Last year the first author published two articles in The-Hearing Journal reporting on studies she conducted on (1) the effectiveness of an online hearing test and (2) the quality of earmolds made from impressions taken by the purchaser as part of the online acquisition process.1,2 Both studies demonstrated reasons for-serious concern about online hearing aid dispensing, especially when done without benefit of professional services.
One reason for concern is that the online hearing tests often failed to determine hearing thresholds accurately. Secondly, the ability of an untrained consumer to make his or her own earmold impressions in order to buy a hearing aid via the Internet is questionable at best. Together, these two studies indicated that dispensing over the Internet can result in ill-fitting hearing aids or even potentially dangerous fittings.
ASSESSING THE PURCHASE PROCESS
For the third and concluding article in our series, we had two hearing-impaired subjects purchase hearing aids of their choice via the Internet so we could assess the process and its results.
One subject has a medically complicated hearing loss, and we wanted to determine if the online company considered any medical factors before dispensing to a consumer. The second subject was a male with presumed presbycusis.
Both subjects were asked to follow the online purchasing process as detailed on the company's web-site. We gave them no professional advice in ordering, but members of our team were present for each Internet interaction and for a phone conversation to the online company.
The first subject (JW) is a 71-year-old woman who was diagnosed with a sudden sensorineural hearing loss (SSNHL) over 10 years ago. Her latest and most severe attack occurred in 2005 after she took a plane flight when she had a virus. She was fitted with binaural BTE aids soon after her diagnosis and has worn hearing aids ever since. Her audiogram can be seen in Figure 1. Of particular note are her word-recognition scores, which on average are poor in quiet and more so in noise. She complains of difficulty understanding speakers with lowpitched voices and in group settings such as restaurants. She finds many communication situations very frustrating.
JW was recruited for our study after she and her husband came to our university clinic in search of a fitting that would improve her speech recognition. She was wearing a pair of BTE aids from a major manufacturer that were originally fitted at an ENT practice where she was being treated for her SSNHL and which is located outside her home state. Since the fitting, JW reported that her local audiologist has adjusted the instruments “probably more than 50 times.” She brought to our clinic a bag full of the earmolds that have been made for her over the years. She said she used most of them from time to time, as she can hear better some days with one and other days with another.
For our study, JW received a routine hearing aid evaluation and was then fitted by an audiologist at our clinic. She also completed the online purchasing process by taking the online hearing test (see Figure 2), having her husband make earmold impressions of her ears, then picking the hearing aids that she and her husband thought were most appropriate and ordering them.
University clinic fitting
After reviewing all JW's test results, including those from the COSI, and a-personal interview, we fitted her with a pair of BTE aids (of a different brand from her old instruments) and also ordered new earmolds. We verified the fitting with real-ear measurement. The hearing aids had a volume control and a telecoil to use with JW's personal neck loop system. Her hearing aids used three programs (basic, noise, and telecoil) as well as an automatic setting.
JW immediately liked the sound of the new hearing aids and could understand most or all of the conversation that took place in the fitting room. We made initial adjustments in response to her complaints about the sound of her voice as well as to what she described as a “popping” sound that seemed to nag her when she spoke. On the follow-up visit, we ground down earmolds because of her complaint that they were rubbing her ear canals and making them sore. We re-adjusted the fitting due to her complaint about the popping sound.
JW continued to experience discomfort with the earmolds, so we ordered new ones, using the original impressions, which were still available at the earmold laboratory. However, she went back to wearing an older pair of earmolds. The patient also continued to be bothered by the popping sound. She stated that she was not using the automatic setting much and most often felt comfortable when the hearing aid was in the noisy setting (program 2). She complained of difficulty using the toggle switch volume control because it was different from her previous hearing aid.
At this point, JW and her husband left on a 3-week vacation. While away, she contacted the clinic to say she wanted to return the new hearing aids due to the popping sound and to get different hearing aids when she returned from vacation. Since the university clinic had ended for the semester, the first author ordered a pair of BTEs made by yet another major manufacturer.
JW was fitted with the new instruments and also with the new earmolds that we had ordered for her. She immediately said she could not adjust to the sound. They were returned to the manufacturer and a fourth pair of BTEs were ordered from a fourth company. After completing the trial period with them, JW again opted to return the aids. Once more, she was unable to follow conversations fully and was generally disappointed with the sound quality. As of this writing, JW has returned to wearing her original pair of hearing aids. It appears that her extremely poor speech-discrimination abilities hampered all of the hearing aid fittings.
JW completed an online questionnaire and then took the online hearing test. After completing the test, she was presented with a choice of more than 40 hearing aids that the online company said were appropriate for her. They ranged from non-custom CICs to custom products and BTEs. Because JW was a previous BTE hearing aid user, she and her husband decided to stay with that style.
Her husband made the earmold impressions and then the couple called the toll-free number listed on the web site for advice on which of the many hearing aids to choose. After being told about the top-of-the-line products, Mr.-W expressed concern about their price. The customer service representative quickly suggested a mid-level product that he said “would be very appropriate also.” There was no discussion with the patient about her hearing loss or her goals or expectations with amplification.
Because the mid-level product was considerably less expensive and because JW had been told it would work “just as well,” she decided to order two BTE aids, made by a well-known manufacturer, along with custom earmolds for a total price of $3300.
When they arrived, we met with JW. We hooked the hearing aids to the computer software and determined that both had been set to “first fit” based on her online audiogram. Two programs were used (basic and noise).
Accompanying the hearing aids were two sets of instructions. One explained how to cut the earmold tubing to fit onto the aid and the other was a general user guide for the hearing aids. The instructions, especially those for cutting the earmold tubing were unclear, even to a trained professional.
We did an electroacoustic analysis and determined that the hearing aids did not reach the target for JW's hearing loss that had been established at our clinic. She could not carry on a normal conversation, even in a quiet room, on program one and could follow only minimal conversation on program two. She said the instruments were set “way too low” and that the volume needed to be increased significantly. She did like the quality of the sound and no longer heard the popping noise that she complained of with the first fitting we gave her. The devices were shipped back to the online supplier for adjustments.
When the hearing aids came back, electroacoustic analysis showed that overall gain had been increased in both programs. While JW could tell that the aids had been turned up, she still struggled with speech understanding. Interestingly, she was very satisfied with the earmolds that the online company made based on the earmold impressions her husband had taken, and she has continued to use them even after this study was over.
JW said she might eventually have obtained a better fit from the online company had she been willing to keep sending the aids back and forth for adjustments during her trial period. However, each mailing cost approximately $30 (for shipping and insurance), and she did not want to invest the time or money. The company offered to see her in person, but its offices are several hours' drive from her home. She returned the hearing aids and was credited the purchase price, less the cost of the earmolds and a $50 restocking fee.
TM, a 57-year-old man, came to our clinic complaining of decreased hearing sensitivity over the past several years. He had no history of middle ear or otologic disease, had never worn a hearing aid, and knew little about amplification.
Results from TM's online hearing test indicated a mild hearing loss in his right ear and a moderate loss in the left. That was the opposite of what was established in our clinic. TM, like JW, was offered a large choice of hearing aids (approximately 60) said to be appropriate for his hearing loss.
TM was familiar with only one brand, because its manufacturer is known for many products other than hearing aids. While he recognized the name as a reputable one, he said, “There is no way I'm going to spend $2000 for a hearing aid, so I'll get another brand instead.” Ultimately, he decided to purchase one hearing aid for his “worse” ear, stating that if it “worked well,” he would get one for the other ear. He selected a non-custom device marketed as “100% digital” costing $499.50, which he felt was adequate for his needs and fairly priced.
After receiving the aid, TM brought it to the clinic for inspection (Figure 3). It fit well in his ear, producing little to no feedback, and was equipped with a volume control and a potentiometer. There were no instructions for adjusting the volume control for more comfort, though there were instructions for changing the potentiometer to a low- or high-frequency emphasis.
As expected, electroacoustic analysis indicated inappropriate gain levels as was indicated through his verified hearing loss. TM initially perceived all sounds as loud. He wore the aid for “a few hours” for the first few days of his trial period and then, according to a family member, discontinued use because it was too loud. He returned the aid to the company. The aid came with offers for other products, including custom hearing aids, which the marketing materials indicated might be more appropriate.
University clinic fitting
TM was seen by a student clinician and by an audiologist at our clinic. Due to the configuration of his hearing loss and lifestyle considerations, it was recommended that TM purchase binaural open-fit BTE aids. He opted to wait for the release of a new product made by a major manufacturer and then ordered two open-fit micro-BTEs on July 1, 2008.
TM was very satisfied with the feel and comfort of the aids. Gain levels were verified with real-ear measurements. Initially, he requested that overall gain be reduced because he found all sounds too loud, but adjustments were made a week later to increase the volume overall and for soft voices. TM has reportedly been wearing his hearing aids inconsistently, but is satisfied with his fit at this point.
In this study, two subjects were fitted with hearing aids both through an online company and by a university clinic. For the online fitting, each subject had to choose which product to purchase from among 40 to 60 aids about which the company gave little or no information. Telephone calls to the company were of little or no help in the purchasing process.
The hearing aids bought online were poorly fitted for both patients. They provided inappropriate gain at the outset, as the levels were based on online hearing test results that were very different from those established in the university clinic.
While these subjects might eventually have been able to obtain a reasonably appropriate fit through the online process, they would likely have had to pay multiple shipping and handling costs and spent much time before getting a proper fit.
The authors would like to thank Kelly Pyle, AuD, and Candace Osenga, AuD, both clinical instructors at the Eckelmann-Taylor Speech and Hearing Clinic at Illinois State University, for their help with this project.