should administer these measures before and after intervention to track progress over time and enable comparison across settings.
Outcome Set At A Glance
| Outcome Domain | Measure | Type |
|---|---|---|
| Understanding speech in complex listening situations |
Abbreviated Profile of Hearing Aid Benefit (APHAB)—Global score |
Subjective |
| Understanding speech in complex listening situations |
Words-in-Noise Test (WIN) |
Objective |
| Hearing-related psychosocial health |
Revised Hearing Handicap Inventory (RHHI) |
Subjective |
Measures
APHAB—Abbreviated Profile of Hearing Aid Benefit
Minimal Clinically Important Difference
Based upon unaided score, a change of 6–12% between unaided and aided Global Scores indicates meaningful benefit.
Outcome domain
Speech-in-Noise
What it measures
Patient-reported difficulty with communication and environmental noises across a range of listening situations (24 items, 18 scored).
Note: Designed for hearing aids but applicable across hearing health interventions.
Access materials
- APHAB webpage (includes PDF versions of the tool in several languages)
- Download APHAB Form A [PDF]
| Patient Instructions | “Please circle the answers that come closest to your everyday experience. Notice that each includes a percentage. You can use this to help you decide on your answer. For example, if a statement is true about 75% of the time, circle “C” for that item. If you have not experienced the situation we describe, try to think of a similar situation that you have been in and respond for that situation. If you have no idea, leave that item blank." (Cox & Alexander, 1995) |
|---|---|
| Pre-test | Administer at time of hearing evaluation or during hearing aid discussion (“Unaided” column). |
| Post-test | Administer at hearing aid follow-up, consider after the trial period or once patient has acclimated (“Aided” column). |
| Time to complete | Approximately 5–15 minutes (18 items) |
| Format options |
|
Global Score Calculation
Calculate the average of the Ease of Communication, Background Noise, and Reverberation subscales (18 items).
Note: Manual scoring is lengthy—NOAH and Windows calculate automatically.
Benefit Calculation
Step 1: Calculate the change
- Subtract the aided score from the unaided score.
- Change = Unaided – Aided
Step 2: Determine if the change is clinically meaningful
| Unaided Score Range | Meaningful Change* |
|---|---|
| 12-18% | ≥ 6% |
| 19-37% | ≥ 8% |
| 38-81% | ≥ 12% |
| 82-100% | Currently not enough data to determine meaningful change |
*Values derived from unpublished data by L. Humes (personal communication, April 3, 2026)
Step 3: Interpret the results
- If the calculated change meets or exceeds the threshold for that unaided score range, the result is clinically meaningful.
Example
- Unaided Score: 26%
- Aided Score: 16%
Step 1: Change = 26% – 16% = 10%
Step 2: An unaided score of 26% falls in the 19–37% range, where ≥8% is meaningful.
Step 3: The 10% improvement is clinically meaningful.
Scoring Guide—Manual Scoring Guide [PDF]
WIN—Words-in-Noise Test
Minimal Detectable Difference
A change of ±3.5 dB in signal-to-babble threshold indicates a meaningful difference in speech-in-noise performance.
Outcome domain
Speech-in-Noise
What it measures
Speech-in-noise performance. Patients repeat monosyllabic words presented against multi-talker babble. Yields a dB signal-to-babble ratio threshold based on percent correct.
Note: Commonly used as a diagnostic tool. Within the core outcome set, administer before and after intervention to capture change.
Access materials
- NIH Toolbox (iPad only; subscription required to score/save)—Instructions for how to download–request the “B-level access form” for the WIN
- VA CD download—WIN tracks on CD 4
- Pre-loaded on some audiometers
| Patient Instructions | “You will hear a woman asking you to repeat various words. Repeat the words she asks out loud so that I can hear you. For example, if you hear her say, ‘Say the word dog,’ you would say, ‘dog.’ If you are not sure what she said, just say what you think you heard. You will also hear people talking in the background. Do your best to ignore them and to focus on the woman’s voice asking you to repeat the words. Do you have any questions?” (Hook & Giella, 2023) |
|---|---|
| Test parameters |
|
| Pre-test | Administer at time of hearing evaluation or hearing aid discussion—or prior to hearing health intervention. To administer the WIN unaided:
|
| Post-test | Administer at hearing aid follow-up, at end of trial period, or once patient has acclimated—or following another hearing health intervention. To administer the WIN aided:
|
| Time to complete | 2:20 (min:sec) per list (5 items per SNR): 4–6 minutes total |
Scoring guide
Mark each word correct or incorrect. Using the WIN Score Sheets (pages 9–12) [PDF], match number correct to the corresponding threshold.
Word lists
Two 35-word lists (5 words per SNR). Multiple word order variants. A third list is available as practice.
Benefit calculation
Compare aided vs. unaided scores. A change of ±3.5 dB is a significant change in speech-in-noise listening abilities.
RHHI—Revised Hearing Handicap Inventory
Minimal Clinically Important Difference
Meaningful difference in hearing-related psychosocial health is determined by dividing the unaided RHHI score by 3.
Outcome domain
Psychosocial health
What it measures
Emotional consequences and social/situational effects of hearing loss (18 items). Derived from the Hearing Handicap Inventory for the Elderly (HHIE) and the Hearing Handicap Inventory for Adults (HHIA).
Note: Commonly used as a diagnostic tool, but within the NASEM core outcome set, it is administered pre- and post-intervention to capture change following hearing health intervention.
Access materials—Download RHHI Form [PDF]
| Patient Instructions | “The purpose of this scale is to identify the problems your hearing loss may be causing you. Answer YES, SOMETIMES, or NO for each question. Do not skip a question if you avoid a situation because of your hearing problem.” (Cassarly, Matthews, Simpson, & Dubno, 2020) |
|---|---|
| Pre-test | Administer at time of hearing evaluation or during hearing aid discussion—or prior to hearing health intervention. If the patient uses amplification, ask them to respond as they hear WITHOUT the device. |
| Post-test | Administer at hearing aid follow-up, at end of trial period, or once patient has acclimated—or following another hearing health intervention. Ask the patient to respond as they hear with the device. |
| Time to complete | Approximately 2–5 minutes (18 items) |
| Format options | Paper and pen (RHHI) [PDF] |
Scoring guide
“Yes” = 4 points, “Sometimes” = 2 points, “No" = 0 points
Total score calculated at the bottom of the form.
Benefit calculation
Step 1: Calculate the change
- Subtract the Aided score from the Unaided score.
- Change = Unaided – Aided
Step 2: Determine if the change is clinically meaningful
- Divide the Unaided score by 3
- Unaided RHHI Score/3 = threshold for meaningful change*
*Calculation from unpublished data by L. Humes (personal communication, April 3, 2026)
Step 3: Interpret the results
- If the calculated change meets or exceeds the threshold for meaningful change, the result is clinically meaningful.
Example
- Unaided score: 30 points
- Aided score: 12 points
Step 1: Change = 30–12 = 18 points
Step 2: Threshold for meaningful change = 30 divided by 3 = 10
Step 3: The 18-point improvement is clinically meaningful.
References
Cassarly, C., Matthews, L. J., Simpson, A. N., & Dubno, J. R. (2020). The Revised Hearing Handicap Inventory and Screening Tool based on psychometric reevaluation of the Hearing Handicap Inventories for the Elderly and Adults. Ear and Hearing, 41(1), 95–105. https://doi.org/10.1097/AUD.0000000000000746
Cox, R. M., & Alexander, G. C. (1995). The Abbreviated Profile of Hearing Aid Benefit. Ear and Hearing, 16(2), 176–186.
Hook, J. N. (ed), & Giella, A. K. (ed). (2023). National Institutes of Health (NIH) Toolbox® V3 Administration Manual. Toolbox Assessments, Inc.
Humes, L. E., Dhar, S., & Singh, J. (2025). Some considerations for the use of the abbreviated profile of hearing aid benefit (APHAB) as a hearing-aid outcome measure. Trends in Hearing, 29(0), 1–19. https://doi.org/10.1177/23312165251359755
Humes, L. E., Dhar, S., & Singh, J. (2025). Some considerations in the use of the Hearing Handicap Inventory for the Elderly and its derivatives as hearing-aid outcome measures. International Journal of Audiology, 1–20. https://doi.org/10.1080/14992027.2025.2511218
National Academies of Sciences, Engineering, and Medicine. "Measuring meaningful outcomes for adult hearing health interventions." (2025). https://doi.org/10.17226/29104
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 and Hearing, 11(6), 430–433.
Wilson, R. H. (2003). Development of a speech-in-multitalker-babble paradigm to assess word-recognition performance. Journal of the American Academy of Audiology, 14(9), 453–470.
Wilson, R. H., & McArdle, R. (2007). Intra- and inter-session test, retest reliability of the Words-in-Noise (WIN) Test. Journal of the American Academy of Audiology, 18, 813–825. https://doi.org/10.3766/jaaa.18.10.2
Ventry, I. M., & Weinstein, B. E. (1982). The Hearing Handicap Inventory for the Elderly: A new tool. Ear and Hearing, 3(3), 128–134.
