Institute of Medicine Committee on Accessible and Affordable Hearing Health Care for Adults, June 30 th 2015

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1 Harvey B. Abrams, Ph.D. Hearing industries Association Better Hearing Institute Institute of Medicine Committee on Accessible and Affordable Hearing Health Care for Adults, June 30 th 2015

2 68 year old married retiree Increasing problems understanding his wife and friends Has to turn up the TV Wondering what he should do next

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4 17K Household Reporters Part-1: Estimate Rates Hearing difficulty Hearing aid ownership Hearing aid adoption Person with HD in Household continue No person with HD in household complete Part-2: Gain Insight on Journey With hearing difficulty With professionals With hearing aids/solutions 1K HA owners 2K Nonowners

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9 60% 57% 55% Can hear well enough in most 50% 47% 49% situations 40% 47% 43% 44% 45% Too expensive 36% 37% 38% 38% 30% 30% 31% 27% 33% 33% Could not afford them 23% 22% 26% 24% 24% 20% 15% 16% 16% 18% 20% 17% 19% No coverage (insurance, etc.) 10% 11% Have other more serious priorities 0% Segment-1 (=206) Segment-2 (n=176) Segment-3 (n=163) Segment-4 (n=150) Segment-5 (n=140) Segment-6 (n=120)

10 Years After Aware of HD This includes those on their 4 th + pair as well so it shows a bigger increase than it would be for just the 3 rd HA. 0 Discuss HD with general medicine doctor Discussed HD with an ENT Had test to Visit 1st HCP - evaluate or among all confirm current HD Got 1st HA(s) - among all Got 2nd HA (among those on 2nd now) Got 3rd+ HA (among those on 3rd now)

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17 Discussed HD with Professional/Assistant 100% 80% 89% Total (3079) 60% 50% HA Owners (980) 40% 20% 0% 33% 31% 34% 23% 27% 22% 20% 3% 31% 22% 2% 4% 2% Non-Owners (2099) A hearing care professional (audiologist or hearing instrument specialist) A 'general medicine' doctor (general practitioner, family doctor, etc.) An ENT (ear, nose, throat) doctor Some other kind of specialty doctor (Internal Medicine Doctor, OBGYN, etc.) None of the above

18 Conclusion or recommendation indicated hearing loss Total (n=996) 11% 6% 6% 5% 25% 33% 60% Said I had hearing loss directly Said hearing loss not bad enough to warrant HA(s) HA Owners (n=231) 9% 8% 5% 4% 4% 43% 82% Said wait awhile before retesting Did not say anything about hearing Non-Owners (n=765) 7% 6% 6% 12% 31% 29% 55% Said hearing was normal Indicated HA(s) would not help enough 0% 20% 40% 60% 80% 100%

19 100% Total (n=996) HA Owners (n=231) 80% 60% 40% 41% % of those told to see an ENT who complied: 80% of total 90% owners 74% non-owners % of those who got this suggestion who complied: 28% of total 30% owners 27% non-owners Non-Owners (n=765) 32% 20% 25% 20% 15% 22% 13% 18% 14% 4% 4% 4% 0% Referred to HCP Referred to ENT Recommended surgery / procedure Recommended HA(s)

20 Conclusion or recommendation indicated hearing loss Total (n=735) 4% 2% 10% 9% 22% 53% 78% Said I had hearing loss directly Said hearing loss not bad enough to warrant HA(s) HA Owners (n=293) 8% 5% 4% 2% 1% 58% 93% Said wait awhile before retesting Indicated HA(s) would not help enough Non-Owners (n=442) 4% 3% 14% 12% 31% 50% 69% Said hearing was normal Did not say anything about hearing 0% 20% 40% 60% 80% 100%

21 Total (n=735) HA Owners (n=293) 100% Non-Owners (n=442) 80% 60% 49% % of those who got this suggestion who complied: 40% of total 54% owners 33% non-owners 57% 40% 31% 33% 20% 20% 11% 9% 13% 19% 0% Referred to HCP Recommended surgery / procedure Recommended HA(s)

22 Conclusions From HCP 84% Conclusion or recommendation indicated hearing loss 55% Total (n=1692) 9% 7% 15% Said I had hearing loss directly 3% HA Owners 6% 56% 95% Said hearing loss not bad enough to warrant HA(s) (n=915) 5% 2% 2% Indicated HA(s) would not help enough 72% Non-Owners 25% 55% Said wait awhile before retesting (n=777) 14% 13% 5% Said hearing was normal 0% 20% 40% 60% 80% 100%

23 Total (n=1692) HA Owners (n=915) Non-Owners (n=777) 100% 87% 80% 60% % of those who got this suggestion who complied: 41% of total 28% owners 46% non-owners 63% 40% 37% 20% 0% 5% 8% 3% Recommended surgery / procedure Recommended HA(s)

24 Owners 80% Non- Owners 60% 61% 57% 40% 40% 48% 20% 0% 26% 10% 22% 18% 24% 24% Discussions with Discussions with Discussions with Discussions with Results from first general medicine ENT 1st HCP* HCP who fit official hearing doctor HA/last saw test (for current difficulty)

25 To get hearing tested To purchase hearing aid(s) Tired of asking to repeat Easy place to get to To evaluate hearing aids Felt ready, willing and able Easy to get appointment Cost (or what I pay) affordable To find out about technology Practice had good reputation Hours worked for me Near place I already go Recommendation from professional Recommendation from non-prof. To appease someone else Hoping to prove hearing normal 38% 5% 36% 28% 33% 23% 30% 16% 12% 7% 12% 12% 28% 27% 18% 23% 23% 22% 21% 18% 18% 15% 16% 26% 12% 11% 10% 15% 9% 12% Owners (n=975) 67% 67% Non-Owners (n=785) 0% 20% 40% 60% 80%

26 Hearing test clearly demonstrated need 54% Trusted the hearing care professional 42% Had some coverage / help paying for HAs 33% The trial clearly showed HA(s) could improve hearing Was impressed with technology/features The price was right/reasonable Could afford it (had funds to purchase HA(s)) 28% 28% 27% 26% Liked the organization/practice Satisfaction guarantee (money back, etc.) Felt pressure from others to purchase HA(s) Special offer/promotion Free trial 18% 13% 10% 8% 8% Felt pressure from doctor/ent to purchase HA(s) Felt pressure from HCP to purchase HA(s) 3% 3% 0% 20% 40% 60% 80% 100%

27 Non-Owners (n=600) 1% 1% 2% 10% 14% 30% 43% HA Owners (n=845) 1% 1% 3% 9% 27% 59% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Very Dissatisfied= Very Satisfied=7

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29 Having insurance that will cover some/more of the cost 51% A hearing test that makes it clear to me that I need one 36% A positive recommendation from my doctor Knowing that unaided hearing loss can contribute to or exacerbate other health issues (memory loss, etc.) A place to evaluate or try hearing aids without feeling pressure to buy on the first visit A recommendation from a hearing care professional I trust Evidence that today's technology makes hearing aids significantly better than they were 5 years ago More information on the latest technologies and how they improve hearing and the hearing aid experience Learning that people who start wearing hearing aids when their loss is minimal tend to end up being more successful hearing aid users None of the above 20% 20% 19% 18% 16% 12% 11% 13% 0% 20% 40% 60% 80% 100%

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31 Years since purchase 6+ (n=115) 8% 4% 4% 10% 20% 35% 19% 2-5 (n=442) 3% 4% 4% 12% 20% 30% 27% <=1 (n=340) 1% 1% 2% 7% 15% 33% 43% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Very Dissatisfied= Very Satisfied=7

32 How Current Hearing Aid Compares to 1 st Hearing Aid (n=433 Owners who have had more than one HA (regardless of age of HA)) Somewhat worse 2% Much worse than 1st hearing aid 0.2% The same as 1st hearing aid 13% Much better than 1st hearing aid 51% Somewhat better 34%

33 Half of repeat purchasers feel their current hearing aid is much better than their first because: Quality of product is better HCP did a better job Willing to use current HA Better sense of what they need, specifically: premium sound quality reduced feedback ease of use

34 Ease of use 1% 2% 8% 9% 30% 50% Product quality 1% 2% 2% 9% 10% 25% 51% Appearance (visibility, aesthetics, etc.) 1% 2% 11% 11% 24% 51% Physical comfort 1% 2% 3% 9% 12% 27% 46% Effort required for maintenance 1% 3% 13% 11% 25% 47% Sound quality 1% 2% 5% 9% 11% 31% 41% Effectiveness of enhanced features 2% 2% 5% 16% 14% 31% 32% Value (quality/performance vs. price paid) 1% 3% 5% 15% 11% 24% 41% Out of pocket price paid 4% 6% 7% 19% 15% 16% 33% 0% 20% 40% 60% 80% 100% Very Dissatisfied= Very Satisfied=7

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38 Hours Per Day Wear Hearing Aid (n=679 daily HA wearers) hours, 1% <= 4 hours, 5% hours, 4% 5-8 hours, 22% hours, 32% 9-12 hours, 36%

39 How often feel made fun of or rejected because.. wearing hearing aid of hearing difficulty (for owners) (for non-owners) How often feel embarrassed because.. wearing hearing aid of hearing difficulty (for owners) (for non-owners) 5% 4% 5% 9% 21% 9% 13% 15% 31% 12% 37% 73% 70% 28% 45% 24% HA Owner/Wearers (n=765 got in last 5 years) Non-Owners (n=2071) HA Owner/Wearers (n=765 got in last 5 years) Non-Owners (n=2071) Never Rarely Occasionally Regularly

40 In the last year, have you found yourself getting more forgetful? 100% 80% 55% 38% 46% 60% No 40% Yes, somewhat more 20% 42% 56% 52% Yes, much more 0% 4% 6% No Hearing Difficulty Hearing Difficulty with (n=4005) no HA (n=425) 3% Hearing Difficulty and a HA (n=233)

41 Over the last 2 weeks, how often have you been bothered by: Little interest or pleasure in doing things? 100% 80% 60% 40% 8% 12% 8% 12% 10% 15% 26% 22% 27% Nearly Every Day For More Than Half the Days 20% 55% 47% 60% For Several Days 0% Not at All No Hearing Difficulty (n=4006) Hearing Difficulty with no HA (n=426) Hearing Difficulty and a HA (n=233)

42 Over the last 2 weeks, how often have you been bothered by: Feeling down, depressed or hopeless? 100% 80% 60% 8% 11% 10% 14% 26% 26% 7% 10% 18% Nearly Every Day 40% 20% 56% 48% 65% For More Than Half the Days For Several Days 0% Not at All No Hearing Difficulty (n=4006) Hearing Difficulty with no HA (n=426) Hearing Difficulty and a HA (n=233)

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44 Inadequate follow-up Failure to provide post-fitting rehabilitation Group-based aural rehabilitation Auditory training Major life changes Loss of spouse Loss of job Loss of independence Significant change in hearing

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46 It is good to have an end to journey toward; but it is the journey that matters, in the end. -Ernest Hemingway

47 Abrams HB, Kihm J. (2015). An introduction to MarkeTrak IX: new baseline for the hearing aid market. Hearing Review, 22(6): Callaghan, R.C., Taylor, L., & Cunningham, J.A. (2007). Does progressive stage transition mean getting better? A test of the Transtheoretical Model in alcoholism recovery. Addiction, 102(10), Glanz, K., Rimer, B.K. & Lewis, F.M. (2002). Health Behavior and Health Education. Theory, Research and Practice. San Fransisco: Wiley & Sons. Kochkin S. (2009). MarkeTrak VIII: 25-year trends in the hearing health market. Hearing Review, 16 (11), Johnson, S.S., Driskell, M-M., Johnson, J.L., Dyment, S.J., James O. Prochaska, J.O., et al. (2006). Transtheoretical model intervention for adherence to lipid-lowering drug. Disease Management, 9(2): Laplante-Levesque, A. (2015). Applying the stages of change to audiologic rehabilitation. Hearing Review, 68(6), 8-12.

48 Logue E., Karen Sutton, K., Jarjoura, D., Smucker, W., Baughman, K., & Capers, C. (2005). Tanstheoretical model-chronic disease care for obesity in primary care: A randomized trial. Obesity Research, 13(5), Prochaska, J. Q., & DiClemente, C. C. (1983). Stages and processes of self-change of smoking: Toward an integrative model of change. Journal of Consulting and Clinical Psychology, 51, Prochaska, J.O., Redding, C.A., Harlow, L.L., Rossi, J.S., Wayne F. Velicer, W.F. (1994). The Transtheoretical Model of Change and HIV Prevention: A Review. Health Education Behavior, 21(4), Saunders, G., Frederick, M., Silverman, S., Papesh, M. (2013). Application of the health belief model: Development of the hearing beliefs questionnaire (HBQ) and its associations with hearing health behaviors. International Journal of Audiology 2013; 52: