Hearing Review July 2014
By Dennis Van Vliet, AuD
Best Practices. What does the term mean, and who decides what are the best practices, or the standard of care? With respect to hearing aids, there are published standards offered by professional organizations and other stakeholders. My experience with these efforts is that a group of experienced clinicians, researchers, and educators meet and develop a series of recommendations. These are offered to the professional community for peer review, and eventually published. The published standards typically are not too specific so that the document can outlive new technology and protocols that may emerge in the time following the release of the document.
The standards typically include language that the practitioner should act ethically, not harm anyone, and use the best available evidence for guidance in the approach we take clinically. The lack of specificity gives us some freedom to develop our own unique approach to patients.
What we see and hear in clinics and offices is that clinicians are typically following guidelines and what they learned in their training, with a number of common elements. Practitioners typically follow a similar path when attempting best practices, and include most of the following:
- Evaluation. A basic need for understanding the type and extent of a patient’s hearing loss is an evaluation performed within the scope of practice of the clinician. The evaluation typically includes procedures to identify and need for medical referral, along with measures to help with any subsequent hearing aid fitting.
- Rehabilitation-specific history with respect to the needs and concerns of the patient. Treatment plans are designed using the unique needs of the patient as a guide to develop specific recommendations to address those needs. A careful interview with the patient and any significant others helps uncover those needs.
- Form factor and technology selection. When the treatment plan includes hearing aids or similar devices, the selection of the technology and the form factor of the hearing aids are a key part of the rehabilitation plan. The fact that form factor and technology choice have matured well beyond the small, medium, and large choices of a decade or more ago suggests that there is room for careful best practice guidelines when approaching these clinical decisions.
- Fitting using appropriate methodology to achieve audibility, comfort, and performance goals. As technology has improved, giving us the capability to make more extensive adjustments compared to the 1970s—when earmold drilling and lamb’s wool in the tubing were the go-to methods—we have had to adapt our skill sets and approach to fitting. Then, as now, audibility and comfort are important, but today there are other important factors to consider that affect performance.
- Verification and validation. There’s a good deal of angst about verification and validation. Most of us report relying on a subjective response rather than following the commonly discussed best practices of objective verification of the fitting, and using a standardized validation method. That is a discussion subject for another time. I will only say that the fitting screen of your programming computer is only an estimate of what is happening in our patients’ ears. Accuracy is dependent upon acoustic parameters, which are affected by the earmold depth, residual cavity size, venting, as well as the information we enter into the computer, such as receiver gain or, in the case of a behind-the-ear (BTE) product, whether it is a thin tube or #13 tube fitting. The data on the fitting screen should be viewed as only an estimate of the signal delivered to the ear and not true verification. Similarly, payment in full for hearing aids and assurance that everything is “fine” is not validation.
- Rehabilitation plan including coaching on behavioral changes to optimize communication, auditory skills training, and global lifestyle changes to encourage wellness and cognitive capacity. Currently, we may talk about this, but I see little evidence that we are successful in getting patients to actively engage in these efforts.
- Ongoing follow-up and support. I think we all offer long-term support, but what are our goals, and how do we direct the follow-up to ensure optimal outcomes for our patients?
I may have asked enough questions in the list above to stimulate some introspection. If you take the time to do that, let me offer some more questions for consideration. When I ask myself what has changed in the past few years in hearing aid offerings that may change how we approach hearing aid fittings, I can think of two critical areas: 1) Wireless connectivity, and 2) The refinement of noise reduction capabilities in hearing aids.
Wireless has a high tech appeal, and brings easy-to-demonstrate benefits to specific life activities, such as telephone communication and television or video enjoyment. Do we have a protocol for selection and setup of wireless systems? Are we following up to see that patients are using them? If they are not, why not? Do we ask if the patient has a pacemaker device? We should ask that question, to ensure that we select a system that will not interfere with a pacemaker.
I discussed noise reduction in last month’s Final Word. We should be developing and implementing protocols for deployment of noise reduction to ensure comfort and performance—not simply allowing defaults to dictate our fittings.
The Final Word? Best practices are in place to help guide us to provide excellent care for our patients. As we look at our daily practice, we need to remember that they are called “Best Practices” not “Good-enough Practices.”
Original citation for this article: Van Vliet D. “Best practices” ? “good-enough practices”. Hearing Review. 2014;21(7):50.