Building Practice Success Through Speechmap Real Ear...
Transcript of Building Practice Success Through Speechmap Real Ear...
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Building Practice Success Through
Speechmap Real Ear Measurements
Chris Stokes-Rees
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Speaker Disclosure
Relevant financial relationships:
• Audioscan
(Applications Specialist)
• Conestoga College, Kitchener Ontario
(professor, H.I.S. program)
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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
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Real Ear Measurements
in a changing landscape
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Evolving Hearing Aid Supply Chain Model
Smriga, D. “Who are we really working for?” presentation at ADA 2014
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Evolving Product and Service
Delivery
Expected to…
• Provide improved access to hearing
aids
• Offer lower cost alternatives than
historically available
• Shift focus towards the product as the
solution
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How to address ‘product focus’ and
highlight our relevance?
Verification Services
“Real-ear measurement”
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Source: Hearing Journal Vol 59 No.4 Apr 2006
Are we conducting REM?
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Are we conducting REM?
Mueller and Picou. Use of real-ear probe microphone measures. Hearing Journal, May, 2010.
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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”
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“We cannot know what a hearing aid does unless it’s performance is
measured”
Harvey Dillon, NAL Australia
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NAL-NL2 REAR Results Using 5 Different Manufacturers’ Programming Software
Sanders, J., Stoody, T., Weber, J., Mueller, H., “Manufacturers’ NAL-NL2 Fittings Fail Real Ear Verification” Hearing Review, March 2015; 21(3): 24-32
55dB
N = 16
65dB 75dB
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NAL-NL2 Comparison to 5 Different
Manufacturers’ Proprietary Fittings
Sanders, J., Stoody, T., Weber, J., Mueller, H., “Manufacturers’ NAL-NL2 Fittings Fail Real Ear Verification” Hearing Review, March 2015; 21(3): 24-32
55dB 65dB 75dB
N = 16
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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 http://www.hearingreview.com/2012/12/the-importance-of-audibility-in-successful-amplification-of-hearing-loss/
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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.
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REM and Patient Satisfaction
82
23
79
32
51
58
6
53
7
31
0 20 40 60 80 100
Measure LDL
Measure Customer Satisfaction
Measure Objective Benefit
Measure Subjective Benefit
REM
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.
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Perceived Value of REM
The Amlani et al UNT study, 2016
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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
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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)
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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
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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.
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Results - Willingness-to-pay
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Results - Loyalty
e.g., “What is the likelihood that you would recommend this provider to family and friends?”
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Results - Loyalty
e.g., “What is the likelihood that you would expand your purchase of additional services offered by this provider?”
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Results - PERVAL
e.g., “The quality of the service I received was outstanding.”
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Results - PERVAL
e.g., “The service provided eases anxiety about how well the product will work..”
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Results - PERVAL
e.g., “The overall value of this experience was high.”
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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
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Speechmap
A quick review
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The Speechmap Screen UCL (SPL, estimated from threshold)
SPL Threshold (converted from HL)
MAP(Minimum Audible Pressure)
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Speech display & analysis
• Percentile analysis used to display the dynamic range of amplified speech.
Maximum levels (peaks or 99th percentile)
Average levels (L.T.A.S.S.)
Minimum levels (valleys or 30th percentile)
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• 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.)
Speech display & analysis
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The counselling challenge…
Explaining
recruitment!
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Use the Speechmap screen:
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“Normal” dynamic range
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“Reduced” dynamic range
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Audiometric Data Entry
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Soft Speech
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Conversational Speech
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MPO
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SII
What is it and how can it help me?
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Speech Intelligibility Index
• ANSI S3.5-1997 “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
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Soft Speech
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Conversational Speech
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SII vs. Predicted CST Score
(from Sherbecoe and Studebaker 2003)
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Live Speech
as a counselling tool
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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.
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Average speech
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Spouse’s voice
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Compared
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RIC/RITE and OC update
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RIC dominates the market
http://hearinghealthmatters.org/waynesworld/2016/major-hearing-aid-disruption/
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Vent effects on HI Gain
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Dome type examples
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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.
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Audiogram entered
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Audiogram entered
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Step 1: HI present but ‘off’
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Step 2: HI turned ‘on’
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Comparison
Difference between curves shows amplification reaching TM
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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
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First audiogram entered
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A good candidate for OC fit!
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Second audiogram entered
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Not recommended
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RECD:
Not just for kids anymore!
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RECD – what it is
• Real Ear to Coupler Difference
• Broadband signal measured in coupler
and in ear canal. RECD = difference in
output, across frequencies.
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RECD – How it is measured
Frequencies at which
RECD was measured
Measured RECD values
Coupler mic
RECD transducer
RECD transducer
Probe mic
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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?
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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!
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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!
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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!
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Example case
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Speechmap test: average RECD
RECD: 3 3 3 3 7 8 10 15 15 11
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Speechmap test: entered RECD
RECD: 3 2 3 5 5 8 5 7 11 8
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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
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Frequency Lowering
How to adjust for optimal benefit
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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!
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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.
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The ‘s’ and ‘sh’ Stimuli
“S” @ 65dB
“SH” @ 65dB
• Special stimuli for use in adjusting frequency lowering function.
• Developed at University of Western Ontario.
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FL Adjustment protocol
1. Run 65dB speech
2. Identify the Maximum Audible Output
Frequency range.
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MAOF
Identify MAOF;
Where SPL
threshold crosses
LTASS and where
it crosses PEAK.
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MAOF Highlighter
3. Run /s/ stimulus. Adjust so upper
shoulder of /s/ is within the MAOF.
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MAOF Highlighter
4. Run /sh/ and check that it does not totally
overlap /s/ signal. Adjust if necessary.
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MAOF Highlighter
On Verifit2, activate MAOF highlighter.
1. Run 65 dB speech test
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MAOF Highlighter
2. Run /s/ in a separate test. From test
setup in /s/ test, select the test containing
65dB speech.
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MAOF Highlighter
MAOF (i.e. target range) highlighted:
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MAOF Highlighter
3. Adjust frequency lowering of instrument
so upper shoulder of /s/ is within MAOF.
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MAOF Highlighter
4. Run /sh/ and fine-tune if necessary.
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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.
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Simultaneous Binaural
A quick update & tips
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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
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Simultaneous binaural on-ear
• The issue: on-ear soundfield typically non-
symmetrical and uncontrolled
vs.
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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
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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.
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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.
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Also: [email protected]