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New BHI Research (Part 2) Efficacy of Hearing Aids in Achieving Compensation Equity in the Workplace Sergei Kochkin, PhD Agenda • Impact of hearing aids on income and employment • Impact of mini-BTEs on the market • Validation of the BHI Quick Hearing Check • Impact of Direct mail and PSAP on private practices 2 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? 4 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. 5 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. 6 Income declines as a function of hearing loss Mild Moderate Severe 7 Significant divergence in income profiles for aided and unaided households Mild Moderate Severe 8 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 9 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. 10 Unaided individuals have significantly higher unemployment rates Segmentation in hearing loss quintiles Considering only individuals still in the workforce 11 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. 12 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 13 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 14 Examples of leveraging income study in media Current OpEd Piece Sample Private Practice Ad 15 Example : Leveraging income study in media 16 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 receiverin-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? 18 Hearing aid style mix (%) CY 2005-2008 Source = MarkeTrak VIII Database 19 Method • Simple comparison – Mini-BTE users – Traditional style users • First look at demography 20 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%) 21 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 22 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 23 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) 24 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 26 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 risk”…if so visit an audiologist 27 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 28 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 29 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% 30 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 32 Relationship between the BHI Quick Hearing Check and average threshold scores Model = 5PTA both ears y = 25.38 + .6787x R2 = .84 33 Probability of hearing loss of 40 dB (both ear average) or higher based on BHI Quick Hearing Check scores 34 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 36 Average BHI Quick Hearing Check Score by level of self and family member perception of hearing loss 37 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 38 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 40 relationships Use of 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. 41 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 42 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 • Also available in paperand-pencil form – – – – Drug store Ads Chiropractor offices Health fair handout 43 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 45 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? 46 Sample of products 47 Resurgence of Internet, DM and over-thecounter sold hearing aids 48 Direct mail firms selling pre-programmed digital open fit hearing aids ($400-$895) 49 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 50 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 Note: Lower ranks denote higher traffic 300 400 Rank (000) 500 600 700 51 Estimated web visitors per month ALDs versus HIA members ALD= Songbird, Sonic XL, Loud n Clear, Ampli-ear 2008 Jan HIA ALD Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec 2009 Jan 0 100000 200000 300000 400000 500000 600000 52 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 - Mn 7 8 15 53 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 54 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? 55 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% 56 Likelihood of purchasing custom hearing aids in absence of PSAP as reported by non-owner population Overall likelihood = 17.8% 57 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. 58 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 59 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. 60 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 61