A retrospective analysis of hearing aid returns and exchanges in a clinical setting over a 5-year period has yielded both expected results, as well as some interesting and unexpected findings. In particular, insured individuals were 5.4 times less likely to return their hearing aids than self-paying patients. As the technology level of the hearing aids increase, so does the likelihood of return. Additionally, new users with milder losses and experienced users with more severe losses are more inclined to return/exchange hearing aids.

The primary goal of hearing care professionals when fitting hearing instruments is to have a satisfied patient who consistently wears their hearing aids and experiences optimal speech intelligibility. Unfortunately, not all patients are successful with hearing aid use, resulting in a number of instruments returned to manufacturers. The purpose of this study was to expand on the previous research regarding hearing aid returns, but with a focus on a comparison of exchange rates and return rates, as well as the effect that advanced technology has on these rates.

Several studies have analyzed hearing aid return rates, revealing a variety of underlying causes.1-5 More than a decade ago, Madell et al.4 indicated that experienced hearing aid users have a significantly lower return rate than new users because of their apparent recognition of the need for amplification. They also reported a higher return rate (27.1%) for those patients with milder losses that may not realize the benefit from amplification. A more recent study by Weigand et al.1 identified the most common reason for hearing aid return as “insufficient benefit.” From these studies, several suggestions have been made for minimizing the rate of return, such as increasing patient education,6 emphasizing the importance of counseling patients towards realistic expectations,7 and the need for the patients to more consistently wear the hearing aids each day during the trial period.8

Understanding “Returns” and “Exchanges”
A distinction should be made between hearing aid “returns” and “exchanges” as viewed by the manufacturer compared to the dispensing professional. Although Strom9 reported an annual national return rate between 17.5% and 18.5% every year since 1994, the recent investigation by Weigand et al.1 in a hospital dispensing clinic revealed an 8.6% return rate. A possible reason for this discrepancy between dispenser and manufacturer returns is that a dispenser typically does not consider a particular case a return if the hearing aids are replaced by a different brand or model.10 In this case, the patient still receives benefit from amplification, but the manufacturer still must accept a hearing aid back for credit. This category of cases is typically termed an “exchange” rather than a “return” by the dispenser, although it still results in a return to a manufacturer.

Another possible explanation for these return rate differences may be the way in which a monaural fitting is viewed by the dispenser. Any hearing aid returned to the manufacturer constitutes a “hearing aid return.” However, if one aid is returned from a binaural fitting, the patient still benefits from amplification from the one aid, resulting in satisfactory hearing aid use. The dispenser may consider this a successful monaural fitting even though it involves a hearing aid return.

Although an exchange or a switch from a binaural to a monaural fitting might be considered a successful fitting in the end as opposed to a true return, it still has a negative impact on the expenditure of time and additional cost to achieve a successful conclusion. For example, if a patient is unhappy with a particular hearing aid fitting and the dispenser and patient jointly decide to try a different form of amplification—whether it be a change in style or an upgrade in technology—the following typical sequence might occur:

  1. The patient is seen for the initial consultation and taking of impressions, and then returns for the hearing aid fitting;
  2. After 2 or 3 follow up visits, the patient requests an exchange for a different style or model. A discussion of that change is conducted and new ear impressions are taken;
  3. A second hearing aid fitting is performed with numerous follow up visits (and even more possible exchanges) to finally result in a satisfactory fitting.

Thus, one can surmise that although the fitting may be successful for the patient, the amount of time spent with that patient could easily be doubled when an exchange takes place. For the dispenser, the cost effectiveness is diminished, and from the manufacturers’ perspective, a return has an obvious deleterious effect on the cost of all products sold by that manufacturer. (For further discussion of this subject, see Sweetow et al’s article in this issue of HR.)

With the advent of advanced programmable and digital technology in many hearing aids, another issue is raised as to whether this new technology will improve the success of hearing aid use and thus reduce the rate of hearing aid returns as well as exchanges. Unfortunately, recent data indicates just the opposite effect has occurred, with a higher rate for the return of digital hearing aids (27.74%) as compared to programmable analog instruments (19.24%).11 A plausible explanation for this seemingly negative impact on the recommendation for higher technology is the interest among existing users to try newer products. A current hearing aid user may be fitted with digital hearing instruments, but after the trial period may decide that the improved benefit is not significant enough as compared to their existing hearing aids to justify a replacement or upgrade at that time.

When experienced users are excluded from the data, a question then arises as to whether advanced technology reduces the return rate for a new user compared to analog products. To date, none of the previous studies mentioned have concentrated on the effect of advanced technology on return and exchange rates.

Another factor that must be considered is the degree of hearing loss of the user. Madell et al.4 reported that patients with milder hearing losses tend to have a higher return rate on hearing instruments. Thus, an important question would be to see if advanced technology for patients with mild hearing loss tend to increase the success and retention of hearing aid use and thus reduce the return rate.

In addition to the effects of technology level and degree of hearing loss on return and exchange rates, the following study evaluated the effects of style, payment, user experience, and binaural versus monaural effects.

Subjects
Hearing aid fittings of 1,296 patients with a mean age of 67.5 who were seen at two private clinics in Southern California were analyzed in this study. The mean age of these patients was 67.5 years old. Forty-six percent of the subjects were female (601) and 54% were male (695). Previous hearing aid users at the time of fitting constituted 56% of the total patients (724), and 44% were new users (573). A vast majority (69%) of these patients were self-paying patients, purchasing the aid with no third-party reimbursement. Eight percent (103) of the patients paid for a portion of the hearing aids with a portion being paid by an insurance company. Twenty-three percent of the fittings (301) were paid in full by a third-party insurance provider or Medicaid.

The hearing loss for each patient was averaged using the 3 speech frequencies of 500 Hz, 1000 Hz, and 2000 Hz for each ear that was fitted with a hearing aid. Thus, if it was a monaural fitting, only the hearing loss for the ear that was fitted with the hearing aid was included in the calculation of the hearing loss data. In a binaural fitting the hearing loss was the average of all 6 frequencies between the two ears. The standard categorization of hearing loss was used to differentiate the patients into the various categories of hearing impairment.12,13 Keep in mind, however, the hearing loss above 2000 Hz was typically worse than the loss at the 3 frequencies used in the calculation. Thus, the categories generally underestimate the overall hearing loss. Table 1 displays a summary of the hearing loss data.

Degree of  Hearing Loss No of Patients Hearing Loss %
    Slight
Mild
Moderate
Moderate-Severe
Severe
Profound
80
395
459
214
110
38
6.2%
30.5%
35.4%
16.5%
8.5%
2.9%
Table 1. The total number and percent for each degree of hearing loss (n=1296).

Fitting Characteristics
Six different audiologists, 2 of which were full-time and the other 4 worked part-time, performed fittings over a 5-year period from 1997 to 2002 at the two clinics. Binaural fittings accounted for 747 of the patients fitted with hearing aids, constituting 58% of all fittings, with 42% being monaural fittings (549). CROS fittings and bone-conduction aids were included in the monaural data. The fitting of FM systems was not included in this study. In addition, any fittings conducted at skilled nursing facilities were excluded.

Hearing instruments from 15 manufacturers were fitted to a total of 1,296 patients (Table 2). Nine of these manufacturers constituted 94.5% of all the hearing aid fittings, with the greatest concentration from 5 of the manufacturers, making up 80.5% of the fittings for a total of 2,036 hearing aids. Although the number of manufacturers used may be considered unusually high, typically only 3 or 4 manufacturers were used for most of the fittings at any given point in time. The manufacturer preference for each dispensing audiologist changed from time to time over the 5-year period.

    Brand # of Patients Total Aids    % of Total Aids
    Siemens
Rexton
Widex
Phonak
Starkey
Oticon
3M/Sonar
Sonic Innovations
ReSound
Others
363
317
171
107
91
52
45
40
35
69
583
450
287
181
140
78
74
68
67
107
28.6%
22.1%
14.0%
8.9%
6.9%
3.8%
3.6%
3.3%
3.3%
5.5%
Table 2. A listing of manufacturers used for the hearing aid fittings with number of aids and percentages.

The style of hearing aids was broadly distributed among the 4 categories, with the in-the-ear (ITE)/half-shell (HS) style and the behind-the-ear (BTE) style each constituting about one-third of the fittings. The remaining third was divided among in-the-canal (ITC) and completely-in-the-canal (CIC) styles as shown in Table 3.

Style # of Patients % of Total
    BTE
ITE/HS
ITC
CIC
413
432
264
186
32%
33%
21%
14%
Table 3. A summary of the different styles of hearing aids used in the fittings.

The level of technology utilized in the hearing instruments that were fitted were separated into 4 categories. The hearing aid fittings were considered conventional in technology when no computer programming feature was available in the aids. The programmable category constituted the hearing aids that had a computer programming feature but still utilized analog circuitry. The hearing aids with digital signal processing were separated into two categories: 1) Entry-level digital aids were classified as those with 4 or fewer bandwidths or processing channels and were absent additional features such as directional microphones or noise reduction capability; 2) Digital hearing aids with expanded multi-channel capability between 5 and 20 bands with noise reduction circuitry and/or directional microphones were placed in the premium digital category. As shown in Table 4, 46% of all the hearing aids that were fitted during this 5-year period had some type of digital processing. Forty percent (525) of the fittings were analog programmable fittings, and 14% (181) of the fittings were performed using conventional technology.

    Technology # of Pts % of Total
Conventional
Programmable
Entry-Level Digital
Premium Digital
All Digital
181
525
310
280
590
14%
40%
24%
22%
46%
Table 4. A summary of the different levels of technology used in the fittings.

Results and Discussion
The hearing aid fittings resulted in a total return of 310 out of 2,036 received back by the manufacturers for a 15.2% return rate. This result is somewhat lower than the average return rate that manufacturers have reported.9,11 When measuring it on a per-patient, rather than a per-aid, basis and eliminating those hearing aids that were exchanged for a different model or brand, the total number of returns were 120 out of 1296 or 9.3%, which is consistent with the 8.6% reported by Weigand et al.1

In total, 67 exchanges occurred for a total of 5.2% of all fittings. If the 20 “partial hearing aid returns” (ie, cases in which the patient kept only one of the two aids in a binaural fitting) were subtracted from the total complete returns, the return rate was reduced to 100 cases or 7.8%. Finally, if the patients that were previous hearing aid users who came in to obtain new hearing aids or to try newer technology were eliminated from the returns, the actual number of potential new hearing aid users that left the office without wearing any hearing aids totaled 37 or 2.9% (Figure 1).

Figure
Figure 1. “Return rates” are contingent on how a hearing aid return is defined. The total aid returns in this study are fairly consistent with manufacturer data. However, if the returns involved an exchange (one or two aids exchanged or one aid of a binaural fitting returned) and previous users are also factored out of the data, the percent of hearing aids returned is 2.9%.

Six key variables were analyzed to determine their effect on return and exchange rates: a) Payment type; b) User experience; c) Hearing loss; d) Monaural versus binaural; e) Hearing aid style, and f) Level of technology. The results are summarized in Table 5.

f01_table5.gif (24708 bytes)
Table 5. A summary of 6 variables and their effect on rates of hearing aid return and exchange.

Payment Type. The Pearson Chi-Square statistic indicates a significant association between hearing aid return and payment type [X2(1)=23.4, p<.0001]. In general, patients are more likely to keep the hearing aids when there is no financial obligation (Figure 2). Insured individuals were 5.4 times less likely to return their hearing instruments. These results are also consistent with previous findings.1 The same pattern of results was not evident with hearing aid exchanges. Although there is a trend toward slightly higher exchange rates among individuals who pay privately, the association between exchange rate and payment type is not statistically significant (Figure 3).

Figure
Figure 2. A significant difference was found in return rates as a function of payment type with a higher return when the patient contributes either partly or fully to the cost of the hearing aids.

Figure
Figure 3. The rate of exchange also showed some difference between self-pay patients and those who received third-party assistance.

User Experience. Although an earlier study by Madell et al.4 indicated that the return rate was lower for experienced users than new users, the present study showed a slightly higher return rate for experienced users. One would expect that an experienced user would rarely return an aid because of an already established appreciation for the benefit derived from hearing aid use. However, the likely explanation for this increase in return rate is the desire of current hearing aid users to upgrade to advanced technology before the end of the typical service life of their hearing aids and the normal replacement cycle. They then discover that the improved benefit of advanced technology does not justify replacement at that time. These results may not only be due to the insufficient performance improvement of the advanced technology, but could also be an habituation to the sound quality and performance of their previous hearing aids. The end result is a higher return rate than what was previously reported.

The effect of user experience (Figure 4) shows that experienced users are more particular about hearing aid styles, options, or technology, showing a significantly higher exchange rate (7.2%) as compared to new users (2.6%) [X2(1)=15.1, p<.001]. This was a likely result when considering that experienced users have a previous reference on which to compare the new instruments and new users are focusing on the benefit of amplification generally rather than specific characteristics of the instruments.

Figure
Figure 4. No significant difference was found in return rates of new vs. previous users. However, experienced users showed a significantly higher exchange rate than new users.

Monaural vs Binaural Fittings. The difference between monaural and binaural fittings was not significant for the rate of return, but did show a significant association for exchange rate [X2(1)=8.76, p<.01]. Figure 5 shows this variation with binaural users requesting an exchange (6.6%) exactly twice as often as monaural users (3.3%).

Figure
Figure 5. There was no significant difference in return rate for binaural versus monaural fittings. However, binaural fittings resulted in a significantly higher exchange rate than monaural fittings.

Hearing Aid Styles. A comparison of hearing aid styles revealed some interesting findings regarding return rate (Figure 6). There is a general trend for returns to increase as the size of the aid becomes smaller, especially for CICs for both new users and experienced users. An anomaly to this trend is toward higher return rates for BTEs for previous users relative to new users. The explanation to this anomaly may be the use of “Demo” BTE aids incorporating digital processing fitted to previous hearing aid users so they can experience new technology without the obligation of a formal purchase. The rate of exchange shows little variability for different styles for all users. However, there are some unusual differences for the smaller styles of instruments with experienced users exhibiting a higher exchange rate than new users (Figure 7).

Figure
Figure 6. The rate of return was higher for CIC style hearing aids for all users, and the BTE style for experienced users.

Figure
Figure 7. The rate of exchange shows little variability for different styles for all users. However, there are some unexpected differences for the smaller styles of instruments, with experienced users exhibiting a higher exchange rate than new users.

Level of Technology. As hearing aids become more advanced in their performance, one expectation might be that benefit from amplification would be more readily realized and result in a lower rate of return. However, as indicated previously, data from manufacturers reveal that just the opposite is true, with as high as a 27% rate of return for digital instruments and 19% for programmable instruments.11 Weigand et.al.1 also reported that the return rate for digital aids was dramatically higher (57%), as well as programmable aids (16.7%). However, their results were based on only 7 digital fittings and 12 programmable fittings out of 394 total fittings, which was insufficient to make any determination of the effect of advanced technology.

This current study, with 590 digital aid fittings (which is 46% of the total of fittings) and 525 programmable aid fittings (40%), presents sufficient data to accurately represent a typical return rate as a function of technology. Results of this study do, in fact, confirm a significantly higher return rate as the technology becomes more advanced, as shown in Figure 8 [X2(3)=30.5,p<.0001]. It is noted, however, that the overall return rate is lower than data previously reported, particularly for new users which show a more gradual increase than for experienced users.

Figure
Figure 8. For all users, the rate of return increases as technology becomes more sophisticated. The rate of return relative to technology is greater for experienced users compared to new users.

Exchange rate is also significantly higher for digital products [X2(3)=13.9, p<.01], especially for experienced users (Figure 9). It is interesting to note that the highest rate of return occurred with entry-level digital hearing aids fitted to experienced users (16.6%).

Figure
Figure 9. As with the return rate, the overall exchange rate for experienced users is significantly higher as technology level increases compared to the new user exchange rate.

Exchanges, Returns and Degree of Hearing Loss. The exchange rate that occurred as a function of degree of hearing loss resulted in one rather obvious effect (Figure 10). Experienced users with a profound hearing loss exhibited the highest exchange rate (12%), which is consistent with the particular needs of this group. These individuals often require some experimentation before deciding on a certain brand and model of hearing aid. There was also a slightly higher rate of exchange for experienced users with a mild or moderate hearing loss.

Figure
Figure 10. The degree of hearing loss shows a variable effect on the exchange rate for all users as well as experienced and new users separately.

Of particular interest is the effect of degree of hearing loss on return rate. As shown in Section C of Table 4, a look at all subjects indicates a relatively random variability on the rate of return across all degrees of loss. However, when previous and new users are separated, a significant trend emerges (Figure 11). A Pearson Chi-Square statistic shows a significant association between degree of hearing loss and type of user (new vs. experienced) [X2(5)=30.25, p<.0001). For previous users, the return rate consistently increases as the hearing loss worsens. Conversely, the return rate decreases as the hearing loss worsens for the new users. The likely explanation for this result is that new users with slight or mild losses do not perceive enough benefit to continue hearing aid use which is consistent with previous data.4 In fact, the two moderately-severe hearing-impaired new users who did not keep at least one aid reported an intolerance for hearing aid use and a refusal to wear them, but the return was not due to a lack of perceived benefit.

Figure
Figure 11. When experienced users and new users are viewed separately relative to the degree of their hearing loss, a significant trend emerges. Return rate increases as hearing loss worsens for experienced users, but decreases as hearing loss worsens for new users.

A possible explanation for the trend of higher returns for those experienced users with greater hearing losses is the assumption that, although these patients already benefit from amplification, the reduced hearing aid benefit as a result of the more severe hearing impairment causes them to search for improved technology. They then become disappointed when the new technology doesn’t meet their expectations. This results in a higher return rate. This assumption appears to be confirmed by the higher rate of return and rate of exchange of digital technology for previous users (15.3% return, 11.9% exchange), than for new users (9.1% return, 3.4% exchange) as previously indicated (Figures 8 and 9).

More on Exchanges. The underlying reason for exchanges are likely the desire of the clients to upgrade the technology of their hearing aids to hopefully further improve their communication abilities and/or to improve the appearance of the aids by changing to a smaller size. Another possibility is an attempt by the user to improve the perceived cost-benefit ratio.

The 67 exchanges were placed into 4 categories:

  1. A style change (17 exchanges);
  2. A change in technology (25);
  3. A brand change (14), and
  4. Other (11), which included comfort and financial issues.

The style changes were primarily from a larger aid to a smaller aid (11). An exchange to a different brand was most often due to product quality issues, although performance and technology may have contributed to the request to make this brand shift. Of the requests for a change in performance related to technology, only 3 of these exchanges were a switch from high-end digital to entry-level digital instruments, and 5 exchanges were from conventional to programmable aids. The remaining 17 exchanges in this category were evenly distributed among programmable and entry-level digital products. The exchange from these mid-level products showed no trend in either direction, with 8 upgrading to advanced technology and 9 downgrading to more basic technology.

Summary
An analysis of hearing aid returns and exchanges over a 5-year period has yielded both expected results, as well as some interesting and unexpected findings. In particular, a financial commitment to the purchase of hearing instruments showed a significant effect on both the rate of returns and exchanges as would be expected. But the rate of return is not different between new and experienced users. The difference in these results relative to earlier studies is due to the return rate from experienced users as they consider upgrading to advanced technology. Experienced users also tend to require more experimentation with different instruments, increasing significantly the rate of exchange. The style of the aid affects return rate, with a higher rate for CIC instruments for all users and a higher rate for BTE instruments for experienced users, resulting in a higher overall return rate.

Exchange rates for experienced users were primarily due to changes in technology. However, there was no consistency with these exchanges; some users reverted back to more basic technology while others regretted the initial hearing aid selection and later requested more advanced technology. Exchanges based on style were also inconsistent with size changes occurring in either direction, although more patients tended to prefer an exchange to a smaller hearing aid.

A rather revealing result was the variable effect of hearing loss on the rate of return as a function of user experience. New users with milder losses returned hearing aids more frequently, but experienced users with more severe losses were even more likely to return aids.

The effect of technology also resulted in higher return rates as the technology level improves, with greater effect for experienced users than new users. It appears that advanced features alone—or the description of features and benefits associated with the promotion of these products—does not always outweigh the increased cost.

Previous research has suggested that counseling is a critical component in increasing patient satisfaction.7 But this should not be only during the post-fitting period to emphasize realistic expectations, but just as importantly, during the initial consultation and pre-selection process. A more conservative approach to determining the degree of hearing aid benefit for those patients with milder losses may be appropriate for new users. This approach may also be more suited to experienced users with more severe losses when introducing advanced technology. The time spent during this counseling session to identify the specific needs and preferences of a given patient regarding style, appearance, and the value and benefits of higher end products may also help minimize the number of exchanges that occur. The dispenser should attempt to identify the relative salience of technology, cost and benefit to the patient in advance.

Despite this suggestion for proper counseling that, at times, is conservative in nature, a goal of having no returns or exchanges in a dispensing office/practice is not necessarily a healthy approach either. Obviously, from the data presented here, returns and exchanges are a significant expense for dispensing practices and manufacturers alike (see article by Sweetow et al. in this issue of HR). However, a “zero tolerance” for returns might suggest that no risk is being taken in encouraging those “fence-sitting” potential users to try hearing aids or the experienced users to upgrade their quality of amplification. If too conservative, a proportionately larger number of patients may not enjoy the benefits of improved hearing for the sake of reducing the number of unsuccessful fittings and minimizing returns.

Further research is needed to sort out issues relative to an appropriate patient counseling strategy.

Acknowledgements
The authors thank Christopher Puppé, Katherine Wafford, and Nicole Hurtado for their assistance with the data collection.

 Miles E. Peterson, PhD, (pictured) is an audiology professor at California State University, Los Angeles (CSULA) and owner of the Hearing Science practices in Southern California. Theodore S. Bell, PhD, is an audiology professor at CSULA.

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Correspondence can be addressed to HR or Miles Peterson, PhD, Hearing Science of Rancho Cucamonga, 8283 Grove Ave, Ste 104, Rancho Cucamonga, CA 91730; email: [email protected].