Total H. A. Ted
Hearing Rehabilitation
Bailey, Jr, MD;
James J.
Pappas, MD; Sharon Graham, MS;
history and development of the hearing aid dispensing system in this country is outlined in relation to the status of dispensing today. We enumerate the problems within the traditional system, \s=b\ The
various attempts to correct them, and advantages of variations of the traditional system. This article presents a concept of total hearing rehabilitation, including the direct dispensing of aids based on the
professional otolaryngological-audiological team working together within the clinic setting. Based on the results of 20-months' experience in dispensing, we advocate a reexamination of professional roles involved in provision for hearing aids.
(Arch Otolaryngol 102:323-326, 1976)
1902, the first commercially avail¬
In hearing Hutchison introduced by Miller able electric
aid
was
Reese Ala.' Within
a decade, Mobile, several manufacturing firms had set up retail offices in the major metro¬
in
politan centers of the United States. Following the appearance of the orig¬
inal carbon electric aid came the vacuum tube, and still later, the tran¬ sistor. With expanded marketing pro¬
cedures, as well as continually increas¬ for the
of
complexity ing possibilities hearing aid circuitry, an on-the-job training procedure developed for those who became involved in retail
Accepted
for publication Feb 26, 1976. From the Ear and Nose-Throat Clinic, Little Rock, Ark. Reprint requests to the Ear and Nose-Throat Clinic, 1200 Medical Towers Bldg, Little Rock, AR 72205 (Dr Bailey).
Michael E.
Winston, PhD
selling of aids. During the period 1950 to 1970, rapid advances were occurring not only in hearing aid design, but also in diagnostic procedures and medical and surgical treatment of hearing loss. Thus, those dealers who had originally been involved in the sale of a relatively simple amplifier became caught up through the evolu¬ tionary process in the science of measuring hearing sensitivity as well as fitting instruments with myriad possibilities in terms of circuit de¬ sign.
1971 national health survey report estimated that 13.2 million persons in the United States had A
substantial bilateral hearing impair¬ ments; of these, 5.5 million were over 65 years of age.2 The Hearing Aid
Industry Conference (HAIC) esti¬
mates there are some 10 million hear¬ ing-impaired persons who have not received medical attention. These sta¬
tistics indicate the need for imme¬ diate comprehensive assault on one of the nation's foremost health needs. There are an estimated 2.5 million hearing aid users; the hearing aid industry postulates that an additional 7.5 million could benefit from an aid. There are currently 15,000 hearing aid dealers, 2,200 of which are certified.Dealer certification is sponsored through the national association (HAIC) and requires a home study course of 20 lessons followed by successfully passing an examination. The majority of these dealers are covered by state licensure statutes.
Downloaded From: http://archotol.jamanetwork.com/ by a New York University User on 06/12/2015
Available statistics indicate that ap¬ proximately 70% of hearing aid users go directly to a dealer rather than to a physician and/or audiologist.-' In essence, "hearing impairment is clearly a major public health problem
requiring competent professional
at¬
tention."- As demands on both aca¬ demic and technical skills increase in hearing aid fitting, it becomes neces¬ sary to reconsider who should provide patient care in the area of hearing aids. In addition to the thorough otological and audiological diagnostic and rehabilitative procedures neces¬ sary before any fitting is attempted, there are currently multiple technical considerations, ie, coupler characteris¬ tics, variable gain adjustments, fre¬ quency response, optimum maximum power
output through compression and choice of various types
circuitry,
of transducers. These developments have resulted in a growing movement regarding the redefinition or reshap¬ ing of professional roles. A tran¬ sitional period has resulted, both in professional philosophies and in actual
dispensing systems.
In concurrence with the rapid changes in diagnosis and treatment of hearing loss, as well as hearing aid technology, the hearing aid dealers
have used the enactment of state licensure statutes as their main
attempt at upgrading required com¬ petency levels. Thirty-eight states are
covered by such licensure. Most of the acts were drawn up from a model licensure bill, which was designed to now
meet and suit HAIC requirements. It has now become obvious that such licensure has not succeeded in sub¬ stantially altering the dispensing sys¬ tem in this country.- Certainly, part of the problem has been the "grandfath¬ er" clause that provides for automatic licensure of those already engaged in dispensing. State boards and the legislation that created them have failed to adequately provide for or control such things as: dealer recertifi¬
cation, equipment calibration,
re¬
quired medical clearance for certain conditions, required trial periods, ade¬ quate supervision of nonlicensed per¬ sons who are in a training-apprentice situation, protection for the incompe¬ tent, and mail order sales.
Consumers, on the other hand, often not aware of the availability or the proper avenue for filing a complaint. Many consumers equate dealer licen¬ sure by the state with adequate qual¬ ifications and competency. Therefore,
are
with licensure, the average consumer believes that he is receiving attention from a person that the state has deter¬ mined to be qualified in hearing health care. Nevertheless, since 1960, when licensure began, the dispensing system has not been sufficiently improved in the opinion of many involved dealers, professionals, and consumers. More recently, a new model bill drawn up in an attempt to solve licensure problems recommends medical and/or audiological clearance before any fitting. In 1971, the American Speech and
Hearing Association (ASHA) Legis¬
lative Council passed "resolution 13," changing ASHA's ethical policies to allow audiologists to directly dispense aids. Such an endorsement, of course, created much controversy. The cur¬ rent ethical policy of ASHA does provide the consumer protection from conflict of interests on the part of the audiologist, and in so doing, destroys one of the major contentions against such a practice. Manufacturers as well have begun to demonstrate a philo¬ sophical change; this however, contin¬ ues to vary greatly from company to company. Changes in advertising and
marketing policies are apparently aimed to attract professional clientele. One manufacturing company has even
advertised that it will offer aids to professionals only. Certainly, this rep¬ resents a change in thinking on the part of the manufacturer in how their product should be dispensed. National legislators have also be¬ active in recent years in come studying this country's dispensing system. Meetings held during 1972 in the US Senate by the Subcommittee on Consumer Interests of the Elderly of the Special Committee on Aging focused on the poor quality of current hearing aid delivery systems.- This was accompanied by the issuance of the American Association of Retired Persons' report "Paying Through the Ear," which successfully delineated specific problem issues in hearing aid delivery. These problems included: (1) the varying quality of hearing aids and hearing health services; (2) the small percentage of consumers obtain¬ ing professional diagnosis; and (3) false and misleading labeling and promotional literature. This timely report, as well as Federal Trade Commission complaint actions, sup¬ ported the findings that benefits to be derived from hearing aids were being misrepresented to the patient, and, in addition, that patients had been misevaluated and misfitted.- These find¬ ings were responded to by the US Department of Health, Education and Welfare in a 1974 report that suggested, among other things, a
prescription by an otolaryngologist or audiologist as mandatory before a sale, with some exceptions. This deci¬ sion was later replaced by one advis¬ ing study of the problem, particularly considering the current and future capacity of the medical and audiolog¬ ical professions to provide the neces¬ sary level and geographic distribution
of manpower. In 1975, the Federal Trade Commis¬ sion submitted proposed trade regula¬ tions on the hearing aid industry. Several restrictions were suggested on sales, including a mandatory trial due to the fact that "many consumers buy aids from which they do not re¬ ceive any significant benefit.":; Other reasons mentioned for such restric¬ tions include "lead" solicitation activi¬ ties undisclosed to the consumer and the elimination of deceptive practices
Downloaded From: http://archotol.jamanetwork.com/ by a New York University User on 06/12/2015
for which "the commission had for some years undertaken extensive adjudicative efforts in the hearing aid industry,"—which have proved inad¬ equate." During its investigation, the Commission received documentary evidence of such practices, and there¬ fore thought that such restrictive requirements were necessary. In addition to legislation regarding the regulation of the dispensing system in general, there is currently much legislative activity regarding Medicare and National Health Insur¬ ance and their potential coverage of hearing aid fittings. The Communica¬ tive Health Care Amendments of 1975 have among their objectives the cover¬ age of aural rehabilitative services under Medicare and partial coverage of the cost of a hearing aid.' The federal government would agree to assume a portion of the cost of an aid only on the written authorization of a physician and an audiologist, certify¬ ing that the device is both necessary and appropriate.' Certainly, the gov¬ ernment cannot afford to assume such costs without professional clearance. The problems apparent in the previous discussion are a result of the traditional system of delivery of hearing aids. In this system, many of the patients go directly to the hearing aid dealer for examination and aid determination. Others are seen ini¬ tially by the physician and audiologist, who determine the likely need for an aid and then, directly or indirectly, refer the patient to some hearing aid dealer for fitting and purchase. In many instances, this places the entire aural rehabilitative process in the control of the hearing aid dealer. Certainly, there are some favorable aspects for the physician and/or audiologist to consider in this tradi¬ tional system. There is no investment in hearing aid inventory or in acquir¬ ing additional diagnostic audiometrie equipment. There is no involvement of professional time and none of the problems incumbent with hearing aid sales, servicing, and repair. Disadvantages in the traditional health care system, however, far outweigh the advantages. Loss of patient follow-up data is among the most important; once a patient leaves
the
medical-audiological clinic, comes difficult or impossible to
tain whether
or
it be¬ ascer¬
not he went to
a
dealer, was properly evaluated, fitted, and counseled, whether he actually obtained an aid, and if so, how well he adjusted to amplification. In addition, many of these patients are unavail¬ able for continuing medical and audio-
logical follow-up since they assume the dealer to be qualified to take the responsibility for their continuing hearing health care.1 For many pa¬
tients, this may result in serious lack
of medical attention to later occurring remediable ear pathological features. A revised version of the traditional system has been offered by some otologists whose offices included the services of an audiologist. This system has been referred to as the "ware¬ house" or "prescription" concept. It is a more attractive alternative to the physician and audiologist in being able to directly control the exact aid fitted and to the patient in terms of reduced cost of the aid." By this method, the patient is directed to a supplier with a recommendation for the exact make, model, and settings for an instrument. One of the primary faults of this concept is the fact that hearing aid responses vary sub¬ stantially between one instrument and another of the same make and model. If referrals are made on the basis of
printed specifications, materials, or from a stock of sample aids, responses with amplification may well differ.
stock earmold also may produce quite different results than those obtained with a custom mold, due to such factors as the length of the canal, the length, diameter, and thickness of the tubing, type of vent¬ ing, and coupler connection. The dispenser in this type of delivery system does no evaluation; therefore, if substantial differences do occur, they go undetected, and hearing improvement thus may not be maxi¬ mal. Also, the patient must leave the umbrella of physician protection and care to get the hearing help that he expected the physician to provide. In our clinic, we are currently offering what we refer to as our total hearing health care system. This is Evaluation with
a
the incorporation of all of phases patient services within the confines of our clinic. Professional evaluation by physician and audiolo¬ gist, medical or surgical treatment, and aural rehabilitation, including hearing aid evaluation, fitting, sales, and service are all provided with this total management concept. A patient may be followed up throughout the process of aural rehabilitation, with continual attention to medical, am¬ based
on
plification-related technical, psychosocial, and communicative problems.
Thus, when the time comes for a second aid, or when communicative problems recur or increase using the first aid, otological and audiological reassessment, as deemed necessary, is available within the confines of the
system. Advantages of this "one-stop" system include continued surveillance
of the hearing loss status by the physi¬ cian and audiologist. In addition, objectivity in hearing aid selection can be increased or at least main¬ tained; patients are evaluated by using their own custom molds and the specific instrument with which they will be fitted. Patient's aids in use as well as all new aids are electroacoustically analyzed in an anechoic chamber to assess performance as well as adequacy for a particular loss. As a result of all of these services, patients have available to them the latest developments in otology, audiology, and hearing aid technology. Patients who either do not choose to have surgical intervention or who receive unsatisfactory surgical results still can be offered rehabilitative assis¬ tance within the clinic. As for cost, aids are being dispensed at sub¬ stantially less than manufacturer's suggested retail prices. The chief deterent to the general otolaryngologist to provide this sys¬ tem is the investment necessary for additional diagnostic audiometrie and electroacoustic equipment, hearing aid inventory, and additional clerical help. Obviously, this system is based on the availability of professional audiological services within the clinic setting. Other objections may be (1) a certain amount of the audiologist's time must be allotted for hearing aid servicing and miscellaneous business
Downloaded From: http://archotol.jamanetwork.com/ by a New York University User on 06/12/2015
procedures associated with direct dis¬ pensing, and (2) patients who live at
distance from the clinic may more difficulty in obtaining prompt hearing aid servicing than if they had obtained the instrument closer to their home. In 1973, a survey of some 200 of our clinic patients was taken using poten¬ tial hearing aid candidates. Of those canvassed, 93% indicated that they would prefer to be fitted and to purchase the hearing aid from the clinic. Therefore, when we moved into our new clinic in 1974, a hearing aid dispensary was opened as a part of our clinic facilities. Initially, aids from manufacturers' lines were two stocked; later, two more lines were added. A technician was added to assist with clerical and servicing tasks. Cost of the instrument to the patient was calculated using the invoice price of the aid plus a fee for professional services from the hearing aid evaluation and fitting procedures in addition to a separate charge for the ear mold. Fees for professional services consider not only professional time, but also include a cost-accounted determination of overhead expenses. This approach to hearing aid charges was designed in accordance with ASHA guidelines. The routine procedure for a poten¬ tial hearing aid candidate is now as follows: (1) audiological assessment, including pure-tone, speech, and im¬ pedance audiometry with any special studies indicated; (2) complete otolaryngological examination with expla¬ nation of findings and counseling by the physician regarding the nature and extent of the hearing loss and available treatment; (3) further coun¬ seling by the audiologist concerning the hearing loss, the nature of amplifi¬ cation with expected benefits and drawbacks, and a discussion of com¬ municative disorders related to or caused by substantial hearing loss; (4) making an ear mold impression; (5) hearing aid evaluation using the custom mold; (6) a 30-day trial with the aid; and (7) a postfitting réévalua¬ tion and recheck. At the time of the recheck, counseling can be continued, the performance of the aid electroacoustically checked, and follow-up some
have
data obtained on patient progress and adjustment. At this time, the patient may also see the physician with
regard to cerumen accumulation, con¬ tinuing surveillance of hearing loss pathological features, or other otolaryngological complaints. During the first 20 months of dispensing, 83% of the aids dispensed were postauricular, 10% were eye¬ glass, and 7% were body style. Various types of contralateral routing of signal (CROS) and bilateral CROS
aids accounted for 13% of the aids fitted. Whenever possible, our pa¬ tients are being fitted using tubing only as a coupler, which has increased patient acceptance due to comfort, cosmetic appearance, and improved speech discrimination. Problems in dispensing have been minimal. This clinic has not been engaged in dispensing long enough, however, to have many service prob¬ lems that occur as aids become older. Fittings are based entirely on profes¬ sional recommendations and patient understanding of these recommenda¬ tions. Each fitting is pursued only at
patient request. The following factors are the major obstacles to patient acceptance: (1) vanity or cosmetic appearance; (2) poor motivation; (3) finances; and (4) the past poor image that hearing aids, in general, have had with the lay public. All aids were dispensed on a trial basis; four percent of the aids were returned during the first 20 months of dispensary opera¬ tion.
Senility and/or poor manual dexter¬ ity in applying and adjusting the aid, lack of substantial improvement in speech discrimination, and cosmetic rejection were the main reasons for return of the instruments
on trial. Acceptance of our total hearing health care system by the local professional community has been good, and refer¬ rals continue to increase from physi¬ cians both within and without our speciality, from speech and hearing clinics, and from state health agen¬ cies. The complexity of the communica¬ tive and psychological disorders re¬ sulting from substantial hearing loss are clearly multifaceted problems
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involving both the general health and psychosocial well-being of the hear¬ ing-impaired individual. The hearing aid is a device that is an integral part
of the aural rehabilitative process. On the basis of our group's 20-months' experience, we certainly recommend to all otologists and otolaryngologists the approach of total management of hearing health care as a means of broadening the scope and improving the quality of patient care for the
hearing-handicapped. References
Berger K: The Hearing Aid. Detroit, Hearing Aid Society, 1970, pp 23-24. 2. Department of Health, Education, and Welfare: A Report on Hearing Aid Health Care. Washington, DC, US Government Press, 1974, 1.
National
pp vi-10.
3. Federal Trade Commission: Hearing Aid Industry proposed trade regulation rules, in The
National Archives of the US 40:26646-26653, 1975. 4. US Congress: Congressional Record 121:81, 1975. 5. Rassi J, Harford E: An analysis of patient attitudes and reactions to a clinical hearing aid selection program. ASHA 10:283-290, 1968. 6. Wilson L, Linnell C: Direct hearing aid referrals. J Speech Hear Disord 37:233-243, 1972.
Hearing Rehabilitation
Bailey, Jr, MD;
James J.
Pappas, MD; Sharon Graham, MS;
history and development of the hearing aid dispensing system in this country is outlined in relation to the status of dispensing today. We enumerate the problems within the traditional system, \s=b\ The
various attempts to correct them, and advantages of variations of the traditional system. This article presents a concept of total hearing rehabilitation, including the direct dispensing of aids based on the
professional otolaryngological-audiological team working together within the clinic setting. Based on the results of 20-months' experience in dispensing, we advocate a reexamination of professional roles involved in provision for hearing aids.
(Arch Otolaryngol 102:323-326, 1976)
1902, the first commercially avail¬
In hearing Hutchison introduced by Miller able electric
aid
was
Reese Ala.' Within
a decade, Mobile, several manufacturing firms had set up retail offices in the major metro¬
in
politan centers of the United States. Following the appearance of the orig¬
inal carbon electric aid came the vacuum tube, and still later, the tran¬ sistor. With expanded marketing pro¬
cedures, as well as continually increas¬ for the
of
complexity ing possibilities hearing aid circuitry, an on-the-job training procedure developed for those who became involved in retail
Accepted
for publication Feb 26, 1976. From the Ear and Nose-Throat Clinic, Little Rock, Ark. Reprint requests to the Ear and Nose-Throat Clinic, 1200 Medical Towers Bldg, Little Rock, AR 72205 (Dr Bailey).
Michael E.
Winston, PhD
selling of aids. During the period 1950 to 1970, rapid advances were occurring not only in hearing aid design, but also in diagnostic procedures and medical and surgical treatment of hearing loss. Thus, those dealers who had originally been involved in the sale of a relatively simple amplifier became caught up through the evolu¬ tionary process in the science of measuring hearing sensitivity as well as fitting instruments with myriad possibilities in terms of circuit de¬ sign.
1971 national health survey report estimated that 13.2 million persons in the United States had A
substantial bilateral hearing impair¬ ments; of these, 5.5 million were over 65 years of age.2 The Hearing Aid
Industry Conference (HAIC) esti¬
mates there are some 10 million hear¬ ing-impaired persons who have not received medical attention. These sta¬
tistics indicate the need for imme¬ diate comprehensive assault on one of the nation's foremost health needs. There are an estimated 2.5 million hearing aid users; the hearing aid industry postulates that an additional 7.5 million could benefit from an aid. There are currently 15,000 hearing aid dealers, 2,200 of which are certified.Dealer certification is sponsored through the national association (HAIC) and requires a home study course of 20 lessons followed by successfully passing an examination. The majority of these dealers are covered by state licensure statutes.
Downloaded From: http://archotol.jamanetwork.com/ by a New York University User on 06/12/2015
Available statistics indicate that ap¬ proximately 70% of hearing aid users go directly to a dealer rather than to a physician and/or audiologist.-' In essence, "hearing impairment is clearly a major public health problem
requiring competent professional
at¬
tention."- As demands on both aca¬ demic and technical skills increase in hearing aid fitting, it becomes neces¬ sary to reconsider who should provide patient care in the area of hearing aids. In addition to the thorough otological and audiological diagnostic and rehabilitative procedures neces¬ sary before any fitting is attempted, there are currently multiple technical considerations, ie, coupler characteris¬ tics, variable gain adjustments, fre¬ quency response, optimum maximum power
output through compression and choice of various types
circuitry,
of transducers. These developments have resulted in a growing movement regarding the redefinition or reshap¬ ing of professional roles. A tran¬ sitional period has resulted, both in professional philosophies and in actual
dispensing systems.
In concurrence with the rapid changes in diagnosis and treatment of hearing loss, as well as hearing aid technology, the hearing aid dealers
have used the enactment of state licensure statutes as their main
attempt at upgrading required com¬ petency levels. Thirty-eight states are
covered by such licensure. Most of the acts were drawn up from a model licensure bill, which was designed to now
meet and suit HAIC requirements. It has now become obvious that such licensure has not succeeded in sub¬ stantially altering the dispensing sys¬ tem in this country.- Certainly, part of the problem has been the "grandfath¬ er" clause that provides for automatic licensure of those already engaged in dispensing. State boards and the legislation that created them have failed to adequately provide for or control such things as: dealer recertifi¬
cation, equipment calibration,
re¬
quired medical clearance for certain conditions, required trial periods, ade¬ quate supervision of nonlicensed per¬ sons who are in a training-apprentice situation, protection for the incompe¬ tent, and mail order sales.
Consumers, on the other hand, often not aware of the availability or the proper avenue for filing a complaint. Many consumers equate dealer licen¬ sure by the state with adequate qual¬ ifications and competency. Therefore,
are
with licensure, the average consumer believes that he is receiving attention from a person that the state has deter¬ mined to be qualified in hearing health care. Nevertheless, since 1960, when licensure began, the dispensing system has not been sufficiently improved in the opinion of many involved dealers, professionals, and consumers. More recently, a new model bill drawn up in an attempt to solve licensure problems recommends medical and/or audiological clearance before any fitting. In 1971, the American Speech and
Hearing Association (ASHA) Legis¬
lative Council passed "resolution 13," changing ASHA's ethical policies to allow audiologists to directly dispense aids. Such an endorsement, of course, created much controversy. The cur¬ rent ethical policy of ASHA does provide the consumer protection from conflict of interests on the part of the audiologist, and in so doing, destroys one of the major contentions against such a practice. Manufacturers as well have begun to demonstrate a philo¬ sophical change; this however, contin¬ ues to vary greatly from company to company. Changes in advertising and
marketing policies are apparently aimed to attract professional clientele. One manufacturing company has even
advertised that it will offer aids to professionals only. Certainly, this rep¬ resents a change in thinking on the part of the manufacturer in how their product should be dispensed. National legislators have also be¬ active in recent years in come studying this country's dispensing system. Meetings held during 1972 in the US Senate by the Subcommittee on Consumer Interests of the Elderly of the Special Committee on Aging focused on the poor quality of current hearing aid delivery systems.- This was accompanied by the issuance of the American Association of Retired Persons' report "Paying Through the Ear," which successfully delineated specific problem issues in hearing aid delivery. These problems included: (1) the varying quality of hearing aids and hearing health services; (2) the small percentage of consumers obtain¬ ing professional diagnosis; and (3) false and misleading labeling and promotional literature. This timely report, as well as Federal Trade Commission complaint actions, sup¬ ported the findings that benefits to be derived from hearing aids were being misrepresented to the patient, and, in addition, that patients had been misevaluated and misfitted.- These find¬ ings were responded to by the US Department of Health, Education and Welfare in a 1974 report that suggested, among other things, a
prescription by an otolaryngologist or audiologist as mandatory before a sale, with some exceptions. This deci¬ sion was later replaced by one advis¬ ing study of the problem, particularly considering the current and future capacity of the medical and audiolog¬ ical professions to provide the neces¬ sary level and geographic distribution
of manpower. In 1975, the Federal Trade Commis¬ sion submitted proposed trade regula¬ tions on the hearing aid industry. Several restrictions were suggested on sales, including a mandatory trial due to the fact that "many consumers buy aids from which they do not re¬ ceive any significant benefit.":; Other reasons mentioned for such restric¬ tions include "lead" solicitation activi¬ ties undisclosed to the consumer and the elimination of deceptive practices
Downloaded From: http://archotol.jamanetwork.com/ by a New York University User on 06/12/2015
for which "the commission had for some years undertaken extensive adjudicative efforts in the hearing aid industry,"—which have proved inad¬ equate." During its investigation, the Commission received documentary evidence of such practices, and there¬ fore thought that such restrictive requirements were necessary. In addition to legislation regarding the regulation of the dispensing system in general, there is currently much legislative activity regarding Medicare and National Health Insur¬ ance and their potential coverage of hearing aid fittings. The Communica¬ tive Health Care Amendments of 1975 have among their objectives the cover¬ age of aural rehabilitative services under Medicare and partial coverage of the cost of a hearing aid.' The federal government would agree to assume a portion of the cost of an aid only on the written authorization of a physician and an audiologist, certify¬ ing that the device is both necessary and appropriate.' Certainly, the gov¬ ernment cannot afford to assume such costs without professional clearance. The problems apparent in the previous discussion are a result of the traditional system of delivery of hearing aids. In this system, many of the patients go directly to the hearing aid dealer for examination and aid determination. Others are seen ini¬ tially by the physician and audiologist, who determine the likely need for an aid and then, directly or indirectly, refer the patient to some hearing aid dealer for fitting and purchase. In many instances, this places the entire aural rehabilitative process in the control of the hearing aid dealer. Certainly, there are some favorable aspects for the physician and/or audiologist to consider in this tradi¬ tional system. There is no investment in hearing aid inventory or in acquir¬ ing additional diagnostic audiometrie equipment. There is no involvement of professional time and none of the problems incumbent with hearing aid sales, servicing, and repair. Disadvantages in the traditional health care system, however, far outweigh the advantages. Loss of patient follow-up data is among the most important; once a patient leaves
the
medical-audiological clinic, comes difficult or impossible to
tain whether
or
it be¬ ascer¬
not he went to
a
dealer, was properly evaluated, fitted, and counseled, whether he actually obtained an aid, and if so, how well he adjusted to amplification. In addition, many of these patients are unavail¬ able for continuing medical and audio-
logical follow-up since they assume the dealer to be qualified to take the responsibility for their continuing hearing health care.1 For many pa¬
tients, this may result in serious lack
of medical attention to later occurring remediable ear pathological features. A revised version of the traditional system has been offered by some otologists whose offices included the services of an audiologist. This system has been referred to as the "ware¬ house" or "prescription" concept. It is a more attractive alternative to the physician and audiologist in being able to directly control the exact aid fitted and to the patient in terms of reduced cost of the aid." By this method, the patient is directed to a supplier with a recommendation for the exact make, model, and settings for an instrument. One of the primary faults of this concept is the fact that hearing aid responses vary sub¬ stantially between one instrument and another of the same make and model. If referrals are made on the basis of
printed specifications, materials, or from a stock of sample aids, responses with amplification may well differ.
stock earmold also may produce quite different results than those obtained with a custom mold, due to such factors as the length of the canal, the length, diameter, and thickness of the tubing, type of vent¬ ing, and coupler connection. The dispenser in this type of delivery system does no evaluation; therefore, if substantial differences do occur, they go undetected, and hearing improvement thus may not be maxi¬ mal. Also, the patient must leave the umbrella of physician protection and care to get the hearing help that he expected the physician to provide. In our clinic, we are currently offering what we refer to as our total hearing health care system. This is Evaluation with
a
the incorporation of all of phases patient services within the confines of our clinic. Professional evaluation by physician and audiolo¬ gist, medical or surgical treatment, and aural rehabilitation, including hearing aid evaluation, fitting, sales, and service are all provided with this total management concept. A patient may be followed up throughout the process of aural rehabilitation, with continual attention to medical, am¬ based
on
plification-related technical, psychosocial, and communicative problems.
Thus, when the time comes for a second aid, or when communicative problems recur or increase using the first aid, otological and audiological reassessment, as deemed necessary, is available within the confines of the
system. Advantages of this "one-stop" system include continued surveillance
of the hearing loss status by the physi¬ cian and audiologist. In addition, objectivity in hearing aid selection can be increased or at least main¬ tained; patients are evaluated by using their own custom molds and the specific instrument with which they will be fitted. Patient's aids in use as well as all new aids are electroacoustically analyzed in an anechoic chamber to assess performance as well as adequacy for a particular loss. As a result of all of these services, patients have available to them the latest developments in otology, audiology, and hearing aid technology. Patients who either do not choose to have surgical intervention or who receive unsatisfactory surgical results still can be offered rehabilitative assis¬ tance within the clinic. As for cost, aids are being dispensed at sub¬ stantially less than manufacturer's suggested retail prices. The chief deterent to the general otolaryngologist to provide this sys¬ tem is the investment necessary for additional diagnostic audiometrie and electroacoustic equipment, hearing aid inventory, and additional clerical help. Obviously, this system is based on the availability of professional audiological services within the clinic setting. Other objections may be (1) a certain amount of the audiologist's time must be allotted for hearing aid servicing and miscellaneous business
Downloaded From: http://archotol.jamanetwork.com/ by a New York University User on 06/12/2015
procedures associated with direct dis¬ pensing, and (2) patients who live at
distance from the clinic may more difficulty in obtaining prompt hearing aid servicing than if they had obtained the instrument closer to their home. In 1973, a survey of some 200 of our clinic patients was taken using poten¬ tial hearing aid candidates. Of those canvassed, 93% indicated that they would prefer to be fitted and to purchase the hearing aid from the clinic. Therefore, when we moved into our new clinic in 1974, a hearing aid dispensary was opened as a part of our clinic facilities. Initially, aids from manufacturers' lines were two stocked; later, two more lines were added. A technician was added to assist with clerical and servicing tasks. Cost of the instrument to the patient was calculated using the invoice price of the aid plus a fee for professional services from the hearing aid evaluation and fitting procedures in addition to a separate charge for the ear mold. Fees for professional services consider not only professional time, but also include a cost-accounted determination of overhead expenses. This approach to hearing aid charges was designed in accordance with ASHA guidelines. The routine procedure for a poten¬ tial hearing aid candidate is now as follows: (1) audiological assessment, including pure-tone, speech, and im¬ pedance audiometry with any special studies indicated; (2) complete otolaryngological examination with expla¬ nation of findings and counseling by the physician regarding the nature and extent of the hearing loss and available treatment; (3) further coun¬ seling by the audiologist concerning the hearing loss, the nature of amplifi¬ cation with expected benefits and drawbacks, and a discussion of com¬ municative disorders related to or caused by substantial hearing loss; (4) making an ear mold impression; (5) hearing aid evaluation using the custom mold; (6) a 30-day trial with the aid; and (7) a postfitting réévalua¬ tion and recheck. At the time of the recheck, counseling can be continued, the performance of the aid electroacoustically checked, and follow-up some
have
data obtained on patient progress and adjustment. At this time, the patient may also see the physician with
regard to cerumen accumulation, con¬ tinuing surveillance of hearing loss pathological features, or other otolaryngological complaints. During the first 20 months of dispensing, 83% of the aids dispensed were postauricular, 10% were eye¬ glass, and 7% were body style. Various types of contralateral routing of signal (CROS) and bilateral CROS
aids accounted for 13% of the aids fitted. Whenever possible, our pa¬ tients are being fitted using tubing only as a coupler, which has increased patient acceptance due to comfort, cosmetic appearance, and improved speech discrimination. Problems in dispensing have been minimal. This clinic has not been engaged in dispensing long enough, however, to have many service prob¬ lems that occur as aids become older. Fittings are based entirely on profes¬ sional recommendations and patient understanding of these recommenda¬ tions. Each fitting is pursued only at
patient request. The following factors are the major obstacles to patient acceptance: (1) vanity or cosmetic appearance; (2) poor motivation; (3) finances; and (4) the past poor image that hearing aids, in general, have had with the lay public. All aids were dispensed on a trial basis; four percent of the aids were returned during the first 20 months of dispensary opera¬ tion.
Senility and/or poor manual dexter¬ ity in applying and adjusting the aid, lack of substantial improvement in speech discrimination, and cosmetic rejection were the main reasons for return of the instruments
on trial. Acceptance of our total hearing health care system by the local professional community has been good, and refer¬ rals continue to increase from physi¬ cians both within and without our speciality, from speech and hearing clinics, and from state health agen¬ cies. The complexity of the communica¬ tive and psychological disorders re¬ sulting from substantial hearing loss are clearly multifaceted problems
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involving both the general health and psychosocial well-being of the hear¬ ing-impaired individual. The hearing aid is a device that is an integral part
of the aural rehabilitative process. On the basis of our group's 20-months' experience, we certainly recommend to all otologists and otolaryngologists the approach of total management of hearing health care as a means of broadening the scope and improving the quality of patient care for the
hearing-handicapped. References
Berger K: The Hearing Aid. Detroit, Hearing Aid Society, 1970, pp 23-24. 2. Department of Health, Education, and Welfare: A Report on Hearing Aid Health Care. Washington, DC, US Government Press, 1974, 1.
National
pp vi-10.
3. Federal Trade Commission: Hearing Aid Industry proposed trade regulation rules, in The
National Archives of the US 40:26646-26653, 1975. 4. US Congress: Congressional Record 121:81, 1975. 5. Rassi J, Harford E: An analysis of patient attitudes and reactions to a clinical hearing aid selection program. ASHA 10:283-290, 1968. 6. Wilson L, Linnell C: Direct hearing aid referrals. J Speech Hear Disord 37:233-243, 1972.
