Building Practice Success Through Speechmap Real Ear Measurements. Chris Stokes-Rees

Transcription

1 Building Practice Success Through Speechmap Real Ear Measurements Chris Stokes-Rees

2 Speaker Disclosure Relevant financial relationships: Audioscan (Applications Specialist) Conestoga College, Kitchener Ontario (professor, H.I.S. program)

3 Today s Agenda 1. REM in a changing landscape 2. UNT study: perceived value of REM 3. Speechmap: review of the basics 4. Speech Intelligibility 5. Live Speech in counselling 6. RIC/RITE and an Open Canal Update 7. RECD: not just for kids anymore 8. Frequency Lowering 9. Simultaneous binaural REM

4 Real Ear Measurements in a changing landscape

5 Evolving Hearing Aid Supply Chain Model Smriga, D. Who are we really working for? presentation at ADA 2014

6 Evolving Product and Service Expected to Delivery Provide improved access to hearing aids Offer lower cost alternatives than historically available Shift focus towards the product as the solution

7 How to address product focus and highlight our relevance? Verification Services Real-ear measurement

8 Are we conducting REM? Source: Hearing Journal Vol 59 No.4 Apr 2006

9 Are we conducting REM? Mueller and Picou. Use of real-ear probe microphone measures. Hearing Journal, May, 2010.

10 Some Reasons for NOT using REMs Too time consuming Too difficult Too expensive You can t verify X, Y or Z instrument. Measuring RECD and entering it in our software will guarantee your fitting is right. Doesn t make a difference

11 We cannot know what a hearing aid does unless it s performance is measured Harvey Dillon, NAL Australia

12 NAL-NL2 REAR Results Using 5 Different Manufacturers Programming Software 55dB 65dB 75dB N = 16 Sanders, J., Stoody, T., Weber, J., Mueller, H., Manufacturers NAL-NL2 Fittings Fail Real Ear Verification Hearing Review, March 2015; 21(3): 24-32

13 NAL-NL2 Comparison to 5 Different Manufacturers Proprietary Fittings 55dB 65dB 75dB N = 16 Sanders, J., Stoody, T., Weber, J., Mueller, H., Manufacturers NAL-NL2 Fittings Fail Real Ear Verification Hearing Review, March 2015; 21(3): 24-32

14 The Importance of Audibility A 10 year old set of analog hearing aids verified to NAL-R prescriptive targets outperformed the six largest manufacturers premium BTE hearing aids programmed to the manufacturer first fit in speech-in-noise testing After being verified to NAL-R prescriptive targets 5 of the 6 premium digital hearing aids outperformed the 10 year old analog hearing aids Leavitt, R. J., & Flexer, C. (2012, December 01). The Importance of Audibility in Successful Amplification of Hearing Loss. Retrieved from

15 Takeaways Selecting a target in programming software does not guarantee that targeted performance will be delivered in the patient s ear. Differences can be substantial and unpredictable. The only way to KNOW what you are delivering is through verification measurements.

16 REM and Patient Satisfaction REM Measure Subjective Benefit Measure Objective Benefit Measure Customer Satisfaction Measure LDL Percent of Patients Below Average Success Above Average Success Adapted from Kochkin et. al. MarkeTrak VIII: The Impact of the Hearing Healthcare Professional on Hearing Aid User Success". Hearing Review, April 2010.

17 Perceived Value of REM The Amlani et al UNT study, 2016

18 Impact of REM on perception of hearing aid services Study in 2016 at UNT looked at the impact of REM on the perceived value of service received This unique study very relevant to address the service vs. product question in hearing aid delivery

19 Participants 60 subjects, bilateral mild-to-moderate SNHL Group 1: Experienced users (> 8hrs/d) Group 2: In The Drawer users (< 8hrs/wk) Group 3: First-time users (never tried)

20 The surveys used 1. WTP (Willingness to pay) One-item question indicating maximum dollar amount individual willing to exchange to obtain a service or product 2. SERVAL (Perceived Value of service) 14-item scale that measures attitude and behavior toward perceived value

21 Procedure All groups divided into REM and QuickFit paths. Exp and ITD groups given pre-surveys, all three groups given post-surveys. Those on QuickFit path, given post-study REM and one more survey.

22 Results - Willingness-to-pay

23 Results - Loyalty e.g., What is the likelihood that you would recommend this provider to family and friends?

24 Results - Loyalty e.g., What is the likelihood that you would expand your purchase of additional services offered by this provider?

25 Results - PERVAL e.g., The quality of the service I received was outstanding.

26 Results - PERVAL e.g., The service provided eases anxiety about how well the product will work..

27 Results - PERVAL e.g., The overall value of this experience was high.

28 Why all this matters? Satisfaction of hearing aid users can be linked to the type of verification services offered Improves perceived benefit and satisfaction with practicioner REM deemed a worthwhile expense

29 Speechmap A quick review

30 The Speechmap Screen UCL (SPL, estimated from threshold) SPL Threshold (converted from HL) MAP(Minimum Audible Pressure)

31 Speech display & analysis Percentile analysis used to display the dynamic range of amplified speech. Maximum levels (peaks or 99 th percentile) Average levels (L.T.A.S.S.) Minimum levels (valleys or 30 th percentile)

32 Speech display & analysis Speech must be analyzed over a period of ten seconds minimum. Prescriptive targets will be shown for the long term average (L.T.A.S.S.)

33 The counselling challenge Explaining recruitment!

34 Use the Speechmap screen:

35 Normal dynamic range

36 Reduced dynamic range

37 Audiometric Data Entry

38 Soft Speech

39 Conversational Speech

40 MPO

41 SII What is it and how can it help me?

42 Speech Intelligibility Index ANSI S Methods for Calculation of the Speech Intelligibility Index Gives a numeric quantity that predicts how much of the speech is audible in a graphic sense: how much of the amplified speech area appears above SPL threshold Unrelated to target formula

43 Soft Speech

44 Conversational Speech

45 SII vs. Predicted CST Score (from Sherbecoe and Studebaker 2003)

46 Live Speech as a counselling tool

47 Live speech as a counselling tool Live speech does not provide an effective, repeatable test for fitting hearing instruments. However, it is a great tool in patient counselling situations.

48 Average speech

49 Spouse s voice

50 Compared

51 RIC/RITE and OC update

52 RIC dominates the market

53 Vent effects on HI Gain

54 Dome type examples

55 Common OC mistakes Assuming that RIC = Open Canal Assuming that a closed dome is 100% closed Attempting to match low frequency targets, or provide LF gain where more occluding coupling may be required.

56 Audiogram entered

57 Audiogram entered

58 Step 1: HI present but off

59 Step 2: HI turned on

60 Comparison Difference between curves shows amplification reaching TM

61 How to determine candidacy 1. Position probe tube in ear 2. Enter audiogram and select a fitting rationale 3. Run 65dB Speech with open ear (i.e. REUR) 4. Compare LTASS curve with targets in the sub-1khz range

62 First audiogram entered

63 A good candidate for OC fit!

64 Second audiogram entered

65 Not recommended

66 RECD: Not just for kids anymore!

67 RECD what it is Real Ear to Coupler Difference Broadband signal measured in coupler and in ear canal. RECD = difference in output, across frequencies.

68 RECD How it is measured RECD transducer RECD transducer Probe mic Coupler mic Frequencies at which RECD was measured Measured RECD values

69 RECD How it is used 1. Test box verification. AKA S-REM Speechmap simulated in a coupler, in the test box Isn t this primarily used in pediatric fittings?

70 RECD How it is used 2. HL Threshold correction. Used in the HL-to-SPL transformation More accurate SPL thresholds Applicable to any ear canal that is not average!

71 Correcting Thresholds When we measure hearing thresholds the audiometer produces a stimulus in the ear The actual level in the ear is affected by the acoustics of the ear canal. The audiometer is calibrated to an average adult ear...for any other canal the actual threshold measured will be different RECD lets us capture what this difference is!

72 Correcting Thresholds Approximately 80% of adult ears exhibit average RECD Pro tip: watch for that 20%! When verifying fit on non-average ear canal, measure HL with inserts and use RECD!

73 Example case

74 Speechmap test: average RECD RECD:

75 Speechmap test: entered RECD RECD:

76 Note On Audiogram Correction... There are a number of ways clinicians use to measure the hearing thresholds (audiogram) including: insert phones headphones sound field speakers RECD can only be used to correct the threshold values if the patient s thresholds were measured with insert phones

77 Frequency Lowering How to adjust for optimal benefit

78 Freq. Lowering - The Concept Some hearing losses have un-aidable regions where important speech information exists Re-positioning input energy in these regions to regions that are aidable can provide access to these important speech cues e.g. steep sloping HF losses!

79 Frequency Lowering Today In 2017 all high-end hearing instruments contain this technology! Some manufacturers default it to on with default settings. To provide best effect it should be adjusted using the latest protocol.

80 The s and sh Stimuli 65dB 65dB Special stimuli for use in adjusting frequency lowering function. Developed at University of Western Ontario.

81 FL Adjustment protocol 1. Run 65dB speech 2. Identify the Maximum Audible Output Frequency range.

82 Identify MAOF; Where SPL threshold crosses LTASS and where it crosses PEAK. MAOF

83 MAOF Highlighter 3. Run /s/ stimulus. Adjust so upper shoulder of /s/ is within the MAOF.

84 MAOF Highlighter 4. Run /sh/ and check that it does not totally overlap /s/ signal. Adjust if necessary.

85 MAOF Highlighter On Verifit2, activate MAOF highlighter. 1. Run 65 db speech test

86 MAOF Highlighter 2. Run /s/ in a separate test. From test setup in /s/ test, select the test containing 65dB speech.

87 MAOF Highlighter MAOF (i.e. target range) highlighted:

88 MAOF Highlighter 3. Adjust frequency lowering of instrument so upper shoulder of /s/ is within MAOF.

89 MAOF Highlighter 4. Run /sh/ and fine-tune if necessary.

90 FL adjustment tip Ideal setting is always the LEAST amount of frequency lowering that is required to set the upper shoulder of the /s/ in the MAOF range.

91 Simultaneous Binaural A quick update & tips

92 Simultaneous binaural Speechmap Aids in efficiency and allows verification of binaural functioning Provided in a number of manufacturers probe tube systems today Equalization at two ears is a challenge

93 Simultaneous binaural on-ear The issue: on-ear soundfield typically nonsymmetrical and uncontrolled vs.

94 Simultaneous REM solutions? It is not possible to equalize a stimulus in level and spectrum at two places (i.e. each ear) at once. Solutions employed currently in the market: Average the error Select one reference mic (left or right) Force sequential measurement Provide tool for ideal patient positioning

95 Points to remember The Verifit Binaural Sound Field Assist and the forced sequential binaural will only activate if the stimulus at both ears is >2dB different If sound field is even, simultaneous binaural measurements will proceed with no user interaction.

96 Tips for simultaneous binaural A good acoustic space is helpful... Keep away from reflective surfaces Patient-to-speaker distance is key... Keep under 60cm (2 feet). Binaural Sound Field Assist is sensitive to external noises. As with any real ear measurements, keep room silent.

97 Also: