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Wednesday, June 7, 2017

Where Does the Day Go? Insights From Appointments in a Large Hearing Aid Practice

​By Jennifer Groth, MA; Maulik Bhatt, MBA; Peter Elsig Raun, M Econ; and Andreas Jahn, MSc

It is sometimes said that if you have seen one hearing aid clinic, you have seen one hearing aid clinic. The implication of this statement is that each hearing aid dispensing practice is so unique that observations made of one site cannot be broadly generalized to others. There are certainly differences among practices. For example, a hospital-based audiology clinic will likely be quite different from a small private practice in terms of staffing, caseload, location, management, facilities, and more. However, regardless of setting, the actual procedures that are carried out to fit, follow-up and manage adult hearing aid wearers will mostly be similar. Hearing care professionals (HCPs) are trained to follow best practice guidelines that are intended to lead to reliably positive outcomes (1-3) and these guidelines do not differ substantially from one another depending on clinical setting. Hearing aid users visit practices for the same reasons: for assessment and guidance regarding their hearing, to have hearing aids fit, to have hearing aids fine-tuned, for service of their hearing aids, etc. In all likelihood, the time spent on these different activities will be similar across practices. Thus, if a large sample analyzing the breakdown of appointments for different activities related to hearing aid dispensing were available, the results should be applicable to a large cross-section of practices throughout the world.


There is no shortage of recommendations and proposals for specific procedures HCPs should follow in the hearing aid fitting process. These recommendations are sometimes related to products and services offered by vendors, or they may be scientifically validated tools for assessing or improving some aspect of hearing aid fitting. Regardless, they often come with the encouragement that implementation will add just minutes to whatever procedures are already carried out at the HCP’s practice. In some instances, the tool or procedure is intended to replace a more lengthy, existing practice and therefore represents time savings. It is fairly easy to estimate how much time is required to carry out a particular task. But is the total of the time for all tasks a good estimate of the time for an appointment? HCPs know how much time an individual would be scheduled for particular activities at their own practice and may have some experience with other practices. It is probable that some practices also track and analyze how time is spent to identify opportunities for increased efficiencies. However, to our knowledge, data of this nature has not been made publicly available.

In this article, we present data covering a more than a 9-year period from a large hearing aid dispensing practice with multiple offices serving an adult population. All offices in this practice follow similar procedures, and they keep track of client contact and other data in their practice management software. Examination of the clinical contact time on a large scale can afford valuable insights to other HCPs in regards to their own practices. It can provide a new perspective on how a practice operates, which can be especially helpful for HCPs who may be considering different pricing models. It can also serve as a benchmark for HCPs who may wish to evaluate how time is spent in their own practices.

DATA SOURCE
The data reported here is anonymized, meaning that no information that identified individual clients or HCPs at the practice was made available to GN Hearing. The information that was uploaded included demographic data describing gender, age and audiometric results from clients of the practice, appointments, hearing aid purchase data, and hearing aid fitting data. The data covers full-year periods extending from 2008 to 2015, as well as the first 10 months of 2016. In all, more than 80,000 unique clients accounting for approximately 500,000 appointments are included.

fig 1.jpg
Figure 1. Gender split of clients by year. There are more men than women served by this practice, and the trend is stable over the years covered in the study.

CLIENTS
The practice served more than 80,000 individual clients in the period covered. The client base contains 58 percent male and 42 percent female clients (Fig.1). The higher percentage of male clients is consistent with reports that prevalence of hearing loss in men is greater than in women. Therefore, it is not surprising that this practice has more male than female clients (4,5). However, the gender ratio of clients is lower than the prevalence of hearing loss by gender in the general population. Although the reason for this is not known, it may be that a greater proportion of females with hearing loss perceive a need for and seek hearing help than males with hearing loss. There is some evidence to support this idea, as women with hearing loss have been reported to have greater awareness of hearing issues and to be more likely to accept their hearing loss than men (6). In addition, increased motivation to obtain a hearing aid as well as higher expectations to treatment with hearing aids has been reported for women relative to men (7). Also, once hearing aids have been acquired, there is evidence that women exhibit more regular use patterns than men (8). In further analysis including fitting data, it will be possible to explore gender differences in use patterns based on datalogging of actual use.

fig 2.jpg
Figure 2. Number of persons purchasing a hearing aid for the first time at this practice by gender and age. More men purchase hearing aids at an earlier age than women.

Further insight on gender patterns can be gained by examining first-time hearing aid purchases per age and gender (Fig. 2). Note that this data is for first-time purchases made at this practice. Therefore, some clients must be assumed to already have been hearing aid owners prior to becoming patrons of this practice. For the period covered in this dataset, more than 200,000 hearing aids were sold with an average of 2.5 hearing aids per client; 20 percent were repeat purchases at this practice and the rest were first-time purchases. The largest number of male first-time purchasers occurs at an age approximately 15 years younger than female first-time purchasers. The number of male and female first-time purchasers is equal at the age of approximately 83 years. Above this age, there are more female than male first-time purchasers at this practice. This pattern is consistent with the fact that women have a life expectancy that exceeds that of men by approximately four years in the country where this practice is located. It is also consistent with cross-sectional studies that reported greater prevalence of hearing loss in males than females (9) and that a greater proportion of males acquire hearing loss at an earlier age than females (10).

The average audiogram per gender across all ages is shown in Figure 3. Unsurprisingly, the audiogram for males is slightly less severe in the low frequencies, and significantly more severe in the higher frequencies than the audiogram for females. This is also consistent with other reports (11).  In all, the clients of this practice appear to be generally representative in terms of age, hearing loss and gender for a typical practice serving adults.

                          fi 3.jpg

Figure 3. The average audiogram by gender for all the clients served at this practice. Consistent with the literature, men have slightly less severe hearing loss in the low frequencies, and more severe hearing loss in the high frequencies than women.


fig 4.jpgFigure 4. The percentage of different appointment types (columns) and average time spent for each appointment type (red circles).

APPOINTMENTS
A unique feature of this dataset is that it provides a breakdown of how time was spent in the practice. Figure 4 illustrates the average percentages of 12 appointment types as well as the average number of minutes spent on each. Year-by-year comparison did not reveal large changes in these patterns, although it is known that the practice has changed their protocols in recent years. This could have affected the method of logging the appointments to some extent. A decrease in the time for fine-tuning was observed along with an increase in other service-oriented appointments, suggesting that other service-oriented appointments may sometimes include fine-tuning. Because this detail is unknown and the observed trends were not large, the data shown in Figure 4 is combined for the entire period.

Evaluation, hearing aid fitting, and follow-up accounts for approximately half of all appointments while service-related appointments comprise the other half. Examples of service-related appointments are fine-tuning of hearing aids, exchange of hearing aids and repair/service of hearing aids. Appointments for fine-tuning are the most frequently occurring, comprising 28 percent of the total appointments. Further detail to fine-tuning appointments is that, for those who have purchased hearing aids at the practice, fine-tuning appointments make up 34 percent of the total appointments. For those trialing, but ultimately not purchasing hearing aids, 11 percent of the appointments are for fine-tuning. However, like most of the service-related appointments, fine-tuning visits take relatively little time. The average length of a fine-tuning appointment is 30 minutes, compared to nearly an hour for appointments for hearing aid evaluations and fittings.

As is common in many practices, appointments for follow-up are a planned part of the hearing aid dispensing protocol. Thus, it would be expected that the percentages of appointments for hearing aid fittings and follow-ups would be similar. This is indeed the case for initial follow-up appointments; hearing aid fittings account for 18 percent of the appointments and first follow-up visits for 16 percent. However, fewer than half of clients fit with hearing aids return for a second follow-up appointment. Considering the much higher percentage of appointments for fine-tuning, this could be an indication that clients might prioritize a need for an adjustment over a regularly scheduled follow-up. In other words, after the first follow-up they might consider follow-up to be pursued on an as-needed basis rather than scheduled. It may also be the case that the practice does not encourage second follow-ups as a regular part of their protocol, and thus fine-tuning appointments occur as needed.

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Figure 5. Distribution of time intervals spent for each appointment type. Most appointment types are consistent in the amount of time spent. 

To gain more insight on how time is used at appointments, Figure 5 breaks down each appointment type into time intervals. Interestingly, most appointment types do not vary a lot in the amount of time they take. Repair/Service, Re-test, and HA exchange are the only appointment types where the great majority of appointments do not fall into one time interval. This observation makes sense in that the reasons for, and thus the time needed to deal with, these types of appointments are less predictable than other types. Knowing which appointment types can vary the most in length and which types do not tend to vary much can be helpful in planning staffing and scheduling so as to provide the best service to clients.

Because it is the most common type of appointment, fine-tuning appointments merit further discussion. Eighty-four percent of visits for fine-tuning take 16 to 30 minutes, and 11 percent take 15 minutes or less. Thus, 96 percent of appointments for fine-tuning are less than 30 minutes. This time considers only the actual contact time between the HCP and client, during which relatively little is likely to be spent adjusting and programming the hearing aids. Much of the appointment is spent on waiting, polite conversation, getting situated in the fitting room, discussion of the issue, and trying to assess the success of any adjustments. The actual time used by the HCP, practice staff, and client to make the appointment happen can go far beyond 30 minutes. Bearing in mind that fine-tuning appointments are motivated by experiences that clients have in their daily environments, this might be an area where newer technologies, such as teleaudiology, might improve efficiency and satisfaction for both the HCP and, more importantly, the client. 

fig 6.jpg
Figure 6. Percentage of hearing aid purchasers as a function of how many fine-tunings are required. The vast majority of purchasers have 3 or fewer fine-tuning appointments.

In testing a teleaudiology model, Angley et al (12) reported that participants said timesavings was the most frequently cited reason they were interested in the​concept. The current dataset also shows that more than 70 percent of clients have at least three fine-tuning appointments (Fig. 6). If the fine-tuning could be carried out at their convenience and quickly trialed in their daily environment, this could have a significant impact both for the client and the practice. Even if one physical appointment fine-tuning could be done with the client in their own environment, this would drastically reduce their time investment and inconvenience. Trends in hearing healthcare, such as teleaudiology, and how they might be used to improve efficiency and satisfaction in hearing aid dispensing practices are discussed in more detail elsewhere (13,14).

SUMMARY

It is probable that not many HCPs have analyzed their practices in terms of how time is distributed among the different types of services they provide. This article presented a large set of data characterizing the appointments of a large practice over more than nine years. The clients of this practice appear to be broadly representative based on studies of hearing loss prevalence by age and gender. An analysis of appointments suggested that fine-tuning appointments may present an opportunity where emerging technologies could increase efficiency and satisfaction for both the HCP and clients. The data from this practice could help inform HCPs regarding their own practices.

Ms. Groth is the director of Global Medical Affairs at ReSound, Glenview, IL. Mr. Elsig Raun is senior director of insights and analytics at the Global Marketing and Business Development of GN Hearing in Ballerup, Denmark, where Mr. Bhatt is a global value management and price analyst, and Mr. Jahn is a graduate candidate.

REFERENCES​​
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