Download BHI Program Review CY04-CY05

New Research from BHI
(Methods of Promoting Your Practice)
Sergei Kochkin, PhD.
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
2
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
3
New HHP Resource Section
www.betterhearing.org/professionals
4
Benefit & Quality of Life Changes
Associated with Hearing Aid Usage
June 2011
Hearing Journal
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
• N=1,900 for hearing aids <= 4 yrs of age
6
Hearing handicap improvement (%)
Mean = 55%
7
Hearing handicap improvement (%) for the
U.S. population in 10 listening situations
8
Quality of life changes attributed to hearing
aid usage by hearing aid owners
9
Quality of life changes attributed to hearing aid usage
75% of hearing aid owners experience improvement in
at least 1 of 14 QOL issues.
10
Consumer satisfaction with QOL changes attributed to
hearing aid usage
8 of 10 people are satisfied with QOL changes in their life due
to hearing aids.
11
Hearing handicap improvement (%) segmented by
composite best practices ranking scored in percentiles
12
QOL changes attributed to hearing aids by hearing aid
owners segmented by composite best practices
ranking scored in percentiles
13
Overall consumer success (mean=5, std=2) by level of
composite best practices ranking scored in percentiles
Highly vulnerable to
disruptive
technologies: overthe-counter, directmail and personal
sound amplifier
Products (PSAP)
14
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
15
Promotion
• Use the positive findings of
hearing aids and quality of life in
your press releases to promote
your practice.
• http://www.betterhearing.org/profe
ssionals/public_relations_campaig
ns.cfm
– Under 2011 customer satisfaction
campaign
– Local press release
– Backgrounder for media
• See how other audiologists are
using our material – sample media
clippings.
16
Efficacy of Hearing Aids in Achieving
Compensation Equity in the
Workplace
The Hearing Journal
October 2010
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?
18
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.
19
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.
20
Income declines as a function of hearing loss
Mild
Moderate
Severe
21
Significant divergence in income profiles for aided
and unaided households
Mild
Moderate
Severe
22
Estimated Income loss ($000) compared to normal hearing
households (n=34,351) by severity of hearing loss for aided
(n=1,818) and unaided (n=3,232) households
23
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.
24
Unaided individuals have significantly higher unemployment rates
Segmentation in hearing loss quintiles
Considering only individuals still in the workforce
25
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.
26
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
27
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
28
Examples of leveraging income study in media
Current OpEd Piece
Sample Private Practice
Ad
29
Example : Leveraging income study in
media
30
Mini-BTEs attract new market, users more
satisfied
Hearing Journal
March 2011
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?
32
Hearing aid style mix (%) CY 2005-2008
Source = MarkeTrak VIII Database
33
Method
• Simple comparison
– Mini-BTE users
– Traditional style users
• First look at demography
34
Demography
Mini-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%)
35
Customer satisfaction
Mini-BTE compared to traditional style
Controlling 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
36
Customer satisfaction
Mini-BTE compared to traditional style
Controlling 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
37
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) 38
Promotion
• Promote the positive
benefits of mini-BTE
based on BHI on
consumer feedback:
•
•
•
•
overall satisfaction
cosmetics
sound quality
multiple environmental
listening utility (MELU)
39
Economics of Verification and
Validation on Private Practices
Hearing Review
June 2011
40
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 realworld 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.
41
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 patient’s 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.
42
Percent of patients reporting that verification and/or
validation was used during the hearing aid fitting
process (New hearing aids, n=787)
Average patient visits to fit hearing aids based on use of
verification (REM) & validation procedures (objective or
subjective).
Patient visits=3.57 – REM*.75 – validate*1.02 +
V+V*.6
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 rate=74.3% 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.
45
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 @$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.
46
Prevalence of Tinnitus and
Efficacy of Treatments
Co-authors
Richard Tyler – U of Iowa
Jennifer Born - ATA
Hearing Review
November 2011
47
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.
48
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
49
Tinnitus population (millions, 2008)
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
51
Incidence of tinnitus by age group. Incidence derived
by comparing age population from NFO panel with
U.S. Bureau of Census population in 2008.
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
53
Severity of Tinnitus
(Means on 0-100% scale; n=3,187)
•
•
•
•
•
% 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
54
Impact of tinnitus on quality of life (n=3,431)
Efficacy of treatments
(n=3,473 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.
56
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%)
57
Direct Query on Hearing Aids.
Effectiveness in mitigating effects of tinnitus (n=1,314)
Direct Query
How often hearing aids are effective in
mitigating effects of tinnitus (n=553)
Greater chance of tinnitus mitigation with hearing aids
when best practices used in hearing aid fitting (n=732)
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
61
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
62
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.
63
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.
64
The Validity and Reliability of the
BHI Quick Hearing Check
Kochkin, S. and Bentler, R.
The Hearing Review
November 2010
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
66
Introduction
• Wide-scale availability of simple selfmeasures 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 risk”…if so visit an
audiologist
67
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 (n=74) but not in use today
68
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
69
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 –
Cronbach’s alpha) very high where a
score of 100% is perfection:
– NCOA database = 95%
– MarkeTrak = 94%
70
Objective Validity
Correlation between audiogram
information and BHI Quick
Hearing Check
Relationship between the BHI Quick Hearing Check and
average speech threshold scores
Model = better ear
72
Relationship between the BHI Quick Hearing Check and
average threshold scores
Model = 5PTA both ears
y = 25.38 +.6787x
R2 = .84
73
Probability of hearing loss of 40 dB (both ear average)
or higher based on BHI Quick Hearing Check scores
74
Subjective Validity
Correlations between
subjective measures of hearing
loss and the BHI Quick Hearing
Check
Average BHI Quick Hearing Check Score by level of
performance on the Gallaudet Scale
Self-ratings MarkeTrak VIII
N=7,201, r=.49
76
Average BHI Quick Hearing Check Score by level of
self and family member perception of hearing loss
77
Average BHI Quick Hearing Check score by level
of Plomp’s difficulty of hearing in noise scale
Self ratings – MarkeTrak
VIII
N=7,201, r=.64
78
Concurrent Validity
BHI Quick Hearing Check
correlations with issues
tangentially related to hearing
loss
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
80
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.
81
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 > 40 dB in
both ears
– Subjective classification of
HL based on consumer
perceptions (standard
audiological classification
judged too conservative
based on consumer
perceptions)
– Recommendation
82
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 paperand-pencil form
–
–
–
–
Drug store
Ads
Chiropractor offices
Health fair handout
83
Impact of Direct Mail and Low
Cost Listening Devices on Hearing
Aid Sales
Hearing Review
June 2010
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 don’t 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
85
Introduction
• Recent proliferation of devices with extensive
television ads.
–
–
–
–
Lee Major’s Bionic Ear
Silver Sonic XL
Loud N’clear
+ 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?
86
Sample products
87
Resurgence of Internet, DM and
over-the-counter sold hearing aids
88
Direct mail firms selling pre-programmed
digital open fit hearing aids ($400-$895)
89
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
90
Relative internet ranking (000)
Internet ALDs versus HIA members
62
67
74
Silver Sonic
Songbird
Loud n Clear
118
HIA10
156
178
HIA9
HIA8
271
HIA7
334
356
385
397
427
462
Ampli-ear
HIA6
HIA5
HIA4
HIA3
HIA2
576
HIA1
0
100
200
300
400
Rank (000)
Note: Lower ranks denote higher traffic
500
600
700
91
Estimated web visitors per month
ALDs versus HIA members
ALD= Songbird, Sonic XL, Loud n Clear, Ampli-ear
Jan
2008
HIA
ALD
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Jan
2009
0
100000
200000
300000
400000
500000
600000
92
Summary demography
Custom 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
93
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
94
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?
95
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%
96
Likelihood of purchasing custom hearing aids in
absence of PSAP as reported by non-owner population
Overall likelihood = 17.8%
97
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.
98
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
99
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 preprogrammed hearing aids at Walmart, Drugstores, Sam’s 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).
100
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
101
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.
102
Acknowledgement
• All MarkeTrak
research is made
possible by a special
grant from Knowles
Electronics.
103