Do Hearing Aid Audiologists Need Evidence Based Practice

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Do Hearing Aid Audiologists Need Evidence Based
Practice?

• Brian Taylor, Au.D.
• Global Training Manager
• Amplifon, Milan, Italy

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The Evolution of Health Care

• Patient Centered Model
• Lets learn as much as we can about your
  condition, and match the treatment to the
  disease, using the best available evidence to
  guide us.

• Medical Model
• You have a disease, take this pill.

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My Bias

• How is Cuba and the hearing aid selection
  process alike??

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Clinical Decision Making Process

• Intuition and experience
• Obsolete knowledge gained in school
• Long-standing traditions
• Information learned from manufacturers
• Copy what others are doing well (Best Practice
  Approach)
• Evidence from well designed, clinically relevant
  studies (EBP Approach)

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Review of EBP

• What is it?
• How does it work?
• Why is it important?
• Its not new 1995 first audiology papers appeared

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What is it?

• A way to make clinical decisions using current
  best evidence. Does our recommendation work under
  real world conditions?

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How?

• Generate a focused, clinical question
• Find the best evidence
• Evaluate the evidence
• Generate a recommendation using the evidence
• Cox, 2005

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Step 1 Generate a Focused Question
Is Digital Noise Reduction (as implemented in
digital hearing aids) effective in real world
listening situations in an adult population?
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Step 2 Go to Pub Med and conduct key word
searches

• Digital noise reduction
• Hearing aids 46
• A. Benefit 10
• B. Satisfaction 5
• C. Clinical Effectiveness 2
• D. Usage 0
• E. Real World 2

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Step 3 Narrow the Search

• Carefully read all the abstracts (15)
• Eliminate all those that pertain to children, and
  implement DNR in analog hearing aids (e.g., ASP)
• Those that make the cut (9) carefully read the
  entire article
• Eliminate all those that didnt use actual
  hearing aids, or were conducted in lab conditions
  only (5)

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Step 4 Grade the Evidence

• Pay attention to
• Number of subjects (N 25 or more)
• Blinding of subjects
• Blinding of authors
• Study design
• Grade the evidence based on the study design

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Step 5Make a Recommendation Based on Your
Reading of the Evidence
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Levels of Evidence

• Level 1a Meta-analysis of well-designed
  randomized control trials
• Level 1b Well-designed randomized control
  trials
• Level 2a Well-designed controlled study without
  randomization
• Level 2b Well-designed quasi-experimental study
• Level 3 Well-designed non-experimental study
  (case studies)
• Level 4 Expert opinion or consensus statement

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Study Design

• Randomized
• Subjects are assigned to one of two groups
  (treatment and control) using a specific
  randomization method

• Non-Randomized
• A study that does not use a control group

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Practical Short Cut

• Look for published meta-analysis
• Peer reviewed July/Aug 2005 JAAA
• Non-peer reviewed Audiology Online
• AAA Clinical Protocol Guidelines Valente,
  Audiology Online

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Why?

• Improves credibility of profession
• Improves quality of care (effectiveness)
• Improves efficiency of care (costs)
• Bess, 1995
• 4. Boosts confidence of service provider

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EB Concept in Practice

• Used to modify or change current clinical
  practices or bahaviors
• Used to make better hearing aid selection
  decisions

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Practices (examples)

• LDL testing at pre-fitting appointment
• Speech audiometry quiet vs. noise, words vs.
  sentences, live vs. recorded voice
• Counseling gain for experienced vs. new hearing
  aid users, when is maximum benefit achieved
• Use of probe microphone to verify a prescriptive
  fitting target

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Popular clinical practice

• Using the thresholds on the audiogram to predict
  real world hearing aid benefit.

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Audiogram
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Conclusion

• Audiometric data is a poor predictor of real
  world benefit.
• Personality seems to be a better predictor of
  success with amplification than the audiogram
  (Cox, et al, 2007)

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Popular clinical practice

• Relying on marketing claims to make decisions in
  regard to advances hearing aid features.

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April, 2007 Hearing Journal

• Best-in-class feedback cancellation
• Hands-free advanced directional systems
• More bandwidth for more speech access
• 360 degrees of directionality
• Most sophisticated DSP platform

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In practice

• Modulation based DNR is on 89 of all my fittings
  (Johnson, HJ, 2008)
• DNR improves speech intelligibility in noise

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EB Review of DNR

• No significant improvement is speech
  intelligibility with DNR on (less than 10
  studies in peer-reviewed journals)
• Limited studies (4 or 5 ) show that DNR improves
  listener comfort
• Bentler, JAAA, 2005 EB review of DNR

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Conclusion

• Although DNR does not improve speech
  understanding in noise, there is evidence from
  well designed studies saying it DNR does improve
  listening comfort.

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Back to the original question.

• Do audiologists need evidence-based practice?
• Hint Its about the consumer, not the profession

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Benefits of EBP for the Hearing Aid Audiologist
in the UK

• More efficient appointments
• Waste less time doing unnecessary tests
• Make better selection decisions (rely less on
  hunches)
• Challenge marketing claims presented to you by
  manufacturers (Wheres the Beef)
• Improved confidence in recommendations
• Results in higher levels of patient satisfaction
  and business revenue

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• Thanks for your attention
• Brian.taylor_at_amplifon.com