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The Ear Foundation Hearing and Communicating in a Technological Era The Latest Hearing Technologies: Uptake and Evaluation [Confidential Report for NHS Innovations] The Ear Foundation [2011] The Ear Foundation, 2011 Contents Contents ..................................................................................................................... 2 Executive Summary ................................................................................................... 3 1. Introduction ............................................................................................................ 6 2. Hearing Aids in the UK ........................................................................................... 9 2.1. Hearing aid provision ....................................................................................... 9 2.2. Hearing aid market ......................................................................................... 10 2.2.1. Public vs. Private ..................................................................................... 10 2.2.2. Retail vs. Wholesale ................................................................................ 12 3. Perspectives of individuals with hearing loss ....................................................... 16 3.1. Background .................................................................................................... 16 3.2. Patient journey ............................................................................................... 16 3.3. Hearing aid owners and non-owners ............................................................. 17 3.4. Buying/obtaining intentions ............................................................................ 18 4. Other Hearing Technologies ................................................................................ 20 4.1. Cochlear Implants .......................................................................................... 20 4.2. Electric Acoustic Stimulation .......................................................................... 23 4.3. Bone Conduction Hearing Aids ...................................................................... 23 4.3. Middle ear implants ........................................................................................ 26 4.4. Brainstem implants ........................................................................................ 27 5. Assistive Technologies ......................................................................................... 28 5.1. FM amplification technology ........................................................................... 28 5.2. Telecoil........................................................................................................... 29 5.3. Speech to text ................................................................................................ 30 5.4. Subtitle Spectacles ........................................................................................ 31 6. Conclusions .......................................................................................................... 32 7. References ........................................................................................................... 33 2 The Ear Foundation, 2011 Executive Summary “You lose total self esteem, you don’t want to mix, anything like that because that’s what deafness does to you”. (Individual with hearing loss, The Ear Foundation, 2011) Advances in hearing technology have given access to speech to many individuals with hearing loss where previously there was little to help them. The current report provides detailed information on the most recent available data on the prevalence of hearing loss, the uptake of hearing aid technology and the public, private, retail and wholesale hearing aid market, the perspectives of individuals with hearing loss, the range of currently available hearing technologies and a range of assistive technologies available for individuals with hearing loss. The findings from the report reveal that: Deafness has a significant functional impact for individuals in their daily routines, living at home, at work and in social and formal situations. Early onset hearing loss (in childhood) impacts on the development of spoken language, reading ability, educational attainment and future employability. Late onset hearing loss impacts individuals‟ communication abilities leading to feelings of isolation, low self esteem and reduced independence. Advancements in hearing technologies provide individuals with hearing loss with the opportunity to overcome many of the challenges they face with routine auditory tasks. Deaf children fitted early in life with hearing technology can (if other things are equal) be expected to acquire spoken language and age appropriate educational attainment. Hearing technologies can significantly improve the quality of life and meet the communication needs for adults with hearing loss. Although hearing technologies do provide considerable benefit, challenges associated with background noise, distance and room acoustics can have a 3 The Ear Foundation, 2011 significant impact on the potential benefits of these hearing technologies. Assistive technologies such as FM systems, telecoil and speech to text facilities can help overcome many of these challenges. The most current figures from Action on Hearing Loss (AoHL) show 10.1 million people in the UK suffer from some form of hearing loss. The most recent iData Research (2011) figures show 3.2 million people suffering with hearing loss are hearing aid users. With the figure expected to rise up to 4.2 million by 2017. In 2010 the UK had the second largest hearing aid penetration rate in Europe at 35.3% and this is expected to rise by 2017 to 40%. Just over 80% of the hearing aids provided in the UK are done so by the public sector (NHS) and approximately less than 20% are provided through the private sector. Although the NHS provide 80% of the hearing aids, because of their purchasing power and the lower prices on hearing aids they can command, they hold 55.6% of the total market share. The private retail companies own approximately 45% of the total market share of the UK. Two of the five largest companies in the private sector are owned by optical store groups, with Specsavers holding 7.6% of the total market share and The Hearing Company (owned by Scrivens Optical Group) holding 2.8% of the total market share in 2010. In 2010, the total retail market share for hearing aids in the UK was worth €617.6 million and the total wholesale market was worth €121.8 million The findings from the most recent European Hearing Instrument Manufacturers Association (EHIMA; 2009) commissioned research identified the more severe the perceived hearing loss the higher the hearing aid adoption rate. The stage of the patient journey at which the highest percentage of dropout rates for individuals with hearing loss who seek advice was after discussing their hearing loss with their GP or ENT doctor. 39% of individuals decided not to have a hearing aid after this stage. When considering individuals with lower degrees of hearing loss the dropout rate at the GP/ENT stage increased to 64%. 4 The Ear Foundation, 2011 Individuals who had purchased their hearing aid from the private sector were slightly more satisfied than those who had received it through the NHS. Similarly those who had the more recent technology were more satisfied than those with the older technology. The most important influencing factor for non owners of hearing aids to purchase/obtain hearing aids was if their GP/family doctor would recommend it. The findings highlight the importance of GPs in the decision making process for individuals with hearing loss. This has serious implications for future uptake of hearing aids and amplification technology bearing in mind the recent government initiatives of GP consortia and any qualified provider (AQP). A range of hearing technology is currently available for individuals who cannot benefit from standard hearing aids including cochlear implants, electroacoustic implants, bone conduction hearing aids, middle ear implants and brainstem implants. These technologies are rapidly developing with outcomes improving. Assistive technologies available to people using amplification technology include the use of FM technology and telecoil/induction loops. The use of speech to text technology as subtitles, in meetings or conferences through palantypists and through captioning at theatres and performance venues by companies like STAGETEXT, also help provide all individuals with hearing loss access to speech. Text removed 5 The Ear Foundation, 2011 1. Introduction “They forget because it’s not a visual illness so people forget and because you catch the odd word... You’ve lost half of the conversation so you felt as if you’ve been left out” (Individual with hearing loss, The Ear Foundation, 2011). The functional impact of a hearing loss is significant. For children with early onset hearing loss, their development of spoken language, reading ability, educational attainment and future job prospects are all impacted. For adults with later onset hearing loss deafness has a functional impact in their daily routines, at home and work and in social and formal situations. The impact of hearing loss on communication abilities results in feelings of isolation, low self esteem and reduced independence. Hearing loss can be of three types, conductive, sensorineural or a combination of the two (mixed). Conductive hearing loss results from middle ear and ear canal problems. The middle ear consists of the eardrum, the middle ear cavity and the ossicles (three tiny bones). Hearing loss of this nature is typically a result of ear infections (otitis media), wax impaction, problems with the ossicles or underdeveloped or absent outer ear. Sensorineural hearing loss results from damage to the cochlea or cochlear nerve. This can be from birth or can be a result of illness, noise exposure or aging. The advancements in hearing technologies including digital hearing aids, bone conduction hearing aids and cochlear implants provide individuals with hearing loss with the opportunity to overcome many of the challenges they face with routine auditory tasks. Similarly, the implementation of the newborn hearing screening program (NHSP; see www.hearing.screening.nhs.uk) has resulted in children being identified with hearing loss and fitted with hearing technology very early in life. Children with hearing loss fitted early in life with hearing technology have improved opportunities to acquire spoken language and age appropriate educational attainment, other things being equal (Davis et al. 1997; Harrison et al., 2005; Yoshinaga-Itano et al, 1998). As a result they can be expected to have improved employment and future prospects. Although the challenges faced by adults with late onset hearing loss are not the same as those faced by children with early onset hearing loss the impact is still significant. The fitting of hearing technologies has significantly improved the quality of life for adults with hearing loss. Furthermore, those with profound hearing loss that previously could not benefit from conventional hearing aids can now benefit from cochlear implants. Although hearing technologies do provide considerable benefit many challenges still exist. A multitude of situational factors such as background noise, competing noise, room acoustics and familiarity with a situation can impact individuals with normal 6 The Ear Foundation, 2011 hearing; the impact for individuals with hearing loss in these situations is magnified. Assistive technologies such as FM systems and telecoil can help overcome many of the challenges associated with background noise, distance and room acoustics. Similarly, subtitles can help individuals with hearing loss to understand speech in difficult listening situations, for example, when watching television at a volume set for individuals with normal hearing levels, or when unfamiliar accents or unfamiliar dramatic contexts are in use. The most recent research conducted by Action on Hearing Loss (AoHL) formerly known as the Royal National Institute for the Deaf (RNID) reports more than 10 million people in the UK are with some form of hearing loss (AoHL, 2011). They further estimate that, due to the ageing population of the UK, by 2031 14.5 million people will be with a hearing loss in the UK. According to the World Health Organisation by 2030 adult onset hearing loss will be in the top ten disease burdens in the UK. A breakdown of the total number of individuals with hearing loss in the UK shows around 6.4 million are of “retirement” age (65+) and around 3.7 million are of “working” age (16-64). From the total number with hearing loss approximately 800,000 people have a severe to profound hearing loss. The following tables show estimated figures for the amount of people with hearing loss in the UK. Table 1.1. Most recent figures for the number of people with hearing loss in the UK (AoHL, 2011) UK All hearing loss Severe/ profound Working age 3,721,000 135,500 Retirement age 6,390,500 685,000 Total 10,111,500 820,500 From the above total, there are an estimated 356,000 people with combined visual and hearing loss in the UK. Of the estimated 365, 000, approximately two thirds (62%) are aged 70 or over. The predicted number of these individuals is expected to increase to 569,000 by 2030. The current number of children (0-16) with permanent hearing loss in the UK is estimated to be more than 45,000. The current report has been set out in five subsequent sections. Chapter 2 will focus on the provision of hearing aids in the UK. This section will cover the uptake of hearing aids by individuals with hearing loss and will also consider the major wholesale and retail market for hearing aids in the UK. The latter will help readers to appreciate the possible routes for the introduction and retail of new technology to help individuals with hearing loss. Chapter 3 will describe the findings from the latest research on the hearing aid adoption rates by individuals with hearing loss. This research was a large comprehensive study and the first of its kind completed in the UK and was conducted by an independent company on behalf of the European 7 The Ear Foundation, 2011 Hearing Instrument Manufacturers Association. Chapter 4 will provide an overview of existing amplification technologies currently available to individuals with hearing loss. Chapter 5 will describe some of the assistive technologies used by individuals with hearing loss. The report will conclude with Chapter 6 providing a summary of the report and recommendations for the introduction of new technology to assist individuals with hearing loss. 8 The Ear Foundation, 2011 2. Hearing Aids in the UK 2.1. Hearing aid provision Hearing aids in the UK are provided through the National Health Service (NHS) and can also be purchased privately through retail shops. The provision of hearing aids through the NHS is free at the point of delivery and this has contributed significantly to the UK having one of the highest hearing aid penetration rates in all of Europe. However, no reimbursement policies exist in the UK for individuals who purchase their hearing aids from the retail sector. The route to acquire a hearing aid through the NHS for adult users varies, however the most common pathway is through the GP who depending on the diagnosis will either refer the patient to the Audiology department or the Ear Nose and Throat (ENT) department at the nearest NHS hospital. Any patient who may have a clinical contra-indication would be referred onto the ENT department and on the consultant‟s approval would be given a hearing aid. Patients have a very minimal choice of hearing aids they receive from the NHS as these are generally pre-selected by audiologists from a limited choice of options. The route to acquiring hearing aids through private retail is much more open in that individuals can directly book their appointment with a private hearing aid dispenser. However, if the dispenser finds any medical contra indications present they must refer the individual to an ENT department and can only fit a hearing aid once the ENT consultant has approved it. Individuals have a much greater selection of hearing aids when purchasing through private retail, however the full cost is paid for by the individual without any reimbursement from the government. The latest figures from iDATA (2010) indicate a total of 9.1 million people in the UK suffered from hearing loss in 2010. Although this figure is lower than the 2011 figures obtained from AoHL (10.1 million), the difference can be attributed to the more inclusive terminology of deafness used by AoHL. This more inclusive terminology is consistent with their role as a campaigning charity. As the iData report provides an overview of the market for hearing aid and audiology devices the more conservative figures provide a more realistic appreciation of the potential for new assistive technologies in this market. In 2010 the number of hearing aid users in the UK was approximately 3.2 million (iData, 2011). The main driver for hearing aid adoption in the UK is the aging population which will see a compounded annual growth rate (CAGR) of 2% over the forecast period till 2017. Currently the UK has the second highest penetration rate in Europe (35.3% in 2010) and this is expected to increase to over 40% by 2017 (4.2 million; iData, 2011). As a result of the increase in the number of hearing aid users the opportunities and need for assistive technologies would be expected to increase as well. 9 The Ear Foundation, 2011 2.2. Hearing aid market To establish the potential for any new assistive technological device for individuals with hearing loss, a better understanding of the hearing aid market is required. The following section will initially provide an insight into the hearing aid market and will differentiate between the public and private sectors in the UK. Thereafter the subsequent section will detail the current distribution of the retail and wholesale market. 2.2.1. Public vs. Private The total hearing aid market in the UK in 2010 was valued at £531 million, a 1.8% increase over the previous year (iData, 2011). The total number of units sold in 2010 was over 1 million making the UK the country with the highest unit sales in Europe. This is primarily a result of the large purchasing order by the NHS. For the year 2010, the percentage of hearing aids sold to the NHS was 81%, and 19% was sold to private retailers. As a result of the large purchasing power of the NHS the average selling price (ASP) of hearing aid units in the UK was one of the lowest in Europe. This does nevertheless result in the government incurring a large expense in the provision of hearing aids through the NHS. Currently the government is introducing new measures to change the way hearing aids are provided in the UK with their “any qualified provider” scheme (AQP). It is expected that this may lead to a gradual shift of patients moving towards the private sector while continuing to receive their hearing aids through NHS funding. In the UK, then, a clear distinction between public and private retail markets exists which is why it would be difficult to fully appreciate the hearing aid market simply using the figures from the total retail hearing aid market. In 2010 the public retail market (that is, the cost of hearing aids purchased by the NHS) was valued at £295 million, with an increase of 3.6% from the previous year. The public retail market value is expected to increase to £320 million by 2017. The last few years has seen an increase in the number of units provided and a corresponding increase in the market value of the public retail hearing aid market. This is in large part because of the “18 week initiative” embarked on by the Government in 2008, where patients‟ waiting times for receiving a hearing aid were reduced to 18 weeks. This prompted an increase in the number of hearing aid units issued. Another potential factor to be considered is the improvements in the hearing aid technology available through the NHS. Hearing aids available through the NHS are purchased through public tender systems every four years. As the NHS is the largest purchasing organisation of hearing aids in the world, it is able to pressure manufacturers to abide by the criteria set out in NHS tender documentation; indeed, in order to win a four year contract manufacturers will often redesign their equipment specifically to comply with the criteria. 10 The Ear Foundation, 2011 The NHS introduced improved criteria for their last tender period. Using their large purchasing power the NHS were able to secure mid-level technology where previously only economy-level or a mix of economy and some features of mid-level hearing aid technology were available. For premium-level technology individuals would still need to go through the private sector. The value of the private retail market in the UK was £235 million in 2010. Although the market value for the private sector was not considerably lower than the public sector, the number of units sold and the current installed base were much lower than in the public sector and the average selling price (ASP) correspondingly a great deal higher. In 2010, the number of units sold in the private sector was 192,632 resulting in an installed base of approximately 1 million. In comparison the NHS had sold close to 1 million hearing aids in 2010 and had an installed base of approximately 4 million. Similarly, the ASP for hearing aids in the private sector in 2010 was £1,224 compared to £320 in the public sector. Year 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 Units Sold Public Private 835,400 198,532 870,487 189,400 901,824 190,536 923,468 192,632 942,861 196,099 960,775 201,002 977,108 207,635 992,742 215,525 1,007,633 224,577 1,021,740 234,908 1,034,001 246,183 Installed Base Public Private 3,501,929 774,291 3,676,026 831,111 3,856,391 888,272 4,041,085 946,062 4,229,657 1,004,891 4,421,812 1,065,192 4,617,233 1,127,482 4,815,782 1,192,140 5,017,309 1,259,513 5,221,657 1,329,985 5,428,457 1,403,840 Average Selling Price Public Private £304 £1,303 £311 £1,272 £316 £1,247 £320 £1,224 £322 £1,205 £323 £1,187 £322 £1,171 £320 £1,158 £317 £1,148 £314 £1,140 £310 £1,133 Market Value Public Private £253.7m £258.8m £271.0m £240.9m £285.2m £237.5m £295.6m £235.8m £303.6m £236.2m £310.0m £238.5m £314.6m £243.2m £317.7m £249.6m £319.6m £257.8m £320.5m £267.8m £320.1m £278.9m Table 2.1 the number of units sold, installed base, average selling price and market value for the public and private sector in the UK 2007-2017 (iData, 2011). Although, because of the improvements in the NHS the demand for hearing aids in the private sector has slowed down, a steady increase in the number of units sold privately is expected over the forecast period. This has been attributed to the mounting budgetary constraints on NHS spending which would be expected to affect the current provision of hearing aids through the NHS. As a result more individuals may look to the private sector resulting in the private sector having a larger share of the compounded annual growth rate (CAGR) compared to the public market. By 2017 the expected market value for the private sector is £278 million with an installed base of over 1.4 million (iData, 2011). 11 The Ear Foundation, 2011 2.2.2. Retail vs. Wholesale The major portion of the retail hearing aid market in the UK comprises of the NHS healthcare system (55.6%). Although, the NHS dispenses just over 80% of the hearing aids the average cost per hearing aid is far less than the private sector. Approximately 200 audiology departments and standalone clinics provide hearing aids through the NHS in the UK. The rest of the 45.4% of the retail hearing aid market is shared out by private companies. The largest single retailer from the private sector is Specsavers who have 7.6% of the total market share. Thereafter the next four companies that have the largest share of the market are Amplifon (7.1%), Hidden Hearing (6.5%), The Hearing Company (2.8%) and David Ormerods/Boots (2.6%). The remaining 17.9% of the retail hearing aid market is held by independent retailers or smaller companies. Figure 2.1 illustrates the retail hearing aid market share in the UK. Figure 2. the total retail hearing aid market share in the UK. Specsavers are also the leading supplier of prescription eyewear in the UK. The majority of their hearing aid departments are based within their optical stores with approximately 110 stores dispensing hearing aids. They also have approximately 15 independent standalone hearing aid stores. They use high retail price discounting with aggressive pricing promotions and are the leaders in unit sales in the private sector. Specsavers has recently initiated a five year partnership with Action on Hearing loss (AoHL) to improve hearing aid uptake in the hearing loss population and increase awareness of issues related to hearing loss. The partnership aims to launch a nationwide advertising campaign to provide free hearing screening to potentially more than one 12 The Ear Foundation, 2011 million individuals with hearing loss who could benefit from a hearing aid. It has been made clear that individuals identified as potentially benefiting from a hearing aid will be encouraged to go to their GP if appropriate, and will not be pressured to purchase an aid from Specsavers. Amplifon had the second highest share of the private sector at 7.1%. Hidden Hearing is a company owned by William Demant which is the market leader in the wholesale hearing aid market (see below) and also owns Oticon the hearing aid company. The Hearing Company is a subsidiary company of the Scrivens Optical Group. David Ormerods group is a hearing aid company that has merged with Boots pharmacies. More recently, the Sonova Group, which owns Phonak has gained a minority ownership in Ormerods/Boots The wholesale hearing aid market distributes to both the public and private sector. In 2010 approximately 90% of the total wholesale market was held by four companies, William Demant, Siemens, Sonova and GN Resound. The remaining 10% of the market was shared out by companies including Widex, Starkey, Puretone, Hansaton, etc. William Demant Company (who own Oticon, Bernafon and Sonic Solutions) were the market leader in 2010 comprising of 31.7% share by value. The company held the leading share in the public market (36.6%) and also held the second highest position in the private retail market (22.4%). Siemens held the second highest position in the total wholesale market. Similar to William Demant, this is because of the large share the company held in the public hearing aid market (33.2%). In the private market Siemens held a market share of 13.8%. Sonova owns Phonak, their main hearing aid company, Unitron and has also recently acquired the second biggest cochlear implant company Advanced Bionics. Sonova held the largest market share in the private market at 34.3%. However their success in the private market was not mirrored in the public market; as a result the company held third position in the overall total market share (18%). GN Resound accounted for 14.7% share of the total wholesale hearing aid market in the UK. Although the company has seen a reduction in market share over the last few years it still held 15.6% of the public market and 12.9% of the private market. GN Resound continues to be regarded as an innovative manufacturer and as a result of newer technology is expected to gain market share in the coming years. Figures 2.2 to 2.4 illustrate the public, private and overall wholesale market in the UK. 13 The Ear Foundation, 2011 Figure 2.2 the public wholesale market share in the UK. Figure 2.3 the private wholesale market share in the UK 14 The Ear Foundation, 2011 Figure 2.4 the overall wholesale market share in the UK. The current chapter provided an overview of the hearing aid market in the UK. The following chapter will focus more on the perspectives of the end user. 15 The Ear Foundation, 2011 3. Perspectives of individuals with hearing loss 3.1. Background In 2009 Avonum, a research company based in Zurich, Switzerland, were commissioned by the European Hearing Instrument Manufacturers Association (EHIMA) to conduct an in depth study on hearing aid adoption rates in Germany, France and the UK. The current chapter will provide an overview of the UK findings from this study. The study was the first of its kind conducted in Europe and provides a comprehensive insight on the perspectives of hearing impaired individuals with and without a hearing aid. The total representative sample included for screening was 14,980 of which 1,335 self reported to having a hearing loss. Of these 513 were using hearing aids and 822 were not. As part of the study the sample was segmented into 6 groups based on each individual‟s „degree of hearing loss‟ which was determined by the following factors: Number of ears impaired (one or two) Stated hearing loss (Mild to Profound) Scores on 6 APHAB (Abbreviated Profile of Hearing Aid Benefit) like questions (Scaled 1-7) When NOT using a hearing aid, how difficult respondents reported it was for them to follow conversations in the presence of noise. The answers to the above factors were provided by the users and as a result were subjective, most especially in the case of the non hearing aid users who may not have had a hearing test. Based on the 6 hearing loss segments the findings illustrated the more severe the perceived hearing loss the higher the hearing aid adoption rate (EuroTrak, 2009). 3.2. Patient journey The individuals from the UK sample were asked to provide feedback on their patient journey based on five distinct stages: Discuss hearing loss with GP or ENT doctor GP or ENT doctor recommend hearing aid Discuss hearing loss with Audiologist or HA dispenser Audiologist or HA dispenser recommends hearing aid 16 The Ear Foundation, 2011 HA purchased or provided (NHS) Although the individuals included in this sample all accepted that they were having troubles with hearing a large percentage (33%; EuroTrak, 2009) did not do anything about it. However once individuals with hearing loss did seek medical advice the largest dropout rate occurred at the GP/ENT doctor stage (39%; EuroTrak, 2009). These figures were lower than the AoHL (2011b) which suggests 45% of people who report hearing problems to their GP are not referred for a hearing test or hearing aids. Once patients had discussed their hearing loss with an audiologist or hearing aid dispenser the dropout rate was minimal at 6% (EuroTrak, 2009). This highlights the significant position GPs are in when considering the provision of hearing aids for this population. The rates for not seeking hearing aids increased for individuals in the lower „degree of hearing loss‟ segments both in terms of seeking advice from a GP/ENT doctor and also for being recommended for a hearing aid by the GP/ENT doctor. 45% of individuals in the lower „degree of hearing loss‟ group did not seek advice from a GP/ENT doctor. From the 55% of individuals who did seek advice from their GP/ENT 64% were not recommended for a hearing aid. As expected the dropout rates for individuals in the higher degree of hearing loss groups were lower. 20% of the individuals in the higher „degree of hearing loss‟ groups (segments 4-6) did not seek GP/ENT advice. From the 80% of individuals who did seek advice from their GP/ENT doctor, just over a quarter dropped out after the advice given. These findings again highlight the important position held by GP‟s and ENT doctors in the decision making process and is especially worrying as GP‟s do little or no hearing testing. Furthermore, for those in the „lower „degree of hearing loss‟ groups the current advancements in hearing technologies do provide advanced amplification options. 3.3. Hearing aid owners and non-owners The „degree of hearing loss‟ for hearing aid users included in the study sample were subjectively captured. The majority of the hearing aid owners had a mild to moderate hearing loss with severe to profound hearing loss accounting for only 32% of the total hearing aid owners. Although the hearing loss levels were subjective, for the hearing aid owners it would be expected that their subjective levels of hearing loss would be reliable. The majority of the hearing aid owners (74%) had received their hearing aid through the NHS with approximately a quarter of the sample (24%) purchasing their hearing aids privately. 2% noted down that they did not know where they had received their hearing aid from. Of those who had purchased their hearing aid 74% had been purchased in 2007 or later. The satisfaction levels for individuals with hearing aids was assessed using a 7 point Likert scale where 1 = very dissatisfied and 7= very satisfied. The results comparing 17 The Ear Foundation, 2011 satisfaction levels for individuals with hearing aids showed 83% of individuals with private hearing aids were „somewhat satisfied‟ to „very satisfied‟. In comparison 76% of individuals who had received their hearing aid through the NHS were somewhat to very satisfied with their hearing aids. The biggest difference for satisfaction levels was for the „very satisfied‟ category where 30% of private hearing aid owners were very satisfied compared to 18% of NHS hearing aid owners. A further comparison was done for satisfaction levels with hearing aids purchased within two years of the study (2007-2009) compared to hearing aids purchased before 2006 (Figure 3.8). The findings highlighted the newer the hearing aid the higher the satisfaction with 82% who had received or purchased their hearing aids within two years being „somewhat satisfied‟ to „very satisfied‟. In comparison 67% of individuals who had received or purchased their hearing aids two or more years previous were „somewhat satisfied‟ to „very satisfied‟ The subjective „degree of hearing loss‟ for non hearing aid owners revealed only 7% of the hearing impaired non owners felt that they had a severe to profound loss. The sample of hearing impaired non owners in the higher „degree of hearing loss‟ groups (4-6) were questioned on reasons for not owning hearing aids. Their responses suggested various reasons for non use of hearing aids with the major reasons cited as: hear well enough in most situations, hearing aids uncomfortable and embarrassed to wear hearing aids. 40% of the individuals cited one of the reasons for non use of hearing aids was because their family doctor recommended them not to. 3.4. Buying/obtaining intentions Both groups of individuals were questioned on what had influenced them or would influence them to obtain/purchase a hearing aid. The question for the two groups was phrased differently: Owner: Thinking back to when you obtained your first hearing aid(s), what influenced you to obtain /purchase the hearing aid(s)? Non-owner: Think about the option to obtain / purchase a hearing aid. What do you think would influence you to obtain / purchase a hearing aid? The results for both groups highlighted differences in what non-owners say would influence them to buy a hearing aid in the future compared to what owners said would influence them to buy. The most important influencing factors for non owners were if their GP/family doctor recommended it (58%), if their hearing loss got worse (57%) and if their ENT doctor recommended it (42%). In comparison those who had purchased their hearing aid cited their hearing loss got worse (48%), their hearing aid dispenser recommending it (41%) and their NHS audiologist recommending it (39%) as their main reasons for purchasing/obtaining another hearing aid. The 18 The Ear Foundation, 2011 findings highlight how non hearing aid owners often rely greatly on GP‟s and ENT doctors for advice and how they are often a barrier to hearing aid use. Both groups were also asked about their buying intentions in the future. The group who already owned hearing aids were more likely to repurchase a new hearing aid. The results indicated 13% of non owners intend to purchase hearing aids within the next two years compared to 20% of existing owners of hearing aids. 19 The Ear Foundation, 2011 4. Other Hearing Technologies 4.1. Cochlear Implants Cochlear implants are surgically implanted electronic amplification devices. Overall they consist of two components, the implant and the external sound processor. The implant includes a receiver coil and associated electronics, which sits under the skin around the mastoid area, and an electrode array that is inserted directly into the cochlea. The external sound processor is housed in a device shaped similar to a hearing aid and has an external transmitter coil that attaches magnetically to the implanted receiver coil. The external processor picks up the sound via a microphone, converts the digitally coded sound into electrical impulses, and transmits these impulses through the two coils to the implant. The implant then sends these impulses to the appropriate electrodes in the array placed in the cochlea and these provide direct electrical stimulation of the aural (hearing) nerve (Figure 4.1). This provides the sensation of sound to the wearer. Cochlear implants provide a treatment option for individuals who do not receive sufficient benefit from a standard hearing aid. Individuals with hearing loss levels ranging from moderate to profound can be considered for cochlear implantation, provided the auditory nerve still has function. With the implementation of newborn hearing screening and the guidelines set out by the National Institute for Health and Clinical Excellence (NICE), cochlear implantation has become routine in the paediatric population. The improved listening abilities offered by cochlear implants have been shown to result in improved speech, language, educational and social outcomes for children with hearing loss (Archbold et al., 2008). Cochlear implants provide the ability to hear spoken language for profoundly deaf children and adults for the first time. They provide access to the high frequency speech sounds at the quiet levels enabling deaf children implanted early (and with no other difficulties) to acquire age appropriate spoken language equivalent to their normally hearing peers (Dettman et al., 2007). Similarly, adults fitted with cochlear implants have significantly benefited with the technology in understanding conversations and using the telephone (Clinkard et al., 2011). A number of studies have determined the cost effectiveness of cochlear implants and have highlighted the significantly improved quality of life and speech perception they provide for both the adult and paediatric populations (Stacey et al., 2006; Summerfield et al., 2002). 20 The Ear Foundation, 2011 Figure 4.1 external and internal components of cochlear implant (www.isvr.soton.ac.uk) In the UK cochlear implants are provided through the NHS through specifically dedicated cochlear implant programme centres. There are currently approximately 25 centres across the UK dealing in both adult and paediatric fittings (www.bcig.org.uk). Each centre has a dedicated team of professionals including specialist ENT surgeons, audiologists, speech and language therapists and teachers of the deaf. For patients to receive a cochlear implant they would be referred to a cochlear implant centre by their local audiology department. The centre conducts a detailed assessment of their suitability to receive the device. If a patient is suitable for the device they are referred to the ENT specialist to undergo the surgical procedure. The surgical procedure can be performed on children in the first year of life. After the surgical implantation of the internal components the external components are fitted by the audiologist. Thereafter an intensive rehabilitation process with teachers of the deaf and speech and language therapists occurs. Regular appointments at the centre are required and the external processor is usually upgraded every five years. Traditionally cochlear implants have been fitted to one ear only but latest UK National Institute for Clinical Excellence (NICE) guidelines have recommended bilateral fittings for children and for adults with additional disabilities (NICE, 2009). As 21 The Ear Foundation, 2011 a result the number of binaural cochlear implant fittings has risen and the overall number of cochlear implant units sold will expectedly rise. There is a very small “private” market for cochlear implants. In contrast to hearing aids, cochlear implants funded by the NHS are the latest available and it is not generally possible to purchase a superior implant or processor even if one had the resources to do so. In children the penetration rate of cochlear implantation is proportionately high in the UK compared to adults. Although many adult patients are suitable candidates for receiving a cochlear implant, the penetration rates are low. In 2010 there were 91,483 cochlear implant users in the whole of Europe (including the UK), with a total of 106,508 cochlear implant devices in use (a small proportion of users are already fitted with two implants) (iData, 2011). According to iData (2011) figures, in the UK 1,670 cochlear implants were fitted in 2010 resulting in an installed base of 17,026. A compound annual growth rate (CAGR) of 8.3% for units sold in the UK is expected, resulting in the number of units sold per year increasing to 2,913 by 2017 (iData, 2011). The installed base for cochlear implants is expected to have a CAGR of 10.2% resulting in an installed base of 33,515 by 2017 in the UK. The UK average selling price (ASP) for cochlear implants in 2010 was €20,032 and it is expected that the price will remain stable with a 1.4% CAGR resulting in an ASP of €22,112 in 2017. The UK market for cochlear implants in 2010 was €33.5 million and with a 9.8% CAGR forecast the expected market in 2017 is €64.4 million. There are four cochlear implant manufacturers, Cochlear, Advanced Bionics, MEDEL and Neuralec. In 2010, Cochlear Europe was the clear market leader in the UK with a 68.3% share of the market. Advanced Bionics was the second leading competitor and had a 16.2% share of the UK market. MED-EL was the third leading competitor with a market share of 14.3% in the UK. Neuralec had the lowest market share in the UK with a 1.2% share of the market. Although Cochlear Europe is the clear market leader and is expected to remain so for the forecast period until 2017, Sonova's acquisition of Advanced Bionics has put the company in a position to challenge for a greater share of the market by using both companies‟ resources. Advanced Bionics did suffer a temporary decline in their market share in 2010 after a precautionary product recall of the HiRes 90K however the company is expected to regain momentum with the support from Sonova as well as the launch of their new cochlear implant product the Neptune. Recently, in 2011 Cochlear have recalled their latest product the Nucleus 5 from the market and the product is expected to remain off the market for approximately 6 months. MED-EL is a well established cochlear implant company based in Austria. Neuralec is a relatively new company based in France and hold the second highest market share in France. The company has however found it difficult to challenge the wide distribution channels of the other three manufacturers in other markets. 22 The Ear Foundation, 2011 4.2. Electric Acoustic Stimulation More recently the use of both a hearing aid and a cochlear implant together in the same ear has become an option (Figure 4.2). The cochlear implant is used to provide the mid to high frequencies and the hearing aid amplifies low frequencies. The inner ear then processes the acoustic and electric stimuli simultaneously. This hybrid hearing system has been specifically developed for individuals with severe to profound high frequency hearing loss. Results have shown good outcomes for patients using electro-acoustic stimulation technology (Gstoettner et al., 2006; Skarzynski et al., 2006). The technology has only recently been introduced in the UK and as such the numbers using it are still low. However, the positive outcomes from current users should increase the numbers receiving this hybrid technology. Figure 4.2 electro-acoustic stimulation, cochlear implant and hearing aid used simultaneously in same ear. 4.3. Bone Conduction Hearing Aids Bone Conduction Hearing Aids (BCHA) are the only amplification technology that provides hearing treatment through direct bone conduction. The sound travels directly through the bone, by-passing the ear canal and middle ear. The bone conduction hearing aid is used in situations where an individual cannot use standard hearing aids because of infections in the ear or if a part of or all the outer ear or ear canal is missing. It has been well recognised as a hearing treatment for conductive and mixed hearing loss since 1977. Research on the benefits of bone conduction hearing aids has highlighted significantly improved quality of life, speech perception and overall satisfaction with bone conduction hearing aids for individuals using the technology (Dutt et al., 2002; Newman et al., 2008) 23 The Ear Foundation, 2011 The implanted bone conduction hearing aid consists of three components. The first component is the titanium implant that is surgically fitted into the skull around the mastoid area. The second component is the abutment that attaches to the titanium implant. The third component is the hearing aid processor which snaps onto the abutment (Figure 4.3). Figure 4.3 the components of a bone conduction hearing aid (www.earfoundation.org.uk) Once the processor is attached to the abutment, sound travels through the skull by vibrations and directly stimulates the inner ear (Figure 4.4). Figure 4.4 sound travels through to the cochlea via vibrations in the skull (www.earfoundation.org.uk) In the case of single sided deafness, the sound is picked up by the bone conduction hearing aid implanted on the side of the deaf ear and the sound travels to the better ear (Figure 4.5). 24 The Ear Foundation, 2011 Figure 4.5 how sound vibrations travel to the opposite ear for individuals with single sided deafness (www.earfoundation.org.uk). Another type of bone conduction hearing aid consists of an internal implanted magnet, an external magnetic spacer and a sound processor (Figure 4.6). This setup avoids the need for an abutment. Figure 4.6 the components for a bone conduction hearing aid using magnets instead of an abutment (www.earfoundation.org.uk). Bone conduction hearing aids can also be worn on a softband. This allows for young children to get the benefit of the aid, without having the surgery (Figure 4.7). The softband can also be used to test the sound of a bone conduction hearing aid with adults before proceeding with the surgery. Figure 4.7 bone conduction hearing aids with softband (www.earfoundation.org.uk). There are two main suppliers for the traditional bone conduction hearing aid using the abutment, Cochlear and Oticon Medical. Cochlear is the market leader for 25 The Ear Foundation, 2011 cochlear implants and Oticon is the flagship hearing aid company for William Demant (the leading wholesale hearing aid company in the UK, as already noted). The other company supplying bone conduction hearing aids in the UK is Sophono, however they specialise in the magnetic implant style of bone conduction hearing aids. Currently the data on the number of units sold and the number of individuals using the bone conduction hearing aid is not available. However, the Ear Foundation has just started a bone conduction database registry for the UK. The national registry should be beneficial in obtaining information on the number of individuals using the technology, the success rates of the technology and the different types of deafness the technology is fitted to. The Ear Foundation is also conducting qualitative research exploring the views and perspectives of families of children who have received the technology and a separate study on the views and experiences of individuals with SSD using bone conduction hearing aids. 4.3. Middle ear implants Middle ear implants use mechanical energy to stimulate the structure of the inner ear. Middle ear implants are suitable for individuals with moderate to severe hearing loss who are unable to gain benefit from standard hearing aids because of infections or if the outer ear and ear canal are missing. The technology is made up of two components, an internal implanted component and an external processor. The internal component of the middle era implant consists of a receiver (vibrating ossicular prosthesis) and a floating mass transducer attached to the small bones in the middle ear. The external component is an audio processor worn behind the ear (Figure 4.8). Figure 4.8 diagram of middle ear implant, floating transducer magnified (www.audio-infos.org). More recent advances in middle ear implant technology have resulted in a totally implantable device with no external components for the user. The device consists of 26 The Ear Foundation, 2011 a rechargeable battery, a signal processor and a microphone, all implanted under the skin. These are connected to an electromagnetic vibrator positioned inside the mastoid bone and attached directly to the middle ear bones. The first fully implantable middle ear device was fitted in the UK in 2011. 4.4. Brainstem implants The auditory brainstem implant (ABI) is an implant that directly stimulates the brain stem. It is clinically suitable for an individual who has a damaged or no cochlear or auditory nerve. This may be due to a tumour or surgery. The technology is the same as a cochlear implant except that the electrical stimulation is used to stimulate the brainstem instead of the cochlea. Currently there are very few recipients of ABI‟s in the UK because of the nature of the surgery and the limited reported benefits associated with its use. Individuals expect to only have an awareness of sound. However more recent research is highlighting outcomes are dependent on the cause of the hearing loss and some level of success has been seen in younger children and adults who did not have a tumour (Coletti et al. 2010). 27 The Ear Foundation, 2011 5. Assistive Technologies The recent developments in hearing technologies such as digital hearing aids, cochlear implants and bone conduction hearing aids have provided access to spoken language that previously have never been experienced. However, there still remain challenges for users of the technology in difficult listening situations. Background noise, distance and reverberation have a significant impact on the ability to listen in educational, work and social settings. Assistive devices overcome many of the challenges present in difficult listening situations and help provide individuals with hearing loss access to speech in these difficult settings. 5.1. FM amplification technology FM amplification technology consists of two components, a transmitter and a receiver. The FM receiver can be attached to standard hearing aids, cochlear implants and bone conduction hearing aids. The FM transmitter is worn by a primary speaker for example a teacher or a lecturer and the microphone of the transmitter picks up the speaker‟s voice. The sound is converted into an electrical signal and transmitted via FM radio waves to the receiver attached to an individual‟s hearing aid/cochlear implant/bone conduction hearing aid (Figure 4.9). Some general purpose receivers attach by electrical lead connection rather than directly to the device as shown. The signal is then amplified/processed by the hearing aid/cochlear implant/bone conduction hearing aid and delivered to the user. The transmission occurs on reserved radio frequency bands. Figure 5.1 FM transmitter and receiver attached to hearing aid. The improved signal to noise ratio provided by FM technology to individuals using hearing devices has been widely accepted in the literature to improve speech comprehension in challenging listening situations. The effects of room reverberation times on adult hearing aid users have long been shown to have a far greater impact on individuals with a hearing loss using a hearing aid compared to normal hearing adults (Finitzo-Hieber and Tillman 1978; Hawkins and Yacullo, 1984). Similarly, these studies have also shown how reduced signal to noise ratios have 28 The Ear Foundation, 2011 disproportionately greater effect on hearing aid users compared to normal hearing adults. Furthermore, the optimal distance for speech discrimination is within a metre from the listener (Ross, 1992). In most rooms, at distances of two metres or less the inverse square law of acoustic signals applies. This law dictates for every halving or doubling of distance, the intensity of the acoustic signal would increase or decrease by 6 dB respectively (Ross, 1992). It would be expected that the optimal distance would not be maintained during routine daily activities and that the distance between the user of hearing technology and the speaker would regularly increase. FM technology is widely used in educational settings with school aged children where the teacher would wear the transmitter and children would be loaned a receiver during the course of the school day (of course one transmitter can be used with a number of receivers). The use of FM with pre-school children and adults is starting to pick up, however the numbers are still very low. Although no data is currently available for the number of adult users of FM amplification technology the expected number of adult users, estimated by the leading manufacturer of FM technology (Phonak), is close to 1 in 500 adults with hearing aids. This remarkably low figure – given the potential advantages that FM technology offers – suggests there is considerable room for expansion in this market. 5.2. Telecoil The telecoil („T‟)/loop function is routinely available with the majority of standard hearing aids (including implants and BCHAs). Once placed on the „T‟ setting the hearing aid can pick up sound coming through a loop system directly into their hearing aids. The hearing aid can only pick up sound in rooms where a floor induction loop has been fitted. The induction loop is a cable that encloses a particular area and transmits sounds in the form of a magnetic field that can be picked up within the coverage area when hearing aids are switched to the „T‟ setting: often the loop is connected to an existing microphone and amplifier/public address system. The coverage area can be as small as an individual‟s front room but can also cover areas as large as conference halls. The induction loop can be found in many public buildings like banks, churches and shopping centres and have been shown to provide great benefit to users of hearing technology (Ross, 2002). Portable induction loops as well as neck loops can also be used. The neck loop is a lightweight cable worn around the neck and can be used with mobile phones and blue tooth enabled devices. Similarly, much smaller „ear hook‟ loop systems have been designed that can be used in place of ear phones by transmitting sound directly to the hearing aid via the „telecoil‟. Although the majority of hearing aids have the loop function or can have them activated the uptake of the technology is not widespread. Findings from the EHIMA study (2010) reported that the majority (62%) of hearing aid owners were not aware of what the telecoil was and only 15% were aware they had a telecoil on their 29 The Ear Foundation, 2011 hearing aid and 8% were not sure. The 15% who did have a telecoil setting on their aids made most use of the setting when using the telephone (68%) and watching television (59%). Other situations where the telecoil was used were at a house of worship/church (43%) and listening to lectures (47%). 5.3. Speech to text Speech to text conversion is widely used to help individuals with hearing loss understand what is being said at public events (more rarely in private meetings or interactions) Speech to text is widely used as “subtitles”, particularly with television programmes, movies, and stage plays (where the subtitles are projected on a special screen above the stage). In these situations the subtitles can clearly be prepared well in advance, and be shown in perfect synchronisation with the speech itself – though this takes some operator skill in a stage play. Companies like STAGETEXT specialise in this. Recent research conducted by the Ear Foundation looking at the long term use and outcomes for cochlear implant users found over 95% of respondents made use of subtitles with televisions and found them beneficial. In situations where the exact text spoken has not been agreed in advance – meetings, conferences, legislative debates – speech must be rendered into text in real time with as little delay as possible. Speech to text reporters, also referred to as palantypists or stenographers (the two systems are slightly different but work in the same way as far as the user is concerned) use a special keyboard to phonetically type every word that is spoken in the meeting or conference. This is then converted into English via special software and displayed on a screen (AoHL, 2011c). Individuals with hearing loss find this useful when trying to follow a lecture or conference presentation. Palantypists and stenographers are skilled and efficient at transcribing speech, but the operators need to be highly trained and this increases the cost of the service. The concentration level required of the operator is also very high and in formal events two palantypists are often used in alternating “shifts” of around thirty minutes each. Providing a palantype service for (e.g.) an eight hour “day conference” may therefore currently cost around £750. For some years efforts have been made to devise computer (hardware and software) solutions that would render speech to text efficiently without human intervention, and at proportionately lower cost. Although many speech to text software packages are available now, the main limitations to the computer based technology is the level of accuracy (word error rate) achieved by such technology. There is a far higher word error rate with the existing packages than with a good palantypist or stenographer (especially when he 30 The Ear Foundation, 2011 or she has been briefed in outline on the subject under discussion). Software packages can be “trained” to respond to an individual‟s voice – for example by asking the individual concerned to read out a number of sentences displayed on the screen by the computer - and this increases their accuracy. This may be practicable when a hearing person wishes to use them for “dictation” but is hardly helpful when an individual with a hearing loss wishes to use the package for general communication. In the absence of this “training”, and when exposed to many new voices and users, the level of accuracy for standalone software packages is questionable. 5.4. Subtitle Spectacles Recently (BBC, 2011), Sony UK has developed „subtitle glasses‟ aimed at movie goers with hearing loss. Currently the movie industry only screen subtitle movies on certain days a week and at odd times. This makes it difficult for individuals with hearing loss to arrange their schedule around these special screenings. Sony UK‟s new visual device places timed “closed captions” on the screen of the glasses so that they are super imposed on the cinema screen. The captions have been prepared in advance and are not generated by speech-to-text conversion. For the user the glasses give the impression that the subtitles are on the cinema screen. The BBC (2011) interviewed an individual with hearing loss on his experience of using the device. He mentions: “The good thing about them is that you're not refocusing. It doesn't feel like the words are really near and the screen is far away. It feels like they're together” The introduction of such a device would give cinema goers with hearing loss the freedom of choice to attend at times that suited them. The current device developed by Sony UK is limited to cinemas for the viewing of movies. 31 The Ear Foundation, 2011 6. Conclusions In summary the above report has highlighted the impact of the advances in hearing technologies and reviewed the current hearing aid market in the UK. Thereafter the perspective of individuals with hearing loss was considered. Subsequently other amplification technologies and assistive devices were described. The report has highlighted the dramatic change in the technological options available to individuals with hearing loss. The range of technologies available for individuals with hearing loss and the quality of the signal processing strategies have seen rapid advancement in recent years. The outcomes for individuals with hearing loss using these technologies, including hearing aids, cochlear implants and bone conduction hearing aids, have been significantly improved. The social, educational, employment and health benefits achieved by the use of these technologies have been considerably positive. However, even with these excellent outcomes there are still many challenges users of hearing technologies face in difficult listening situations. Even individuals with normal levels of hearing can find difficult listening situations challenging, however these challenges are magnified for individuals using hearing technologies. The use of assistive technologies such as FM systems, telecoils and subtitles allows users of hearing technologies to overcome many of the challenges associated with distance, reverberation, background noise and poor acoustic conditions. Text removed. 32 The Ear Foundation, 2011 7. References Anovum (2009) EuroTrak: New survey of the market for hearing aids in Germany, France and the UK: First globally comparative study of hearing, hearing loss and hearing aids. European Hearing Instrument Manufacturers Association. AoHL (2011a) „Facts and figures on hearing loss and tinnitus‟ Action on Hearing Loss, London, UK. 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