New Research from BHI (Methods of Promoting Your Practice)

1
New Research from BHI(Methods of Promoting Your
Practice)

• Sergei Kochkin, PhD.

2
Agenda

• Update of Best Practices impact of hearing aids
  on quality of life
• Impact of hearing aids on income and employment
• Economics of verification and validation on
  private practices
• Positive impact of mini-BTEs on the market
• Prevalence of tinnitus and treatment efficacy
• If time
• Validation of the BHI Quick Hearing Check
• Impact of direct mail and PSAP on private
  practices

3
Promotion

• Goal to leverage positive research findings from
  non-profit BHI to promote your practice.
• Redesign of HHP section on BHI website to make
  resources more accessible
• Our general design for campaigns
• National press release
• Customizable press release for audiologists
• Media handout or backgrounder

4
New HHP Resource Sectionwww.betterhearing.org/p
rofessionals
5
Benefit Quality of Life Changes Associated with
Hearing Aid Usage

• June 2011
• Hearing Journal

6
Method

• Consumers rated on 0-100 scale hearing handicap
  improvement in 10 acoustic environments due to
  their hearing aids.
• Consumers rated 14 QOL changes in their life due
  to hearing aids
• N1,900 for hearing aids lt 4 yrs of age

7
Hearing handicap improvement ()
Mean 55
8
Hearing handicap improvement () for the U.S.
population in 10 listening situations
9
Quality of life changes attributed to hearing aid
usage by hearing aid owners
10
Quality of life changes attributed to hearing aid
usage 75 of hearing aid owners experience
improvement in at least 1 of 14 QOL issues.
11
Consumer satisfaction with QOL changes attributed
to hearing aid usage8 of 10 people are satisfied
with QOL changes in their life due to hearing
aids.
12
Hearing handicap improvement () segmented by
composite best practices ranking scored in
percentiles
13
QOL changes attributed to hearing aids by hearing
aid owners segmented by composite best practices
ranking scored in percentiles
14
Overall consumer success (mean5, std2) by level
of composite best practices ranking scored in
percentiles
Highly vulnerable to disruptive technologies
over-the-counter, direct-mail and personal sound
amplifier Products (PSAP)
15
Summary

• The average benefit (hearing handicap
  improvement) achieved by patients with recent
  hearing aid technology is 55.
• The upper bounds of hearing handicap improvement
  may be in the 65-70 range.
• Wireless revolution and inductive looping should
  improve this figure.
• 75 patients report at least one area of their
  life was improved through wearing hearing aids.
• 8 out of 10 hearing aid users are satisfied with
  the changes that have occurred in their lives due
  to hearing aids
• 9 out of 10 patients are projected to experience
  significant improvements in their QOL once they
  experience a 70 reduction in their hearing
  handicap.
• Strong relationship between quality hearing
  healthcare, benefit and quality of life
  improvements

16
Promotion

• Use the positive findings of hearing aids and
  quality of life in your press releases to promote
  your practice.
• http//www.betterhearing.org/professionals/public_
  relations_campaigns.cfm
• Under 2011 customer satisfaction campaign
• Local press release
• Backgrounder for media
• See how other audiologists are using our material
  sample media clippings.

17
Efficacy of Hearing Aids in Achieving
Compensation Equity in the Workplace

• The Hearing Journal
• October 2010

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Update of 2005 study

• What is the mitigating impact of hearing aids on
  income for hearing aid users compared to
  non-users controlling for demography and hearing
  loss?
• Are people with hearing loss more likely to be
  unemployed?
• Do people with hearing loss believe their
  compensation is equitable compared to their peers
  with equal skills, experience, and education?
• Do people with hearing loss believe they have
  been passed over for promotions?

19
Method

• MarkeTrak VIII database
• Aided 1818 households in which the head of
  household or spouse indicated that one or more or
  them had a hearing loss and that one or both wore
  a hearing aid.
• Unaided 3232 households where neither the head
  of household nor spouse wore a hearing aid, but
  where one or both reported having a hearing loss.
  
• Normal hearing 34,351 households in which
  neither the head of household nor spouse reported
  having a hearing loss.

20
Method

• People with hearing loss segmented into ten
  hearing loss groups (deciles) based on subjective
  information (via factor analysis)
• Ears impaired
• Gallaudet scale
• Subjective evaluation of loss
• BHI Quick Hearing Check (15 items)
• Plomp difficulty of hearing in noise scale
• Controlled for demography (household composition,
  age, geography and degree of hearing loss) in
  calculating income per household.

21
Income declines as a function of hearing loss
Mild
Moderate
Severe
22
Significant divergence in income profiles for
aided and unaided households
Moderate
Mild
Severe
23
Estimated Income loss (000) compared to normal
hearing households (n34,351) by severity of
hearing loss for aided (n1,818) and unaided
(n3,232) households
24
Salary differential (000) between aided and
unaided subjects by severity of hearing loss in
deciles
(000)

• Mitigating impact of hearing aids for mild HL
  90-100
• Mitigating impact hearing aids for moderate to
  severe HL 77 - 65
• The estimated cost in lost earnings due to
  untreated hearing loss is 176 billion
• cost to society in terms of unrealized federal
  taxes is 26 billion.

25
Unaided individuals have significantly higher
unemployment ratesSegmentation in hearing loss
quintiles Considering only individuals still in
the workforce
26
Key findings

• No evidence that people with hearing loss
• feel passed over for promotion more than normal
  hearing subjects.
• feel discriminated against in the workplace with
  exception of older people with hearing loss.
• Hearing aid efficacy
• Use of hearing aids have significant impact on
  achieving compensation equity for people with HL
  in the workplace.
• Unaided subjects more than twice as likely to be
  unemployed.

27
Leveraging these findings

• Cost to individual and society is very large and
  needs to be leveraged
• Convince people with HL to seek early solution to
  their hearing loss.
• Convince HR executives that aided individuals are
  good for their corporations.
• Convince politicians that tax credits will help
  people with hearing loss become more productive
  citizens

28
Leveraging income study in media

• Tools on BHI website

• 1 page media or patient handout
• Detailed fact sheet on income study for media and
  patient
• OpEd pieces which may be modified to promote
  audiology practice
• Handout to Human Resource executives
• Sample media clips from colleagues
• Customizable press release
• The original publication

29
Examples of leveraging income study in media

• Current OpEd Piece

• Sample Private Practice Ad

30
Example Leveraging income study in media
31
Mini-BTEs attract new market, users more
satisfied

• Hearing Journal
• March 2011

32
Introduction

• BTE hearing aids represented less than 20 of
  hearing aid sales prior to 2000.
• With introduction of open-fit hearing aids and
  receiver-in-the-canal hearing aids (RIC), BTEs
  now represent 63 of all hearing aid sales.
• In looking at the resurgence of BTE hearing aids,
  we wanted to answer two key questions
• Did mini-BTE hearing aids result in market
  expansion?
• Do mini-BTEs improve the consumer's experience
  with hearing aids?

33
Hearing aid style mix () CY 2005-2008Source
MarkeTrak VIII Database
34
Method

• Simple comparison
• Mini-BTE users
• Traditional style users
• First look at demography

35
DemographyMini-BTE versus traditional style HA

• No age differences between the two samples
• Mini-BTE users
• more likely to appeal to males 64 versus 58
• on average earn 15,000 more per year
• more likely to be married (72 versus 61)
• more likely to be in the work force (38 versus
  26)
• have a less severe hearing loss and less
  difficulty hearing in noise
• more likely to purchase binaural hearing aids and
  more likely to have a bilateral loss
• more likely to be a new users (59 versus 41)
•  

36
Customer satisfactionMini-BTE compared to
traditional styleControlling for degree of
hearing loss (ANCOVA)

• Overall satisfaction ratings are significantly
  higher for mini-BTE hearing aids (85 versus 76)
• No significant differences in
• perceptions of benefit or value (despite higher
  ),
• hearing aids in the drawer
• brand loyalty

37
Customer satisfactionMini-BTE compared to
traditional styleControlling for degree of
hearing loss

• Significant differences with corresponding
  practical significance (10 or more)
• Product variables visibility, warranty
• Sound quality variables all 13 variables
  measured
• 4/19 listening situations performance on cell
  phones, telephones, in large group situations and
  in the schoolroom/classroom
• lower on ability to control volume

38
Key findings

• Did not tap into younger segments of people with
  hearing loss.
• But is expansionary influencing HA purchases by
• more affluent
• more active and elderly consumer segments
• with milder hearing losses
• Controlling for degree of hearing loss mini-BTE
  hearing aids would appear to offer significant
  improvements in
• overall satisfaction
• cosmetics
• sound quality
• multiple environmental listening utility (MELU)

39
Promotion

• Promote the positive benefits of mini-BTE based
  on BHI on consumer feedback
• overall satisfaction
• cosmetics
• sound quality
• multiple environmental listening utility (MELU)

40
Economics of Verification and Validation on
Private Practices

• Hearing Review
• June 2011

41
Introduction Time is Money!

• In Best Practice publication it was determined
  that the number of patient visits to adjust the
  hearing aid were highly correlated with
  real-world success.
• Comparing patients who experienced above or
  below average success with their hearing aids the
  following was discovered
• 76 of above average patients were fit in 1-2
  visits compared to 40 of below average patients
• 47 of below average patients required 4-6 visits
  to fit their hearing aids compared to 7 of above
  average patients.

42
Introduction Time is Money!

• Highly successful patients required fewer visits
  to the clinic.
• What could explain this difference in number of
  visits?
• Hypothesis lack of verification (real-ear
  measurement) and validation (confirmation of a
  patients performance with their hearing aids)
  during the hearing aid fitting increased the
  number of patient visits. For some patients the
  result was
• Less than optimum fit,
• reduced hearing aid utility,
• mediocre benefit each of
• End result rejection and return of the hearing
  aids for credit.
• In this study we will explore the relationship
  between verification, validation and patient
  visits.

43
Percent of patients reporting that verification
and/or validation was used during the hearing aid
fitting process (New hearing aids, n787)
44
Average patient visits to fit hearing aids based
on use of verification (REM) validation
procedures (objective or subjective).
Patient visits3.57 REM.75 validate1.02
VV.6
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Simulating Impact of V V

• In 2010, nearly 2.7 million hearing aids were fit
  in the U.S. hearing aid market representing over
  1.5 million patients (binaural rate74.3 in
  2008).
• Assuming the same distribution of best practices
  as noted by patients and the estimate of reduced
  patient visits.
• The systematic utilization of both verification
  and validation procedures while fitting hearing
  aids will reduce patient visits by a total of
  521,779 visits.
• This is an opportunity available for every one of
  the 64 of U.S. practices not utilizing both
  verification and validation.

46
Simulating Impact of V V

• Assuming 45 minutes a visit
• inclusion of these best practices could reduce
  the time spent with patients in fitting hearing
  aids by 391,334 hours in a single.
• Manpower cost _at_144 per hour 56.3 million
• Much higher cost when you consider lost revenue
  due to hearing aid returns (18.6 national
  average)
• This additional time frees the hearing healthcare
  professional for additional counseling,
  marketing, community outreach or in fitting new
  patients with hearing aids.
•  

47
Prevalence of Tinnitus and Efficacy of Treatments

• Co-authors
• Richard Tyler U of Iowa
• Jennifer Born - ATA
• Hearing Review
• November 2011

48
Introduction

• 40 of non-adopters do not see audiologists for
  their hearing loss because they have tinnitus and
  believe nothing can be done. (MarkeTrak VII).
• Thus they suffer from both untreated hearing loss
  and tinnitus.
• Need to convince people with tinnitus that by
  visiting an audiologist you can help them manage
  their tinnitus.

49
Method

• 80,000 household MarkeTrak survey where we added
  to our normal screening survey Does anyone in
  your household have tinnitus (ringing in their
  ears). captured up to 5 family members.
• Scales time of day experienced, loudness,
  annoyance
• Impact on life
• Efficacy nine treatment methods
• Hearing aids Direct probe

50
Tinnitus population (millions, 2008)
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Population Commentary

• Approximately 30 million experience persistent
  tinnitus (10 population)
• Around half of hearing aid owners and
  non-adopters report tinnitus
• Another 13 million people are aware of their
  tinnitus but not hearing loss
• The market for hearing healthcare much larger
  than thought

52
Incidence of tinnitus by age group. Incidence
derived by comparing age population from NFO
panel with U.S. Bureau of Census population in
2008.
53
Tinnitus Demography Commentary

• Peaks at ages 65-84 85 drop due to
• Lack of family member awareness
• Non-survey of nursing homes
• Tends to affect
• Lower educated
• Smaller rural communities
• Retirees and those on medical disability
• Single people
• Lower income

54
Severity of Tinnitus(Means on 0-100 scale
n3,187)

• time of day 49
• Loudness 41
• Annoyance 39
• Disabling estimate (70-100) 22
• Key QOL impact
• Ability to hear
• Ability to concentrate
• Ability to sleep

55
Impact of tinnitus on quality of life (n3,431)
56
Efficacy of treatments (n3,473 on 0-100 scale)

• Aided awareness on 9 treatments
• Hearing aids music medication relaxation HHP
  counseling Non-wearable sound generator
  herbs/dietary supplements wearable sound
  generator psychological counseling
• Consumer asked
• If they tried treatment for their tinnitus
• 0-100 scale on efficacy or tinnitus mitigation.

57
Efficacy of Treatments

• No method tried by more than 7 of people.
• Hearing aids were not viewed as a treatment.
• Highest rated (median mitigation)
• Hearing aids (34)
• Music (30)
• Relaxation techniques (10)

58
Direct Query on Hearing Aids.Effectiveness in
mitigating effects of tinnitus (n1,314)
59
Direct QueryHow often hearing aids are effective
in mitigating effects of tinnitus (n553)
60
Greater chance of tinnitus mitigation with
hearing aids when best practices used in hearing
aid fitting (n732)
61
Opportunity

• People may not visit you for their hearing loss
  but they may if you hold the promise of relief
  for their tinnitus.
• The market for hearing healthcare is dramatically
  expanded when you consider
• 40 of non-adopters with hearing loss not
  visiting audiologists because they have tinnitus
• 13 million additional with tinnitus reporting
  they do not have hearing loss

62
Promotion

• Move toward ADA sponsored Tinnitus Management
  Certification Program if you do not have the
  credentials now for tinnitus management.
• Review BHI material on setting up a tinnitus
  clinic.
• Distribute BHI Guide to Tinnitus

63
Promotion

• Take a course in Cognitive Behavioral Therapy.
• Learn about tinnitus management resources and
  outcome measures.
• Read and distribute a good consumer handbook on
  tinnitus to your patients with tinnitus.

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Promotion

• Learn from your peers on how to promote tinnitus
  in your practice.
• Look for updated Opinion Editorials from BHI in
  the future.
• Set correct expectations on tinnitus mitigation
  with HA
• 30 moderate substantial relief
• Could be 50-60 with best practices.

65
The Validity and Reliability of the BHI Quick
Hearing Check

• Kochkin, S. and Bentler, R. The Hearing Review
• November 2010

66
Introduction

• Key obstacle to hearing aid adoption is awareness
  of degree of hearing loss
• 50 of people admitting hearing loss have never
  had their hearing tested professionally
• Have insufficient information to seek a hearing
  solution and to visit an audiologist
• Problem recognition is a precursor to problem
  resolution

67
Introduction

• Wide-scale availability of simple self-measures
  of hearing loss may influence increased
  throughput into audiologist offices
• BHI adopts the American Cancer Society and
  American Diabetes Association models with online
  testing Are you at riskif so visit an
  audiologist

68
BHI Quick Hearing Check

• 15 items standard signs of hearing loss.
  Sample items
• I have a problem over the telephone
• I have trouble understanding things on TV
• I have to strain to understand conversations
• Many people I talk to seem to mumble
• Based on AAO-HNS 5 minute test
• Revised by Koike and validated on small sample
  (n74) but not in use today

69
BHI Quick Hearing Check

• BHI adopted the test
• Changed to 5 point Likert scale (Strongly agree
  Strongly disagree)
• Validated on 11,000 subjects using 4 databases
• NCOA database self perceptions
• NCOA database spouse perceptions
• MarkeTrak VIII database self perceptions
• Objective HL information from 64 clinics on 987
  patients
• Audiogram (5 frequencies)
• Speech discrimination scores

70
BHI Quick Hearing Check reliability

• Separate factor analysis of NCOA and MarkeTrak
  database items demonstrate one dimension
• Unidimensionality means we can add the items
  together
• Reliability (internal consistent Cronbachs
  alpha) very high where a score of 100 is
  perfection
• NCOA database 95
• MarkeTrak 94

71
Objective Validity

• Correlation between audiogram information and BHI
  Quick Hearing Check

72
Relationship between the BHI Quick Hearing Check
and average speech threshold scoresModel
better ear
73
Relationship between the BHI Quick Hearing Check
and average threshold scoresModel 5PTA both
ears
y 25.38 .6787x R2 .84
74
Probability of hearing loss of 40 dB (both ear
average) or higher based on BHI Quick Hearing
Check scores
75
Subjective Validity

• Correlations between subjective measures of
  hearing loss and the BHI Quick Hearing Check

76
Average BHI Quick Hearing Check Score by level of
performance on the Gallaudet Scale
Self-ratings MarkeTrak VIII N7,201, r.49
77
Average BHI Quick Hearing Check Score by level of
self and family member perception of hearing loss
78
Average BHI Quick Hearing Check score by level of
Plomps difficulty of hearing in noise scale
Self ratings MarkeTrak VIII N7,201, r.64
79
Concurrent Validity

• BHI Quick Hearing Check correlations with issues
  tangentially related to hearing loss

80
Scores on the BHI Quick Hearing Check correlated
with QOL issues

• According to spouses of people with HL
• Concerns about safety
• Family accommodation
• Rejected by others
• Withdrawal
• Difficulty in communication
• Independence of person
• Effect of hearing loss on family
• Compensatory behavior
• Cognitive functioning
• Self confidence
• Discrimination against individual
• Anger frustration
• Emotional stability
• Introversion

• According to individual with HL
• Anger frustration
• Withdrawal
• Impact of hearing on health
• Phobia symptoms
• Paranoia
• Overall health and pain assessment
• Anxiety symptoms
• Activity on phone with social network
• Depression symptoms
• Problems with friends
• Problems with all relationships

81
Promotion using the new BHI online hearing test

• Complete redesign of BHI online hearing test
• URL created
• www.hearingcheck.org
• Items presented one at a time with background
  photo
• Internet banner ads now directing traffic to the
  test as well as Google ads
• BHSM initiative similar to American Diabetes and
  Cancer risk test campaigns.

82
BHI Online Hearing Test

• Comprehensive report
• BHI Quick Hearing Check score
• Norm compared to U.S. population with HL
• Estimated dB loss better ear speech range
• Estimated dB loss 5 tone PTA both ears
• Probability HL gt 40 dB in both ears
• Subjective classification of HL based on consumer
  perceptions (standard audiological classification
  judged too conservative based on consumer
  perceptions)
• Recommendation

83
Using the new online hearing test at BHI

• Encouraging hearing health industry to link to
  this online hearing test at www.hearingcheck.org
• Developed logos for hyperlinking. Placement on
  your website
• Also available in paper-and-pencil form
• Drug store
• Ads
• Chiropractor offices
• Health fair handout

84
Impact of Direct Mail and Low Cost Listening
Devices on Hearing Aid Sales

• Hearing Review
• June 2010

85
Introduction

• Low cost listening devices (PSAPs) and direct
  mail hearing aids have been available for at
  least 25 years.
• PSAPS
• Price range 20-50
• Some infomercials 2 for 19.95
• Most notable historically Whisper 2000
• Legal as long as they dont target people with
  hearing loss.
• Direct mail
• Products such as Crystal Ear usually sells in the
  300 range
• Some DM firms even allow consumer to take their
  own ear impressions
• Legal in many states with medical waiver

86
Introduction

• Recent proliferation of devices with extensive
  television ads.
• Lee Majors Bionic Ear
• Silver Sonic XL
• Loud Nclear
• dozen others
• Apparently tend to be introduced close to
  recessions
• How many people with hearing loss are using them?
• Do these devices cannibalize legitimate hearing
  aids sales?
• How do people with hearing loss rate these
  products?

87
Sample products
88
Resurgence of Internet, DM and over-the-counter
sold hearing aids
89
Direct mail firms selling pre-programmed digital
open fit hearing aids (400-895)
90
Increased trend in non-owner purchase of
listening devices

• Use less expensive device in place of hearing
  aids
• MarkeTrak III (1993)
• 2.6 somewhat a reason
• 1.1 definitely a reason
• 3.7 Total
• MarkeTrak VII (2004)
• 5 somewhat a reason
• 3 definitely a reason
• 8 Total
• MarkeTrak VIII (2008) analysis to follow

91
Relative internet ranking (000)Internet ALDs
versus HIA members
Note Lower ranks denote higher traffic
92
Estimated web visitors per monthALDs versus HIA
membersALD Songbird, Sonic XL, Loud n Clear,
Ampli-ear
2008
2009
93
Summary demographyCustom vs DM vs PSAP
Demography Custom Direct Mail PSAP
Male 59 71 53
Age (mean) 71 71 66
Income (Median) 41k 31k 31k
Income (Mode) 112k 21k 24k
Employed () 29 28 35
Marital Status () 62 52 57
Binaural HA () 76 41 n/a
Yrs aware of HL -Mean 7 8 15
94
Targeting

• Direct mail hearing aids are marketed to
  compensate for hearing loss where legal
• Some calling them PSAPs
• Due to legitimization of them by FDA
• PSAPs not sold to compensate for hearing loss
• But here are some of the PSAP ad messages
• Never miss another word at lectures, movies,
  shows, or even church
• Turn up the volume on what people around you are
  saying
• Listen at the level you want without disturbing
  others
• Hear a pin drop from across the room
• Turns ordinary hearing into extraordinary hearing
  

95
Hearing loss distribution

• What is the hearing loss profile of DM and PSAP
  customers
• People with admitted hearing loss
• Compared to your typical patient
• And what is the likelihood PSAPs took business
  away from you?

96
Hearing loss decile distribution of owners of
custom hearing aids, direct mail hearing aids and
personal sound amplifying products (PSAP)
Decile 50 or higher 83 79 72
97
Likelihood of purchasing custom hearing aids in
absence of PSAP as reported by non-owner
population
Overall likelihood 17.8
98
The numbers please!

• 3.28 (280,000 people) of hearing aid owners
  indicated they received their hearing aids by
  direct mail (2008)
• 3.68 (270,000) were direct mail hearing aid
  owners in 2004
• 4.79 of the non-adopter population uses PSAPs
  representing 1,237,700 people
• Total market 1.5 million people with hearing
  loss.

99
Cannibalization

• Probable cannibalization of custom hearing aid
  market by PSAP owners approximately 17.8
• Translating into 220,310 PSAPs probably siphoned
  off from the custom hearing aid market
• Considering a four year purchase cycle the
  hearing aid industry is probably losing about
  55,000 patients a year

100
Conclusions

• Approximately 1.5 million people with hearing
  impairments use either direct mail or personal
  sound amplification to compensate for their
  hearing loss.
• Number much higher if you consider
  over-the-counter pre-programmed hearing aids at
  Walmart, Drugstores, Sams Club, etc.
•  
• Users of these devises on average have incomes
  10,000 less than custom hearing aid users.
•  
• 3 out of 4 PSAP or direct mail hearing aid users
  have hearing loss profiles equivalent to the
  custom hearing aid user
•  
• The PSAP user has been aware of their hearing
  loss on average for 10 years compared to 3 years
  for the typical hearing aid user (median).

101
Conclusions

• Little doubt that PSAPs are used to compensate
  for hearing loss
• Estimate that less than 18 of PSAP users
  substituted personal sound amplification products
  for custom hearing aids
• In the absence of PSAPs in the market place in
  all likelihood the majority would have lived with
  their hearing loss

102
Promotion

• Markets are perfect! Products and services will
  be developed and introduced to meet unmet
  consumer needs.
• The best strategy is to practice BEST PRACTICES
• Share our eGuide and press on How to Buy Hearing
  aids and let the public know this is the ONLY
  hearing solution.
• Share our press release BHI Warns on
  Do-it-Yourself Hearing Care.

103
Acknowledgement

• All MarkeTrak research is made possible by a
  special grant from Knowles Electronics.