09/15/17. What is the Impact of Game Changers in the Hearing World? Paradigm Shifting Connectivity. Game Changers in Hearing Aids 2017

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1 Game Changers in Hearing Aids 2017 What is the Impact of Game Changers in the Hearing World? Paradigm Shifting Connectivity To Audio Sources To Apps Between Hearing Aids To Professional Services A Paradox of Game Changers? Personalization Internet Research Maker Culture / DIY Connectivity Social Media Or a Convergence of Game Changers? What are the Capabilities of Connectivity Today? Personalization Internet Research Maker Culture / DIY Connectivity Social Media 1

2 Connectivity in Amplification Marketrak 9 Personalization The Hearing Aid Environmental classification Feedback suppression Directionality Noise reduction Sound Connectivity Remote control Tinnitus masking Special functions (frequency shaping, geotagging, Find My Hearing Aid, etc.) Made for iphone Accessories Satisfaction: Hearing Aid Alone vs. Hearing System Hearing Aid+Accessory+App Hearing Aid+Accessory Hearing Aid Only Connectivity to Audio Sources and Apps 76% 78% 80% 82% 84% 86% 88% 90% 92% %Satisfaction The challenge Listening in noise Listening over distance Listening in environments with reverberation And listening without visual cues (e.g., phone) An Effective Solution Improving Signal-to-Noise Ratio (SNR) Via Wireless Signal Transmission 2

3 Wireless Signal Transmission via Accessories Wireless accessories overcome many problems that hearing aids alone cannot address: Hearing aids continue to become smaller causing difficulty handling controls for people with dexterity issues Many hearing aid users have difficulty hearing or understanding television and prefer volume levels that are uncomfortably loud for others in the room Hearing aid users often have difficulty hearing on the telephone, particularly mobile phones Difficulty hearing in noise where the hearing aid directional microphones are not enough to help the user Benefit Users can understand speech in noisy reverberant environments with the addition of accessories to their hearing system. Signal Transmission Signal Transmission Telecoils Analog Telecoil FM Infrared Digital NFMI + Bluetooth (open platform RF) Proprietary radio frequency (RF) 900 MHz Proprietary radio frequency (RF) 2.4 GHz Looping and T-coils The signal is transmitted electromagnetically, and requires a telecoil in the hearing instrument. Digital wireless can be used for transmission with extra devices and/or between hearing aids (earto-ear) Transmitter Receiver Telecoil FM Systems Advantages Improved signal-to-noise ratio Can install loops pretty much anywhere, including at home Telephone Integrated seamlessly into HA Can still use with earphones with no hearing aid Convenient Uses programmable HA frequency shaping Drawbacks Loop systems in public venues are expensive and require installation of loop More expensive than FM or IR system Cannot be used in more than one location at a time, or else interference will occur Telecoil strength varies across HA models, telephones Uses radio frequency transmission Modified or modulates a electromagnetic wave as a carrier of the signal The transmitter selects the carrier frequency and the receiver must tune to the carrier Long range (1000 ) 3

4 FM Systems & Benefits Infrared (IR) Advantages Improved SNR Used personally or with a group Uses HA frequency shaping Can separate multiple transmission signals via channels Doesn t require installation of loop (like telecoil loop systems) Drawbacks Requires use of extra equipment (receiver) even when used with Has Personal receivers are expensive Not always secure Must be tuned into correct channel Similar to FM but uses a much higher carrier frequency Uses AM instead of FM by pulsing the signal through the wave Operates at almost the same frequency as light, so acts like light Infrared Advantages Improved SNR More secure than FM Can be used personally or with a group Inexpensive (~$40 home, $3000 group) Can be used with or without HAs Drawbacks Need line of sight Does not take advantage of HA frequency shaping Requires use of extra equipment (receiver, neckloop) even when used with HAs Prone to interference from other light sources 2 Fun Examples of Interference in Daily Life #1: Automatic Soap Dispenser vs. Wall Heater Remote Control #2: Trick-Or-Treat Bowl vs. the Sun Analog vs. Digital Digital wireless transmission An apple to oranges comparison Both types have pros and cons Analog- less power consumption, may be better for large environments like theaters or lecture halls, universal Digital- Opens up the world of modern technology to be used with hearing aids, may not require as much extra equipment Listeners can successfully use both types! Audio source to accessory Analog-to-digital conversion (ADC) Greater the information being sent, the more energy/time it takes to be sent Must code digital signal to reduce size Send digital signal to transmitter/receiver Get the signal from the first device, send the signal to second device Decode audio signal Digital-to-analog conversion (DAC) Hearing aid 4

5 What Else Is There to Know about the Evolution of Wireless Signal Transmission? Let s Talk about Digital Delay! Delay of Transmission Sound Delayed with respect to Vision What is an acceptable delay? An undesirable lip-sync effect occurs at 120 ms when the visual occurs before the audio An undesirable effect occurs at 120 ms when the visual occurs before the audio Delay of Transmission NFMI How about an open ear? Transmission delay of 40 ms interferes with speech intelligibility benefit of wireless transmission for open fittings due to echo (Whitmer et al., 2011) Near Field Magnetic Induction NFMI systems contain strong transmission energy within the localized magnetic field The power density of near-field transmissions is extremely restrictive once you leave the transmission area, the signal strength rapidly deteriorates The carrier frequency is generally 10-14MHz So as wireless technology evolved, it became necessary to ensure that the delay was less than 40 ms. 5

6 NFMI NMFI combined with Bluetooth (RF) NFMI is great for HA-to-device (such as remote control) or ear to ear transmission of audio signals because transmission takes place within a small area (around 1m) Acceptable power consumption for hearing aid Signal is strong within transmission area, is weak enough outside area to decrease chance of interference with other WL signals BUT- long-range signals cannot be transmitted using this technique Bluetooth radio frequency is used for communication between audio source (such as cell phone) and a gateway device (streamer) NFMI transmission is used between the streamer and hearing aids Streamer is typically worn around the neck as the hearing aids/user needs to be within the NFMI field Near Field Magnetic Induction (NFMI) NFMI Combined with Bluetooth Bluetooth Coding Bluetooth Decoding NFMI Coding Considerations for this approach: Need to wear the gateway device around the neck Sound quality can be affected by orientation of the gateway device and HA Sound quality can also be affected by the delay of additional components A/D 2.4 GHz 2.4 GHz Bluetooth radio frequency is used for communication between an accessory and a Gateway device and NFMI transmission is used from the Gateway device to the hearing instruments. Why is it called Bluetooth? What is Bluetooth? Fun facts: Named for the 10th century Danish King, Harald "Bluetooth" Gormsson, that united warring tribes His initials (in runic alphabet) make the logo His nickname is thought to have come from a darkened front tooth as a result of fight or battle The Bluetooth technology was developed by Ericsson in 1994 Bluetooth is a unique wireless technology intended to realize three objectives: Eliminate the connection of wires Allow multiple devices to be connected at the same time, and to function as an intelligent whole Make location centric connectivity seamless 6

7 Proprietary Radio Frequency Systems Wireless Systems based on Proprietary Radio Frequency (RF) The proprietary RF system uses a radio to generate an electrical wave and an antenna to send the information. This type of transmission is referred to as far-field The electrical wave carries the information A/D Proprietary Coding 2.4 GHz 900 MHz 866 MHz 2.4 GHz 900 MHz 866 MHz Proprietary Decoding Uses ISM bands - Industrial, Scientific and Medical Frequency Band ISM Bands ISM Bands ISM bandwidth is defined by the ITU-R (International Telecommunications Union) for radio communication. Higher frequency transmission allows for greater data transmission. A trade off exists between amount of data transferred and current consumption. 900 MHz (US, Greenland, & some eastern Pacific Islands) 868 MHz (EU) 2.4 GHz (Worldwide, no geographical limitations) Primary drawbacks are: Battery drain or power requirements 2.4 GHz radio frequency Uses frequency hopping to transmit packets of data Can use up to 79 frequencies (1MHz intervals) in the 2.4GHz spectrum Personal network for up to 7 devices in theory Conventional wireless transmission hits the thermal noise floor at 1 meter. 2.4 GHz transmits as far as 10 meters before it hits the thermal noise floor. Why Doesn t 2.4 GHz or Proprietary RF Require a Body-Worn Streamer? 7

8 frequencies 09/15/ GHz radio frequency Antenna in Hearing Instrument HAs headset Wireless mouse Cell phone Mp3 player HAs Mp3 player HAs Cell phone headset Wireless mouse Cell phone Cell phone headset time Mp3 player HAs headset Devices agree on transmission frequency to send and receive each small data packet The Reception Doughnut HI built-in antenna Flexible antenna Antenna 45 mm long Antenna in Proprietary 2.4 GHz TV / Audio Streamer Hold it! So what is the difference between proprietary 2.4 GHz wireless and Bluetooth? They are transmitting in the same frequency band (2.4 GHz), they are both based on radio frequency But the protocols, or the rules guiding the data transmission, makes our RF transmission proprietary Bluetooth is an open platform, meaning many devices can use it 8

9 Bluetooth Smart Digital Wireless Transmission: Bluetooth Low Energy Introduced in 2011 Contains a low energy feature that has enabled a new breed of products that can communicate wirelessly for long periods of time without requiring much power Products include fitness monitors and many others. They can transmit data to Bluetooth Smart Ready devices, such as PCs, tablets and smartphones Bluetooth & Bluetooth Smart Some 2.4 GHz Languages Latency for Bluetooth protocol exceeds 40ms and is often up to 125ms depending on the audio compression technique used Combinations of the streamed sound with amplified sound or direct sound of this magnitude are perceptible as echoes and even lip synch issues when watching television Even small delays, though not consciously perceived, will cause a mismatch between audio and visual signals has a significant negative impact on the television viewing experience (Reeves & Voelker, 1993) Bluetooth Smart eliminated the audio channel to allow for fast and efficient transmission of data 2.4 GHz Proprietary Language Bluetooth Smart Apple Audio Streaming Wireless Fitting: Benefits for Fitter and Patient End User Benefits 9

10 NEW Noahlink Wireless Who can benefit? Problems Feedback on the phone Family member says TV is still too loud/can t hear TV Can t hear speaker in church/lecture/meetings Can t hear in noise (car or restaurant) Solutions No need to hold the phone to the ear Sound is processed through the HAs Listen can receive the signal of interest from mouth to ear Impact of Improving Multiple Environmental Listening Utility (MELU) on Overall Satisfaction Who Would Benefit from a TV Streamer Accessory? (All hearing aid owners n=2,572) % Satisfaction Number of Listening Situations Satisfied Couples who disagree about TV volume Any end user who struggles to understand what is being said without closed caption activated on their television Kochkin (2005) MarkeTrak VII Who Would Benefit from a Phone Accessory? Who Would Benefit from a Remote Control? Any user with a Bluetooth enabled phone who has difficulty understanding speech on the phone when using other methods (unaided, acoustic phone program or telecoil) Any user who would like to talk on the phone hands free Any end user wishing to make changes to the hearing instrument settings discreetly, without having to draw attention to the hearing instruments. Any end user with manual dexterity issues limiting their range of motion for their arms or who have difficulty finding or feeling the hearing instrument controls with their fingers. Any end user who has selected a micro hearing instrument model for cosmetic reasons and who wants to be able to make changes to the volume and program settings in the device 10

11 GN ReSound, all rights reserved. Apple, the Apple logo, iphone, ipad and ipod touch are trademarks of Apple Inc., registered in the U.S. and other countries. 09/15/17 Who would benefit from a Remote Microphone Accessory? Anyone who wants to make listening easier in noisy situations or at a distance Anyone who has one or more situations they struggle with despite hearing aids The 2.4GHz Wireless Revolution Made for iphone (Mfi) - A direct connection to everything they love Favorites Apps Offer Convenience Internal locus of control More personalized settings Volume Bass/treble Favorites Geo-tagging List view Map view Three-dot menu Detail view 11

12 SRT (db SNR) SNR (db) 09/15/17 Lab Test Results: Directionality, FM and Remote Microphone Comparison Lab Test Results: Distance Adaptive FM system + Remote mic Directionality HA mic + HA mic meters distance 3.0 meters distance 6.0 meters distance Adaptive Directional SNR Wireless Remote Mic SNR Wireless Remote Mic + HI Mic SNR Updated Proof of Benefit Testing Methods Objective: To validate the speech intelligibility benefit obtained with a newer wireless remote microphone, as compared to directionality alone. To compare speech intelligibility benefit of a newer remote microphone with a newer FM system. Test material Dantale II test material (Wagener et al, 2003) Test setup The Dantale II material was presented from a Brüel & Kjær head and torso simulator (HATS). The external microphones were placed on the torso of the HATS The speech intelligibility tests were conducted with a fixed speech level of 55 db SPL, while the noise level was adaptively varied to find the SRT. Updated Proof of Benefit Results Benefit of Remote Microphone and Bimodal Wireless remote microphone provides 15dB more SNR benefit than directionality. No significant differences in speech intelligibility between updated remote microphone and updated FM system technologies. Remote FM Mic System Directional Mics Alone Wolfe, J. Cochlear Wireless Accessories for Bimodal Users. Presentation, San Antonio, TX,

13 GN ReSound, all rights reserved. Apple, the Apple logo, iphone, ipad and ipod touch are trademarks of Apple Inc., registered in the U.S. and other countries. 09/15/17 Benefit of Phone Accessory vs. MFI Streaming of FaceTime Test Condition 1: Acoustic Phone Unilateral Audio (Jespersen & Kirkwood, 2015) Test Conditions 2-3: Phone Accessory, Audio Only Test Conditions 4-5: Phone Accessory, Audiovisual Unilateral Streaming Bilateral Streaming Unilateral Streaming Bilateral Streaming Test Conditions 6-7: MFi, Audio Only Test Conditions 8-9: MFi, Audiovisual Unilateral Streaming Bilateral Streaming Unilateral Streaming Bilateral Streaming 13

14 Mean Percent Correct Mean Percent Correct Mean Percent Correct 09/15/17 Test Participants Test Setup 15 individuals with severe-to-profound hearing loss (10 male & 5 female) Median age: 77 years Median years of experience with amplification: 32 (1 st quartile: 25; 3 rd quartile: 39) Testing was done in a sound treated room with a loudspeaker setup as shown below: Test Material and Procedure Results: Unilateral Audio Conditions (n=15) Test material Dantale I speech material 100% 80% Procedure 9 phone conditions completed over 2 sessions (counterbalanced test order). Each session initiated with two training rounds; one being the audio only signal and one being the audiovisual signal. Aim to obtain a percentage correct score for each test condition. Speech and noise presented at constant SNR level of either 10/13/16/20 db. The SNR level at which the participant had around 60% correct with the audio only signal was chosen. 60% 40% 20% 0% 6% Acoustic Phone Audio Unilateral 45% 45% Phone Accessory Audio Unilateral MFi Audio Unilateral The Phone Accessory and MFi phone handling strategies provide a significant benefit compared to acoustic phone, even in the unilateral condition. Results: Benefit of Bilateral Streaming (n=15) 100% Results: Benefit of Visual Information (n=15) 100% 80% 65% 80% 71% 60% 55% 60% 48% 40% 40% 20% 20% 0% Unilateral Streaming Bilateral Streaming 0% Audio Audiovisual A bilateral phone handling strategy provides an average significant benefit of 10% for both wireless connectivity solutions (Phone Accessory & MFi) compared to a unilateral strategy. A visual phone handling strategy provides an average significant benefit of 23% for both wireless connectivity solutions (Phone Accessory and MFi) and in both the unilateral and bilateral condition. 14

15 Mean Percent Correct 09/15/17 Results: Benefit of bilateral- & visual information (n=15) What It Really Means 100% 80% 78% 77% 60% 40% 20% 0% 6% Acoustic Phone Audio Unilateral Phone Accessory Audiovisual Bilateral MFi Audiovisual Bilateral A bilateral, audiovisual phone handling strategy provides an large significant benefit for both wireless connectivity solutions (Phone Accessory and MFi) as compared to the traditional phone use solution. Pilot Study: Remote Control Apps as a Way of Helping Patients Accept Prescriptive Targets? Why Was the Study Conducted? Why? What if it s too loud? Purpose: Evaluate the impact of clinician-directed versus patientdirected hearing aid gain settings, via real-ear insertion gain measurements. I don t want to have to come right back to have the volume changed right afterwards! Group A: Traditional fitting method, where the audiologist asked How Does It Sound? and made adjustments to the fitting through the fitting software based on patient s initial reactions. Group B: Patients were fitted with hearing aids pre-programmed to target settings, and then muted and the app volume set to the lowest level. They were then asked to increase the volume on the app to a comfortable level. Differences in Patient Engagement were intrinsic to the design of Group A vs. Group B interactions. Null Hypothesis: No Difference in Final Gain Settings between Groups Research Question: How do the Fitting Methods Influence the Hearing Aid Gain Settings? Group A How Does it Sound? Increase the volume so that it s comfortable and helps you hear well Group B iphone for patient to adjust volume during fitting Started at experienced target settings. Hypothesis: Will end visit with decreased gain settings with respect to target gains. Started at experienced target settings, but muted and with app VC at lowest point. Unmuted hearing aids and asked to adjust to a comfortable yet beneficial level. Hypothesis: Will choose to increase gain settings to about the same level as Group A. 15

16 Participants Results: Group A Subjects Wanted Less Gain than Targets wireless transmission 14 participants completed the pilot study. Ages ranged from with and mean of 67 years. All were experienced with amplification (a mix of manufacturers). Results: Group B Subjects Increased Gain to Prescribed Target Levels Connectivity Between Hearing Aids How is Wireless Used in Our Industry? 4 Goals of Wireless Technology in Hearing Aids Today: Requires ear-to-ear Connectivity and programming Convenience features Synchronized volume control and push button Automatic telephone handling Enhanced signal processing Using wireless capability to make a feature work better/provide better benefit, e.g., Coordinated automatic directionality, coordinated tinnitus sound generator Binaural processing Using exchange of data for streaming or enhanced signal processing to do any or all of the following: Maximize speech audibility Maintain listening comfort Speed of Ear-to-Ear Transmission How fast is it? Actual transmission of the signal is 10 8 m/sec (the speed of light) How long does it take for the signal to be transmitted? There is a delay that involves processing of the action to initiate the transmission. For exchanging data about the environment, this involves the time for each hearing aid to update the analysis of the environment, and then for the hearing aid to initiate the transmission. Therefore, about 1-2 seconds. For user actions like VC and program changes, some processing also has to occur in the hearing aid for it to initiate the transmission. Plus, for this VC and program changes, there is commonly an added delay of about 400 ms to avoid the beeps being on top of each other on the two ears. 16

17 Speed of 2.4 GHz Ear-to-Ear Transmission How long does it actually take between the time a signal is initiated on one ear and received on the other? This is variable and depends on the individual and the environment. The device initiating the action will continue to send the data packages of info to the other ear until the other ear says it got the info. There is a time out on the order of up to 120 seconds. After this limit is reached, the HI will stop trying to send the info (until a new action is initiated). For user operations like VC and program change, the shortest possible time would be around ms because of the builtin delay. If there is no acknowledgement from the receiver ear by the end of the time-out period, the transmission is cancelled. Why the Redundancy in 2.4 GHz Ear-to- Ear Transmission? GHz does not travel through or around objects easily. The antennae are designed in such a way that they point the signal to refract around a surface rather than just directing into free space. This means it works well for most people, less great on others. Why the Redundancy in 2.4 GHz Ear-to- Ear Transmission? 2. Environments that provide no surfaces for reflection of the transmission can degrade performance, so there can be more variation depending on where you are. Easier to get reliable e2e performance in a building than in an open park! 3 Tactics to Achieve These Ear-to-Ear Goals: Mirror operation from one side to other Synchronized volume control Steering of other algorithms Automatic directional steering Binaural compression Streaming of sound Sound is streamed for other ear for audibility, or is used for enhanced signal processing CROS Coordinated automatic directionality What are the Demands of Hearing Healthcare Consumers? Growing body of research Information searching on a topic of interest: Top online activity for Baby Boomer or seniors via smart phone or tablet (IPSOS and Google, 2013) Connectivity to Professional Services Significant number of study participants willing to use telemedicine for audiological care (Eikelboom and Atlas, 2005) Reasons? Reduction of waiting time for appointments Reduced costs 17

18 What are the Demands of Hearing Healthcare Consumers? Perceptions of internet-based hearing instrument acquisition 18 experienced HA users Results: Participants noted greater convenience for fitting and follow-up needs E.g., fine tuning in real-world listening environments with professional guidance HOWEVER Patients preferred audiologist expertise to pure online solutions Patients expressed trust in audiologists over online retailers Chandra N, Searchfield GD. (2016). Perceptions toward internet-based delivery of hearing aids among older hearing-impaired adults. J Am Acad Audiol 27: Our Patients Need and Want Us! Humes L, Rogers S, Quigley T, Main A, Kinney D, Herring C. The effects of service delivery model and purchase price on hearing aid outcomes in older adults: a randomized double-blind placebo-controlled clinical trial. American Journal of Audiology. 2017; Accessed online on March 10, 2017 at: epdf.aspx?doi= /2017_aja Reprinted version in ASHA Leader Paradigm Shifting: Patients as Consumers Paradigm Shifting: Patients as Consumers Examples: Ratings and surveys of medical professionals and facilities How long was your wait time before seeing the doctor? HealthGrades and other online ratings for providers Price-shopping Examples: Ratings and surveys of medical professionals and facilities Greater Patient Engagement How long was your wait time before seeing the doctor? HealthGrades and other online ratings for providers Price-shopping How Can We as Hearing and Health Professionals Meet These Changing Needs? Financial Link to Patient Empowerment Greater patient engagement Better goal achievement and functional outcomes have been attributed to patients and their families becoming more actively involved in the process Turner-Stokes L, Rose H, Ashford S, Singer S. (2015). Patient engagement and satisfaction with goal planning: Impact on outcome from rehabilitation. International Journal of Therapy and Rehabilitation 22(5). Accessed online on July 6, 2016 at: /ijtr Engaged health care recipients are proactive Tend to achieve better outcomes than those less engaged in their care Hibbard JH, Greene J. (2013). What the evidence shows about patient activation: Better health outcomes and care experiences; fewer data on costs. Health Affairs, 32(2): ,000-patient study on patient empowerment Patients with lowest activation or engagement score on a survey had significantly higher costs Why? Increased need for multiple follow-up visits Hibbard JH, Greene J, Overton V. (2013). Patients with lower activation associated with higher costs; delivery systems. Health Affairs 32(2):

19 Professional Guidance Of course, not EVERY individual is the best candidate for self-engagement Professional responsibility to consider the individual patient when determining how best and how much to promote selfengagement BUT, professional support to encourage greater engagement and understanding can actually increase a patient s activation level (Hibbard JH, Greene J. (2013). What the evidence shows about patient activation: Better health outcomes and care experiences; fewer data on costs. Health Affairs, 32(2): ) Since many patients are already online and making active choices about providers and services, it may make sense to promote higher levels of engagement Audiological Touchpoints that Currently Promote Patient Engagement and Satisfaction Increased satisfaction and reduced return rates due to Verification measures Outcome measures (questionnaires, sound field SNR testing) Valente M, Potts LG, Valente M. (1995). Signal testing approaches; clinical procedures to improve user satisfaction with hearing aids. In: Tobin H, ed. Practical Hearing Aid Selection and Fitting. Baltimore: Department of Veterans Affairs: Chapter 6. Patients self-perception of benefit and satisfaction Counseling General communication between patient and professional Street RL, Makoul G, Arora NK, Epstein, RM. (2009). How does communication heal? Pathways linking clinician-patient communication to health outcomes. Patient Education and Counseling 74(3): Strom KE. (2005). HR interviews Sergei Kochkin, PhD. Hearing Review, 12(11):24-32, 82. Even When Programming and Fine- Tuning the Hearing Aid? Survey of 100 hearing aid users 90% said they wanted to be more actively involved in the HA fitting process! Schweitzer C, Mortz M, Vaughan N. (1999). Perhaps not by prescription but by perception. High Perform Hear Solutions 3: More Personalization = More Engagement! Greater value shown to be perceived for products or processes in which the user had a role in creating Norton MI, Mochon D, Ariely D. (2012). The Ikea Effect : When labor leads to love. Journal of Consumer Psychology 22(3): In the realm of hearing aids, user-controlled apps and favorite settings can achieve the same effect Personalization + Convenience + Professional Care Connectivity to the Audiologist Adds Up Users benefits: More efficient fitting process with intuitive, on-the-go fine-tuning capabilities Better fit and consequently better sound quality Online Services Cloud Hearing care professionals benefits: Higher user satisfaction More efficient clinic management with more time for valuable counselling Reduced return rates Better hearing User app Patient Hearing care professional Fitting software or web portal 19

20 Connectivity to the Audiologist Adds Up Connectivity to the Audiologist Adds Up Better hearing Better hearing Better hearing Greater satisfaction More likely to purchase Better hearing Greater satisfaction More likely to purchase Better hearing Greater satisfaction More likely to purchase Better relationships Greater convenience Game Changers in Hearing Aids CONNECTIVITY 20