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Instead of a hearing aid evaluation, let's assess functional communication ability

Sweetow, Robert W.

doi: 10.1097/01.HJ.0000295755.39258.9a

The author proposes that the basic battery of measures now used to evaluate a hearing aid fitting be replaced with an assessment of how effectively a patient's treatment enhances his or her ability to communicate.

Robert W. Sweetow, PhD, is Director of Audiology and Professor of Otolaryngology at the University of California, San Francisco, and co-developer of LACE (Listening and Auditory Communication Enhancement) training.

Readers may contact Dr. Sweetow at



Periodically, governments, businesses, and professions must reassess their mission and goals in order to sustain their competence and maintain their relevance. The objective of this paper is to propose a variation in our profession's direction and to provide a general road map toward rendering this change viable.

Specifically, I am advocating that the generic “hearing aid evaluation” be replaced by a “Functional Communication Assessment” designed to yield results that will lead to an “Individualized Communication Enhancement Plan” (ICEP) for every patient.

This Functional Communication Assessment would be a battery of objective and subjective measures intended to assess residual auditory function beyond what can be determined by pure-tone and monosyllabic word-recognition-in-quiet testing. From these data, an ICEP would be constructed that would contain any or all of the following: education and counseling, communication strategies, individualized auditory training, hearing aids, assistive listening devices, and group education and therapy.

The goal of this proposal is to shift our focus from one that is product-oriented (i.e., centered around hearing aids) to one that is process-oriented (centered around enhancing communication).

The reason for this change is straightforward. Hearing aids are designed to provide access to acoustic information. However, communication, the ultimate objective for our patients, incorporates not only hearing, but also listening skills, cognitive-based interpretation, and communication strategies.1,2

Hearing aids may (or may not) be one component of an overall rehabilitation plan, but a rehabilitation plan is not a component of a hearing aid fitting. In other words, the current tendency to supplement hearing aid fittings with additional therapy is misguided. Instead, hearing aids should supplement the global plan of communication treatment.

Dispensing hearing aids is vital and it's a noble pursuit. In my counseling courses, I frequently quote the statement “selling is the transference of passion in the presence of need.”3 But when Dr. Raymond Carhart pioneered the field of audiology, he intended it to comprise both diagnostic and therapeutic functions.4 When the primary focus is placed on hearing aids, it may inadvertently create an unnecessary restriction on our ability to provide comprehensive care, and this can send the wrong message to patients and other stakeholders.

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Many professionals believe they are providing rehabilitation services merely by presenting instructions to accompany hearing aid fittings. Others argue that it is impractical to provide rehabilitation because such services take too much time and are not reimbursable.

I disagree with both contentions. There are numerous methods for providing rehabilitation services that do not require significant professional time. Hawkins presented an evidence-based review of the benefits gleaned from group-based AR.5 Formal instruction in hearing aid and accessory management can lead to increased usage,6 and, therefore, to enhanced function and activity when summed over time.5,7

Group instruction can deliver both education and emotional support. There are abundant resources of content and material for group AR.8–10 Evidence exists to support the efficacy of such programs in terms of reduced return-for-credit rates, increased usage, and greater initial patient satisfaction.11,12

Group-based aural rehabilitation may not always meet the needs of the individual patient. For this, it may be helpful to provide individual auditory training. Sweetow and Palmer conducted an evidence-based literature review that demonstrated the potential benefit of these services.13

Evidence is also emerging that clearly demonstrates that patients who complete individual auditory training (AT) such as LACE14 have significantly lower return-for-credit (RFC) rates on new hearing aid purchases.15–17 A recent issue of Seminars in Hearing offered a number of papers illustrating the plethora of new auditory training programs using computer technology.18

The argument that hearing healthcare professionals are not reimbursed for therapeutic services previously had merit, because, unfortunately, audiology has been assigned a Standard Occupational Classification (SOC) listing as a diagnostic rather than a therapeutic profession. However, last year, the Centers for Medicare and Medicaid Services (CMS) created new CPT codes (92626 and 92627) that implicitly recognized the need for an appraisal of residual auditory function beyond what the pure-tone audiogram provides.

At the same time, CMS established an Auditory Rehabilitation: Post-lingual hearing loss CPT code (92633) for therapeutic intervention. Regrettably, it stopped short of explicit recognition of the need for auditory rehabilitation by listing the code but not allowing for Medicare reimbursement. Audiologists continue to criticize the SOC code, as it impacts their ability to obtain reimbursement from Medicare, while also giving private insurers a rationale for denying reimbursement for these services.

This is an area in which audiologists should emulate their colleagues in speech-language pathology, who do not face these limitations on reimbursement for their therapeutic efforts. We need to state a clear objective to provide our own version of an “individualized educational plan” for every patient.

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A Functional Communication Assessment (FCA) should ascertain the practical abilities and needs of the individual patient. This is information that cannot be obtained directly from basic testing (i.e., pure-tone audiometry and speech-recognition testing in quiet). The assessment does not require a battery of new tests. Rather, it can be done using existing test procedures that are underutilized.

Each of the test results yielded by the FCA should lead to the rationale contained within the ICEP, as explained below. Table 1 lists some of the practical measures currently available that exemplify the concept of looking beyond the audiogram to define residual auditory function in a clinically appropriate time frame. The measures listed in Table 1 were selected because they generally require less than 5 minutes of the clinician's time to administer and score.

Table 1

Table 1

Of course, it would not be practical to conduct all these measures on every patient. But a minimum of one or two subjective measures to help determine the patient's needs and one or two objective measures to help define the patient's functional abilities should be conducted. In addition, newer approaches such as the Performance Perceptual Test19 offer the means to compare individuals' objective performance with their subjective impressions of their own performance. This can lead to important counseling as well as further training considerations.

Thus, as shown in the example, all the information from the FCA that is needed to create an ICEP can be obtained in about 15 minutes. The selection of which measures are appropriate for a given patient is not predetermined and should remain flexible so it can be based on the individual's case history and the information gleaned from other test measures.

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The components of the ICEP (see Figure 1) depend on the results of the FCA. It is essential to introduce the concept of the FCA and ICEP to the patient at the very outset of the process. When patients call to request an appointment for a hearing aid evaluation, they should be informed that they can expect the following steps to occur:

Figure 1

Figure 1

  • They will be given a comprehensive interview along with written questionnaires to help the professional and patient establish their specific history and communication needs.
  • They will be given a comprehensive battery of hearing and listening tests to assess their ability to hear soft sounds as well as to understand speech in quiet and in noise.
  • They will be provided with an individualized communication enhancement program that may include any or all of the following:
    • ○ a plan for learning about their particular hearing loss
    • ○ a training program that may be completed at home or in the clinic
    • ○ hearing aids fitted to their specific hearing loss and communication needs and/or other hearing assistive devices, including alerting and listening devices, and subsequent detailed instruction and demonstration regarding the use and care of these devices
    • ○ a workshop to learn more about living effectively with hearing loss
    • ○ counseling for the patients and members of their support system to enhance participation and address emotional and practical limitations
  • They will be offered at least one return visit to assess the effectiveness of the communication program.
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Following is an example of an FCA battery and the resultant ICEP. Note that the information acquired from this test battery would not have been obtained from basic audiometry and speech-recognition tests.

A 68-year-old female presented with a rather nebulous complaint of “difficulty hearing her daughter and grandson.” Audiologic testing revealed a bilateral asymmetrical mild to moderate hearing loss with thresholds approximately 15 dB better in the high frequencies in her left ear. Word-recognition scores in quiet were 82% in her left ear and 60% in her right ear. She had tried hearing aids for a week 2 years prior and returned them because they were “more annoying than helpful.”

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The FCA included the HHIE-S, which the patient completed while waiting in the reception area. The results indicated that the patient was not only limiting her social contacts because of her hearing loss but that she was frustrated and having arguments with family members. Because it was likely that hearing aids would need to be part of the ICEP, an ECHO was administered and the results suggested that the patient had unrealistically high expectations about what hearing aids should be able to do for her.

Objective tests included a Quick SIN and an ANL. The Quick SIN score of +9 dB SNR reflected significantly greater difficulty understanding speech in noise than would have been predicted based on her word-recognition scores in quiet. ANL test results agreed with the Quick SIN and showed that the patient was adversely affected by even relatively low levels of background noise.

In view of the asymmetry, a binaural interference test was administered and the results suggested that her performance improved when she received speech in both ears rather than in her left ear only. The total time added to the session was 15 minutes.

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The information collected in the FCA led to these recommendations in the ICEP:

  1. The patient was asked to have her family members accompany her on the next visit in order to educate all parties to recognize that compromises were necessary by both the patient and her family members to allow for better communication. A written list of communication strategies was provided.
  2. The patient and her family were strongly encouraged to participate in group education and social support classes at no additional charge.
  3. It was decided to try a binaural fitting despite the asymmetry, given the results of the binaural interference test.
  4. The patient was counseled extensively regarding realistic expectations.
  5. Given the patient's difficulty in noise, it was recommended that she participate in home-based auditory training.
  6. When the patient returns for a check of her performance with the hearing aids and her communication in general, a PPT will be administered to determine if her subjective impression of her auditory abilities is consistent with her actual performance.
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When we give patients a product orientation rather than a goal orientation, we increase the likelihood that the patient will experience failure and disappointment. If that occurs, patients may blame the fact that their (unrealistic) expectations were not met on the hearing aids or on the hearing healthcare professional rather than taking responsibility for helping themselves by enhancing their communication skills through the multitude of tools we have at our disposal.

Pioneers of aural rehabilitation (many of whom form the core of the Academy of Rehabilitative Audiology), such as Ross, Erber, Tye-Murray, Kricos, McCarthy, Gagne, Boothroyd, Holmes, Preminger, Thibodeau, and many others whom I am unintentionally omitting have long recognized the importance of offering comprehensive rehabilitation to all patients seeking the help of hearing healthcare professionals. Many of us did not heed their recommendations because of practical concerns and limitations. But, as I explained earlier, I believe these concerns are no longer valid.

Some practitioners find it difficult to overcome the inertia that grips our profession regarding the order and degree of importance of the various components in the rehabilitation of patients with impaired hearing. Consider, for example, how long it took the average audiologist to incorporate otoacoustic emissions measurement into the clinical battery.

It is time to expand our battery of tests to truly establish each patient's residual auditory function and communication needs. Children with special needs receive an individualized education plan (IEP). Why should adults be treated any differently?

It is our ethical obligation to ensure that patients and those close to them understand the complexities of human communication and the importance of their collaborative participation in a comprehensive approach to maximizing residual auditory and communication abilities.

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