Evidence Must Trump Orthodoxy Even During Uncertain Times

Author: Terry Mactaggart

The Lancet Commission on dementia prevention, intervention, and care published a report a few months ago that highlights recommendations for policy makers and individuals to help reduce dementia risk worldwide. As many audiologists might recall, The Lancet Commission published a comprehensive, landmark report on this topic just three years ago, but the science in this area has been rapidly changing. In their updated report, published on July 2020, the Commission added three new risk factors: The newly identified factors are 1) traumatic brain injury in mid-life, 2) exposure to air pollution in later life, and 3) excessive alcohol use, defined as more than 14 drinks a week.
Figure 1. Modifiable risk factors associated with dementia. Source: Dementia prevention, intervention, and care: 2020 report of the Lancet Commission. Lancet, 396, 413–446.

Figure 1 includes data from this landmark report. It shows all 12 risks across the life course, and how much the reduction of each factor could potentially reduce the prevalence of dementia, worldwide. In theory, up to 40% of dementia cases could be prevented or delayed by modifying all 12 risk factors—up from the 35% in the 2017 report. Remarkably, hearing loss is the leading modifiable risk factor —a strong argument for hearing testing and intervention to occur at mid-life, not old age, as is primarily the case today.

Of note to audiologists is that the largest modifiable risk factor, contributing 8% to the overall 40% of potentially modifiable risk factors, is hearing loss. A percentage that is down from 9% in the 2017 report. Given that hearing loss is the leading modifiable risk factor in midlife, it makes sense for healthcare professionals to promote the use of hearing protection in high noise areas for everyone, and to encourage routine and periodic hearing screening beginning in middle age, in addition to the use of hearing aids when indicated. Of course, encouraging people to engage in the process of routine hearing screening is not easy. As recent studies suggest, even when an easy to use app-based hearing screening is available, more than 80% of those individuals failing the hearing screening and requesting to be contacted by an audiologist do not initiate further action. Further, of the thousands of individuals who fail an online hearing screening, just over half of them believe they have a hearing loss.

The challenge might be even more daunting when in comes to encouragement of hearing aid use. Not only are audiologists plagued by the usual suspects like stigma, inconvenience and complacency – typical behaviors for persons with chronic conditions, but the evidence that hearing aid use stymies the trajectory of dementia is conflicted as other recent studies suggest. What is more, as researchers Barbara Weinstein and Jan Blustein recently point out in a 2020 article, published in JAMA-Otolaryngology, many marketing claims in the industry surrounding the topic of hearing aid use and dementia are misleading and inaccurate.

If audiologists want to be a paragon of trust and integrity, it’s critical that they stick to the science and refrain from erroneous, confusing and deceptive claims, and when patients seek our services we avoid the perception of trying to sell something.

To help us unravel these issues—balancing the needs of persons with hearing loss with the demands of trying to run a business during a once-in-a-century pandemic, let’s examine how we can better serve our patients—persons coping with hearing loss and communication challenges during one of the most uncertain moments in our lifetimes.
Serving the Consumer – a New North Star?
Concerns about coping with the COVID-19 crisis and what may lie beyond have preoccupied our personal and professional lives thus far in 2020. And they will undoubtedly linger for a considerable time.

One silver lining is a growing recognition of the importance of relating to our clientele at a distance —i.e. by relying on the Internet using contemporary communication processes as well as direct-to-consumer hearing detection and treatment technologies.

Responding to these needs can presage a more effective approach to improving and extending care for those currently in the system in addition to providing hearing health knowledge and services to the many millions who have been left out. There are compelling reasons to set such a goal as our New North Star!.

For more than seven years, I’ve argued that our scope of hearing health delivery is falling short and the industry as we know it will inevitably be disrupted. The breadth of the hearing problem, the way it traditionally has been managed, coupled with the growth of personalized medicine and consumer electronics has made that a safe bet. Underlying these perceptions has been a quest for a 21st century model that can be applied much more widely, yet remain profitable for practice owners.

The Basic Premise – Given the large number of people who are uninformed or otherwise distracted and are clearly not engaged, hearing loss has become the largest untreated chronic health issue in our society. In fact, taking what we now know about the consequences of ignoring or delaying detection and treatment, it’s grown to become a serious public health problem. This series of posts enlarge on this foundation by focusing on the consumer and how this deficit should be addressed.

Let’s start with “the facts” – The customary numbers are well known. About 48 million Americans (say 15% of the population) report some degree of permanent hearing loss, age being the strongest predictor. Adding 5 million more for Canada brings the total to well over 50 million. At best, slightly more than 20% of these have been treated with hearing devices, of whom at least that same percentage (about 20%) become non-compliant soon after fitting.

Having accumulated well over 160,000 structured hearing data sets from the general public, including those with signs of hearing change within the normal range, we can assert with confidence that these estimates are outdated and understated, likely by at least 50%. Our conservative estimate of those impacted in both countries combined lies between 70-75 million people. And we can anticipate that number will grow, not only as a function of Boomers aging but also because of what is expected to become a tsunami of younger people joining the cohort because of their “crank up the sound, forever listening-with-buds” life style.
Why are so many people left out?
There are several well-known reasons—stigma of older age, access to services and acquisition cost of products being the major ones. These are well documented in the literature and summarized in the Academy of Sciences report and the subsequent Congressional Act of 2017 which mandated a new class of over the counter hearing devices.

While wireless wearable devices have become commonplace and miniaturization and performance improvement of hearing instruments continues to occur, promotion by the industry still focuses primarily on older people who become “patients” even though this label plays into an emotional bias held by many against such messaging. Inadvertently perhaps, this leaves behind the tens of millions who are earlier on in their journey yet clearly experiencing hearing change.

Reliance on bricks and mortar clinics as the major distribution source staffed by relatively few professionals compared to the need also weighs in heavily. Participants are often compelled by ownership or financial arrangements with suppliers to perpetuate the existing limited access, high price model.

Family physicians know their patients and are well positioned to perform a key “gatekeeper” role, but they often lack the training and tools as well as the connections and confidence to refer to local dispensers.

If the system was operating effectively, establishing a baseline hearing profile for everyone over 40 and under 12 would be as commonplace as tracking blood pressure. In the majority of medical practices we have worked with, 70% or more of the patient roster should have their hearing tested given age and/or lifestyle and/or co-morbidities.

The hearing industry is also one of the last anywhere to bundle upfront in the price of a device a number of future services rather than allowing the buyer to select and add what he or she believes may be needed. Students of industrial structure would argue that this is very unusual - a function of the market power and scarcity of alternatives the industry has traditionally enjoyed. The net result with few exceptions is the “sticker shock” that consumers typically experience when confronted by pricing.
What is the experience of those using hearing instruments?
The simple answer is “mixed” at best. About 25% of those who purchase hearing aids don’t use them after a period of trial. Reasons include lack of comfort, frequency and expense of service required, encroachment of background noise and one that is prime – inadequate orientation, training and support. Aided hearing requires the wearer to persevere while experiencing a new way of processing sound. Many find this hard to adapt to and abandon the effort. Basically, the hassle of hearing aid use outweighs the perceived benefit to be gained.
How and why is the hearing environment/market changing?
There are obvious, now evident signs. Deregulation is a leading indicator as are the growing number of companies reaching out to consumers directly with less expensive devices. An encouraging, if hard to completely isolate factor, is what appears to be a growing awareness among the public about the importance of hearing health.

One explanation is simply to note that we are living in the 21st century rather than the 20th where the Internet, Mobile Me and Medicine 3.0 are increasingly apparent. Consumers are more sophisticated and capable of taking control of their health and wellbeing with new tools that are increasingly being made available. Systems that are perceived to be closed, offering solutions at high prices, are less favoured.
What do consumers typically want from a product or service?
This is a central question, one that as a participant/observer of the industry, I am not confident has ever been adequately addressed. We certainly have a handle on what most audiologists respond to but what about the consuming public at large? While some might argue the point, preoccupation by the industry with product development and selling to its distributor channel has limited gaining a comprehensive and dynamic appreciation of what the ultimate customer expects and is motivated by.

Applying Marketing 101 suggests there are seven factors that make a product famous, nurturing trust, loyalty, and recommendation. These are summarized as:
  • Quality of pitch – Clear information about what the product or service is and how it is used – its utility.
  • Reliability – What you see, read or hear about is what you actually get.
  • Convenience in use – Competent direction leading to trouble free application.
  • Ease of acquisition – Few, if any, hoops to jump through, no surprises or tricks.
  • Try before you buy – Ideally a chance to experiment and experience before paying.
  • Post acquisition support – Particularly important when installing or adjusting to the product or when service is complex.
  • Warranty – Hassle free recourse if the product or service does not work effectively.
Other lessons from the front lines of audiology often include...
  • Don’t just talk at customers, teach them!
  • Listen and learn as much as you teach...
  • Acknowledge shortcomings and mistakes...and move quickly to correct them.
A credible argument can be made that leading suppliers and top practitioners rank quite well when these performance criteria are applied. My personal rating on a 10-point scale lies in the 7.5 to even 8 range. At a guess, that would likely decline by at least two points should the industry as a whole ever be measured. Full disclosure—I tend to be a hard marker.

Recall too that we are referring here primarily to the hearing aid aspect of the industry, rather than the full sweep of hearing health. Our hearing triage indicates that that cohort represents about 30% of those who have tested. In engaging consumers, it is critical to consider the needs of the entire target group and adopt a broader perspective. That is where our new North Star is located!
What do consumers need (even if many are not aware of needing to want it)?
This is where the rubber hits the road if you buy into the Basic Premise—i.e. that excluding so many from the hearing health system represents a growing public health issue; and to fix it requires more than a 20th century brick and mortar solution. That notably is out of tune with the times and will not come close to providing the necessary reach.

Consider what is becoming commonplace in other fields of healthcare and wellness. Recent science combined with virtual means of detection and treatment are available in a growing number of areas. “E-patientry” and the younger doctors supporting it, began to emerge almost ten years ago. MedTech is now one of the hottest categories in the professions as well as the investment community. Hearing health has lagged rather than lead these innovations.

Applying such lessons widely and making a hearing health process of high quality available to millions of people is undoubtedly daunting but not impossible to achieve. Or at least to work aggressively towards.

We take as a given the importance of understanding and becoming proactive about one’s hearing status as well as the incidence of hearing change in the general population. It is similar to what we have learned with the COVID dilemma, however. Without adequate testing (and testing 2%-4% of the relevant population is clearly inadequate) we can’t make any significant advance in confronting the problem.

As a first step, therefore, providing easily accessible and reliable testing via the Internet using any device, anywhere, at any time is fundamental.

Then comes the equally important question of trustworthy evaluation, recognizing that such classification will be preliminary but still indicative. It is here that inadequacies are apparent – the traditional 25db threshold for normality across the three frequency speech range of an audiogram does not account for its pattern or the subject’s medical history; it also ignores any measure of confidence that a seasoned audiologist would apply. Taken to its extreme (commonly experienced - just try the great majority of tests available on the Internet), it often leads to the promotion of a hearing instrument – what some refer to as “Click Bait”. Trolling for low hanging fruit, even with “audiological support” is now de rigeur. The objective almost without exception is to sell yet another device. Critics recognize this as “weaponizing” the test. Using our 10-point scale, this approach would warrant no more than a three.

When properly tested and evaluated, preliminary hearing triage becomes possible—i.e. the subject’s hearing status can be classified into standard audiological categories. Our data sets indicate that about 80% of the population represent routine cases – they are relatively easy to treat. 20% are complex. A minority—about 30% on average—have or are trending towards what appears to be a permanent Sensorineural problem and should consider a hearing device with appropriate guidance. Another 20% appear to be treatable (Conductive indication) and, if constant, should take action at home and in consultation with their family doctor. The remainder indicate either a Normal pattern and level (the largest category who should keep testing themselves periodically) or Mixed (something is going on, possibly a combination of conditions that can’t be separately classified signalling that a full work up is warranted). In every case it is appropriate that the family physician be kept informed given his/her experience with the patient, knowledge of the patient’s chart and co-morbidities. Using hearing protection when exposed to loud sound is also paramount.

The key we believe to addressing a very wide audience (not just the obvious segment—older with more advanced sensorineural losses the industry concentrates on) involves providing an attractive and inexpensive hearing health package consisting of five components—testing, classification and triaging, pointing towards best next steps given a person’s hearing status, making coaching about hearing available including connections when needed to medical and audiological talent, and, if appropriate, providing access to products and services that could be helpful. That combination represents a MedTech solution that avoids bias. It is the closest thing to “personalized medicine” one can achieve for hearing. And are a few steps beyond what has generally been available to date.

The flow chart in Figure 2 illustrates this hearing health pathway. Hearing health tech involves a five-step process designed to educate and empower the consumer about taking control of his/her hearing status.
Figure 2. Hearing health tech is an End-To-End process incorporating effective methodologies, easily understandable guidance and, when requested, reliable advice and solutions.

What does this wish list for consumers imply for the industry?
Strengthening Education, Access and Availability are key ingredients. Also recognizing that while the industry with adaptation can provide important leadership, it will never attain the scale required to confront the problem entirely. Coalitions and partnerships will be required as well as new sources of public and private funding.

Messaging will need to become much more consumer specific. Appealing to a 25-year-old or someone 45 are each different than to a person reaching senior status. Yet all of them may have or be developing hearing issues.

“Protect yourself”, “Be the best you can be”, “Stay connected to people and things that matter” are themes that generally resonate and could be used much more. But they need additional context – why should a kid in a band care? or a diabetic? or those who are beginning to turn the volume of their TV’s up?

This isn’t rocket science; seasoned marketers understand what’s required. They would argue that the relatively universal pitch that has worked for decades should be recast. A dose of self-reflection about behaviour often leads to the same conclusion.

The business model will also need to evolve quite sharply. A good start is underway in adopting virtual care. In the future, that will become the primary method to attract, motivate and treat most “patients” (quotations represent my observation and bias – make limited use of that term in reaching out to a much wider demographic; cut back on the “white coat”. It’s about wellness, not being sick...!).

More reliable methods for testing and evaluation must accompany this development. Software embedded AI and pattern recognition algorithms can detect and classify even early changes within the normal range as well as situations that are obvious. Reports can then be delivered that apply what measure of confidence should be assigned to the results in addition to recommending what best next steps are warranted. Widespread use of such innovations can broaden the base of those tested by a substantial amount. Adding simple speech testing also makes good sense.

The goal of this hearing triage must above all be to inform the subject about his/her status and its importance rather than sell a hearing aid—a premise that will engender trust and greater receptivity to take action. A multiplier effect often results—trusting people leads to others they know who are encouraged to learn more about their hearing function. A reasonable guess suggests that a “happy initial customer” creates an influential ripple to 2.5 others.

A greater range of hearing products and price points needs to be offered if the largest pool of potential clientel (those with mild and moderate hearing loss) is to be attracted. There are a growing number of relatively inexpensive alternatives that will satisfy that clientele, at least for a while. Additional services should be proposed and costed accordingly.

Counselling, an original keystone of audiology, will almost certainly become more significant and sought-after. By tailoring programs well and progressively to match a client’s needs, there is little reason to doubt that it will become an important revenue producing service via insurance and/or user pay.

In sum, at least for routine cases, hearing telehealth will become the norm for prospecting, testing, counselling and treatment. That’s no longer revolutionary. It’s becoming commonplace throughout the spectrum of health and wellness.

What scenarios are possible for responding? Preparing for the future requires agility. Thinking about how strategies might vary with different yet plausible scenarios has eclipsed older methods of strategic planning. There is more than one pathway to consider.

Some argue that because the industry has faced into significant change in the past and held its position, the hearing marketplace will evolve slowly and conservatively. This might be called the “Small Change—Stay Put” possibility. Margins will likely be under greater pressure and use of the Net will be an expected adjunct. But the basic model will still be dominant, at least for the current generation of owner-operators.

An alternative future envisages a service model without walls, call that Virtual Choice. Application of existing technologies and those on the immediate horizon (AI, AR and VR, for example) will facilitate a learning through fulfillment and follow-up process that is satisfying for many consumers, both urban and rural. Virtual linkages up through full integration with trusted providers (family physicians and pharmacists in particular) will present a value chain that is available for millions more people. And the agile hearing specialist will be able to dovetail more effectively into the health and wellness process becoming a featured aspect of the health hub.

A third could conceivably foresee the entry of new players who rapidly dominate the market. Such a scenario might be dubbed the “Nuclear Alternative”. The majority of the FAGMA giants (Facebook, Apple, Google, Microsoft, Amazon, to which we should add Samsung) are staking out turf in the human health/wellness spectrum, areas they predict are key to their future growth. And they already have access to extensive customer bases across the entire demographic and are capable of investing billions in technology, marketing and acquisitions rather than the millions that the hearing industry conceivably has on offer. Another compelling feature is that hearing is considered more than just interesting as the human ear is a pathway to several other health-related measure. Exploiting that avenue is already underway —check out, for example, the latest Apple message when opening their health app.

Such a future could extend the reach of hearing health well beyond what we have or can imagine through steady yet unspectacular evolution. How probable it is remains an open question. If realized, it would imply a significant retreat from the existing model of providing hearing instruments through retail and place much more emphasis on education and counselling.
Where to from here?
Hearing, like almost every other industry, is being disrupted; the future until further evolution occurs is ambiguous. It’s likely safe to conclude that five years from now and certainly by ten it will take on quite a different cast. Four drivers are clear...

  1. Hearing health is becoming a big deal! As consumers, we ignore it at our peril. This is recognized increasingly by the medical and public health establishments.
  2. The present model is dated and falls well short of achieving anything close to the New North Star objective posed earlier as an aspirational target.
  3. In fact, it’s a variation of a patient-professional delivery process that is over a century old and beyond it best before date.
  4. Significant change relying on 21st century methods is well underway throughout healthcare. Hearing health will not be an exception.
While more brainstorming and much greater experimentation is warranted, three steps appear important in the short term.
  • Take as a given the need to expand reach and supplement present practice by adopting virtual technologies.
  • Strengthen and leverage counselling and research activities to better understand the mind of the consumer. Present patients and their kin provide an important window into that learning.
  • Experiment with, if not fully embrace, the OTC revolution. It has the potential of having a profound impact.
My best sense is that a new business model will emerge quite soon. A broader product and service mix will dictate trade-offs and acumen from a financial perspective. Progressive practices will be more integrated into their communities through use of technologies and partnerships. Undoubtedly some will fail or fade away; others will likely thrive.    
Terry Mactaggart is the President and CEO of Ultimate Kiosk Inc. and Summus Hearing Solutions Inc., AI-enabled software companies with proprietary technologies aimed at capitalizing on opportunities in international hearing health. He has substantial experience with private venture creation, financing and growth as an investor, consultant, director, chairman and president of a number of companies – both privately owned and publicly traded – as well as of a private equity fund. A broad international perspective has been gained from these activities as well as from his leadership of The Niagara Institute and his time with the World Bank. Terry has a BA (Political Science and Economics) from the University of Toronto and an MBA from Stanford University. He can be reached at [email protected]