Academy of Doctors of Audiology

Author: Erica Bennett, Au.D., Ph.D., Brad Stach, Ph.D., Harley Wheeler, Au.D., and James Benson, MS

Outcome validation is an important component of any aspect of health care. Hearing aid treatment is no exception. Validation of outcomes can take one of several forms and has the potential to impact audiologic practice in several ways.

The most used outcome measures are designed to assess the impact of hearing aid amplification on self-perception of communication success. Results from self-assessment scales administered following hearing aid fittings can be useful in providing feedback about the quality and success of care related to an individual patient. Feedback from patients can direct providers in their decisions about technologies or additional care that may be necessary for success. Outcome measures can also be used administratively as important quality metrics for assessing the effectiveness of providers and programs. Finally, in their aggregate form, outcome measures can provide more generalized data to drive health care policy.

There are primarily two sources of gathering hearing aid outcome data, those that are market-based and those that are patient-based. The largest market-based source is MarkeTrak1,2, a multi-part data-gathering approach that identifies significant trends and issues in the hearing loss population. This approach is based on a survey that is sent to a National Opinion Panel, which consists of households that are balanced based on the latest US census information. The survey targets individuals with hearing loss, regardless of whether they wear hearing aids. The survey is designed to investigate hearing aid adoption rate, consumer satisfaction, and general demographics of both hearing aid owners and non-adopters. To date, the MarkeTrak data have been very beneficial in providing generalized trends across a large sampling of the population. However, the approach is not without limitation. One challenge is that the survey requires self-reporting of hearing loss, which any clinician would understand is an inexact approach at best. Also, the survey is not limited to hearing aid users and excludes important populations, such as individuals in nursing homes. In addition, the survey does not ask individuals to compare their hearing before and after hearing aid usage.

The other source of hearing aid outcome data is patient-based. These data are generated from self-assessment of communication function with or without, or before and after, hearing aid use. These self-assessment scales are generally designed to answer the following questions:

1. How did the intervention affect not only the patient, but their communication partners?
2. How did the intervention improve the communication abilities of the patient?
3. Were the goals for the intervention successfully met?

There are several subjective self-assessment scales available that attempt to address these questions. For example, measures, such as the Abbreviated Profile of Hearing Aid Benefit (APHAB)3 and the International Outcome Inventory for Hearing Aids (IOI-HA)4 have been used in an effort to validate hearing aid fitting outcomes. These are based on standard questions relating to patient experience. Another, the Client-Oriented Scale of Improvement (COSI)5, involves the audiologist and patient participating in joint goal setting at the outset of the evaluation, which are then re-assessed following the implementation of treatment.

The value of validation of outcomes on an individual patient is important as it allows for assessment of treatment outcomes, recognizes areas for improvement, and aids in counseling, Yet, despite its value, and despite the availability of these self-assessment measures, outcome validation of hearing aid intervention is fairly uncommon. According to survey data6, less than 20% of clinicians routinely administer any type of self-report of outcome. There are several reasons that such measures and data collection are not in widespread use, most of which are simply practical limitations to their implementation. Many of these outcome measures are lengthy and time consuming to administer. In addition, the majority do not seem to capture the audiologist’s clinical needs and do not engage the patient. Indeed, the very process of administration of the measures, scoring the outcome, collecting data over time, receiving individual patient feedback and being able to view the patient data in aggregate can be quite cumbersome to the busy clinician.

In this paper, we describe the implementation of an approach to hearing aid outcome validation and data collection aimed at reducing the burden incumbent in the process of self-assessment outcome measurement. Several years ago, we began assessing outcomes on all patients fit with hearing aids at the Henry Ford Health System in Detroit, Michigan. Patients are surveyed at periodic time intervals, and data are automatically assessed in individual patients and, over time, in the aggregate. Here we describe both the process of data collection and a summary of the results obtained over the past year. The questionnaire used in the hearing aid outcome data collection is called the Patient Centered Outcome Measure (PCOM). This measure was designed by integrating well-established self-report outcome measures of hearing aid users. Four of the questions were derived from the International Classification of Functioning (ICF) Measure of Participation and Activities Screener, two questions were from the International Outcome Inventory for Hearing Aids (IOI-HA), and two additional questions were added to address the quality of support for patients and their willingness to recommend hearing aids to others. The survey was administered through a cloud-based patient engagement system called SEngage. SEngage is a solution provided by QM2 Solutions, a company dedicated to assisting practices with patient engagement. They are a leader in patient outcomes and expert in data collection, garnering consistent high participation by connecting to patients through email and/or text, then linking patients into a HIPAA secure portal to leave feedback.

SEngage allows patients to complete a patient interview (or survey) on their home computer, laptop, smart phone, tablet, or other device with a web browser. SEngage does not require the patient to download an application, rather the web enabled solution requires only internet access and a web browser. In addition, SEngage sends the patient customized, practice branded emails or texts that include instructions, education, and a secure link into the system’s patient portal. Finally, SEngage schedules the patient communication per the project guidelines and sends reminders to patients who have not completed their scheduled engagement. Patients are uploaded into the system from the practice’s legacy system through automated uploads. This process does not require interaction from the providers or staff of the department. (Smaller organizations may manually enroll a patient into the SEngage system). A key element of this project evaluates the level of effort a practice would need to implement an outcomes/experience program and the level of patient data up-take through an automated, web-based engagement system.

The PCOM was conducted with patients via the communication mode of their choice (e-mail or text). The approach was designed to provide consistent monitoring of patients’ experience and satisfaction with their care over time. For this study, all patients received surveys at 14, 90 and 180 days following their hearing aid delivery appointments. The survey, shown in Figure 1a, asks patients a series of eight questions. The first four questions require patients to compare their hearing abilities both before and after the hearing aid intervention recommended by their audiologist. The final four questions address overall satisfaction with the devices and their providers, and the amount of time devices are used. Figure 1b shows a view of the survey from the patient’s mobile device or laptop. The results from the eight questions of the PCOM are displayed in Figures 2 through 10. The first four questions required patients to compare their time before and after hearing aid use. Currently, only data from the 14-day survey have been analyzed. Figure 2 displays the individual patient responses to the statement “Because of hearing difficulties you feel anxious, frustrated, angry, sad, or fatigued”. Responses are displayed before hearing aids (x-axis) and after hearing aids (y-axis). The red shaded area indicates a negative change (a regression with hearing aids), whereas the green shaded area indicates a positive change (improvement with hearing aids). Five percent of patients reported a negative change, indicating they felt more negative emotions pertaining to their hearing loss following hearing aid use. However, 45% of patients indicated a positive change in mental health status attributed to hearing aid use. Figure 3 displays the average percentage of change from baseline for negative, neutral (no change) or positive changes. In addition, Figure 3 compares the data from the PCOM to the most recent MarkeTrak10 study7,8. In this study, 5% of patients reported a negative change in emotions related to hearing loss following hearing aid use, which is consistent with the MarkeTrak study. In the current study, half of patients reported no change in their emotions following hearing aid use. Finally, 45% of patients reported an improvement in negative emotions pertaining to hearing loss, compared to only 34% in the MarkeTrak data.

Individual patient responses to the statement “Considering your hearing’s effect on your life you routinely engage in community or social activities” are shown in Figure 4. Results from the PCOM demonstrate that 4% of patients reported a negative change, meaning they were less likely to engage in social activities after hearing aid use. 75% of patients indicated no change and 21% of patients indicated a positive change, meaning they were more likely to engage in community or social activities following hearing aid uptake.



Individual patient responses to the statement “Considering your hearing, describe your willingness to actively talk to family members or friends who are sitting in the same quiet room with you” are shown in Figure 5. Two percent of patients demonstrate a negative change, meaning they were less likely to talk to communication partners in quiet rooms, 70% demonstrated no change and 28% demonstrated a positive changing, meaning they were more likely to engage in conversation in a quiet room.

Results from individual patient responses to the statement “Because of hearing difficulties, you move away from a background noise source or move closer to a speaker to better hear or see them in conversation” are displayed in Figure 6. This statement demonstrated the greatest change following hearing aid use with 60% of patients reporting a positive change, suggesting they do not need to move away from a background noise source as frequently when utilizing amplification. Only 5% of patients reported a negative change and 35% of patients reported no change.



The average number of hours patients utilized hearing aids/day is shown in Figure 7. Most patients (90%) report use of their hearing aids at least 4-8 hours/day. This is significantly higher than previously reported data as compared to the study by Cox and Alexander3 (reporting 74% wear their hearing aids 4+ hours per day) and MarkeTrak2 (reporting 69.1% for new users).



Figure 8 shows the average patient response by rating to the statement “Think about the situation where you most wanted to hear better before you got your hearing aids. In recent weeks, rate how much the hearing aids have helped in those situations”. On this scale, a score of 10 meant that the hearing aids were extremely helpful and a score of 0 meant the hearing aids were not helpful at all. Most patients (82%) reported that their hearing aids were helpful indicating a rating of 7 or higher. No direct comparison can be made with MarkeTrak data; however, similar MarkeTrak questions asked if patients had a hearing handicap reduction (54% of patients reported a reduction2) and if patients reported benefit with their devices (63% reported they did2).



The average patient response to the question “Independent of how your hearing aids are performing, how would you rate the quality of support that you have received for your hearing aids?” is shown in Figure 9. A score of 10 indicates that their audiologist support was outstanding and a score of 0 indicates that their audiologist support was poor. The average patient response to this question was a score of 9, indicating that patients were highly satisfied with the clinical care provided by the audiologists. In addition, 94% of patients indicated a score of 7 of higher suggesting a high satisfaction with their care provider.



The average patient response to the question ““Based on my current hearing health experience, I would recommend hearing aids to my family and friends” is shown in Figure 10. A score of 10 indicates that the patients strongly agree with this statement, while a score of 0 indicates that patients strongly disagree with this statement. On average, patients reported a 9.5 on this scale indicating that they are very likely to recommend hearing aids to others. When looking at percentage by individual rating, 90% of patients reported a 7 or higher, suggesting the vast majority would recommend hearing aids to their friends. This is significantly higher than previous reports with the MarkeTrak data2 indicating 75% of patients would recommend hearing aids to others.



Finally, this SEngage was used to engage 1,094 patients at Henry Ford Health System (HFHS) and has become standard of care for our patients. Thus far, the survey has consistently high participation and low attrition rates, with an uptake of 31.5%. Anecdotally, many patients reported that the survey was enjoyable and made them feel involved in their healthcare. The responses led to a robust set of data for analysis and normalization of this questionnaire for our clinical population. Subjective outcome measures are not used routinely by many clinical audiologists. We describe a new outcome-measure process that is easy to use for the audiologist and the patient and provides valuable data for clinical care. The PCOM proved to be feasible and easy to use for the audiologist with an almost seamless integration into our clinical practice. As described, the survey is automatically sent to all patients who receive a hearing aid delivery at our clinic via their preferred mode of communication, requiring no extra effort on behalf of the audiologist. In addition, the survey is sent at numerous time points (14, 90 and 180 days) so the audiologist can track patients over time. The survey is short and easy to manage for patients, resulting in high participation and low attrition, with a 31% uptake. Following completion of the survey, the data are available to audiologists in a user-friendly format. Data can be organized by audiologist, patient name, date of delivery, etc., in a manner that allows the audiologists to view their own patients and track their progress throughout time.

Once the survey was deemed to be clinically efficient, it was important to determine how patients were subjectively performing with hearing aids in our clinical population. To date, very little published data exist on large sets of patients regarding hearing aid outcomes. The first four questions asked patients to compare their hearing abilities before and after hearing aid use. Results from those questions indicate patients showed substantial improvements with their devices, with the most notable change in background noise, something that is typically problematic for patients. The smallest change was noted in the question pertaining to quiet settings; however, this is likely because many patients did not demonstrate difficulty with quiet situations prior to hearing aid use.

The final four questions asked patients to report utilization of devices and rank general satisfaction with the devices and their care team. Ninety percent of patients were wearing their hearing aids at least four hours per day, with 73% of patients wearing them eight hours or more per day. In addition, when asked about overall satisfaction with devices, their care team, and willingness to recommend the devices to family and friends, the majority of patients had responses of seven or higher for all questions, consistent with a high satisfaction rate.

Overall, the PCOM was efficient, patient friendly, and provided useful clinical data for our staff and program. The results of the PCOM were consistent with other hearing loss surveys, demonstrating the ability to capture accurate patient responses in a more clinically useful way. Future use of the data will include automatic e-mails or texts offering virtual visits to patients that indicate a low rating on any of the questions. As the audiology landscape changes, including the addition of delivery models such as telehealth and over the counter devices, outcome measures and consumer driven care are becoming a priority. It is important for audiologists to have an easy to use tool to subjectively measure patient performance and to compare the results of their patients to those of similar demographics. Through collection and use of these data clinically, more effective treatment decisions can be made for patients. As this survey is implemented clinically, future research on patient performance with various styles and levels of hearing aid technology can be evaluated.

In addition, as other treatment models become more common, the efficacy of telehealth and other strategies can also be validated. Beyond the use of a new survey, the use of on-going, digital patient engagement tool to collect patient feedback is an important advancement in the management of chronic disease. A growing body of research demonstrates that the use of secure portals to collect information from patients in real time increases engagement, patient understanding, activation, and improved coordination of care.

In a large healthcare system, the PCOM has proven to be an effective measure to monitor patient performance and to assist patients in feeling more involved in their own healthcare.     Erica Bennett, Au.D, Ph.D. is a senior staff audiologist at Henry Ford Health System. She earned her AuD and PhD from the University of Wisconsin. She completed her externship at Henry Ford Health System and has been working as a clinical audiologist there since 2017. Her clinical areas include amplification, cochlear implants, and diagnostics. In addition to clinic, Dr. Bennett is also the research coordinator for the Audiology department and helps facilitate ongoing research projects.

Brad A. Stach, Ph.D. is director of the Division of Audiology, Department of Otolaryngology-Head and Neck Surgery, of the Henry Ford Medical Group and Henry Ford Hospital in Detroit, Michigan. He also serves as a faculty member and oversees the clinical education component of the AuD program at Wayne State University Department of Communication Sciences and Disorders. Dr. Stach is the author of a number of scientific articles, books, and book chapters and is the Audiology Editor-in-Chief for Plural Publishing. He also serves as Advisor to the American Medical Association CPT Health Care Professionals Advisory Committee. He is a founding board member of the American Academy of Audiology and has served as its President and the Chair of its Foundation’s Board of Trustees.

Harley Wheeler, Au.D. completed both undergraduate and doctoral clinical audiology studies at James Madison University and his clinical externship with Henry Ford Health System. His interests and work broadly pertain to cochlear implants/ auditory prostheses, vocal emotion recognition, and pitch perception.

James Benson is the President and Founder of QM2 Solution with its headquarters in Elkhart Lake, Wisconsin. Before QM2 solutions, James worked as a practice administrator and management consultant to surgical subspecialty groups. James served national leadership roles within the Association of Otolaryngology Administrators (currently known as ASCENT), as consultant to the AAO-HNS Board of Governors and was co-founder of the Large Group Executive Forum for Otolaryngology Practices. James speaks nationally on areas of healthcare quality, outcomes, experience, benchmarking, and business development. James has a Bachelor of Science degree from the University of Wisconsin-Madison and a Master of Science from the University of Wisconsin-Green Bay (Quality and Systems Design (2000)). 1 An Introduction to MarkeTrak IX: A New Baseline for the Hearing Aid Market. http://www.hearingreview.com/2015/05/introduction-marketrak-ix-new-baseline-hearing-aid-market/.

2 MarkeTrak VIII: 25-Year Trends in the Hearing Health Market. http://www.hearingreview.com/2009/10/marketrak-viii-25-year-trends-in-the-hearing-health-market/.

3 Cox, R and Alexander G. The Abbreviated Profile of Hearing Aid Benefit. 1996. Ear Hear. 16(2):176-86

4 Cox, R. and Alexander G. The International Outcome Inventory for Hearing Aids (IOI-HA): Psychometric properties of the english version. Int J Audiol. 2002;41(1):30-35. doi:10.3109/14992020209101309

5 Dillon H, James, A. and Ginis, J. 1997, Client Oriented Scale of Improvement (COSI) and its relationship to several other measures of benefit and satisfaction provided by hearing aids. J Am Acad Audiol. 8(1):27-43.

6 Kirkwood DH. Survey probes dispensers' views on key issues raised by Consumer Reports. Hear J. 2010;63(5):17-18. doi:10.1097/01.HJ.0000373446.75826.e1

7 MarkeTrak 10: Hearing Aids in an Era of Disruption and DTC/OTC Devices - Hearing Review. https://www.hearingreview.com/uncategorized/marketrak-10-hearing-aids-in-an-era-of-disruption-and-dtc-otc-devices-2. Accessed July 9, 2020.

8 Picou EM. MarkeTrak 10 (MT10) Survey Results Demonstrate High Satisfaction with and Benefits from Hearing Aids. Semin Hear. 2020;41(1):21-36. doi:10.1055/s-0040-1701243

9 Stewart MT, Hogan TP, Nicklas J, et al. The Promise of Patient Portals for Individuals Living With Chronic Illness: Qualitative Study Identifying Pathways of Patient Engagement. J Med Internet Res. 2020;22(7):e17744. doi:10.2196/17744