Health-Related Quality of Life Benefits with Hearing Aids: A Conversation with Drs. Anna Jilla and Carole Johnson

In this episode, hosts Maggie Kettler, AuD, and Sarah McAlexander, AuD, interview Anna Jilla, AuD, PhD, and Carole Johnson, AuD, PhD, to discuss their work with the American Academy of Audiology writing group examining the health-related quality of life benefits of hearing aid use. They explore new evidence showing how hearing aids improve overall well-being, the importance of evidence-based care, and what these findings mean for patient counseling, policy, and the future of hearing health care.

Transcript

SPEAKER_01 0:02

Welcome to Sound Practice, sponsored by the AAA Foundation, where Hearing Meets Understanding. We're your hosts, Sarah McAlexander and Maggie Kettler, and in this podcast, we'll explore evidence-based clinical care and audiology, focusing on new research in the assessment and management of hearing imbalance disorders. From the latest advances in audiology and hearing technology to real conversations about hearing loss, balance, and cognition, sound practice aims to translate research into real-world application, supporting informed clinical decision making and improved patient outcomes. Whether you're an audiology professional, a student, or simply curious about the world of sound, you're in the right place. Turn up the volume, tune in, and let's listen closer. This is Sound Practice. On today's episode, we'll be talking with Anna Gilla and Carol Johnson on their work with the American Academy of Audiology's writing group on the health-related quality of life benefits of hearing aid use for adults. Anna Gilla AUD PhD is an audiologist, researcher, educator, and health policy advocate whose work focuses on population health, health economics, and healthcare policy to address disparities and inadequacies in hearing imbalanced care. She was recently recognized by the American Academy of Audiology for her contributions to the profession with the Outstanding Early Career Award. She currently works as an assistant professor in the Department of Communicative Disorders at the University of Louisiana at Lafayette. Carol Johnson, AUD PhD, is an audiologist, researcher, and educator known for her research in auditory rehabilitation and community engagement to improve hearing health and well-being for unserved and underserved populations. She currently works as the director of the Hearing Evaluation, Rehabilitation and Outcomes, also known as Hero Laboratory, and is pursuing her Master's of Public Health from the University of Central Oklahoma. Welcome to Dr. Gilla and Dr. Johnson.

SPEAKER_03 1:58

Thanks for having us. Thank you. Yes. Thank you so much for spending some time talking to us about these really important issues in audiology. It's always such a privilege to be able to sit down and have this conversation in such an informal setting. And hopefully, our listeners today will get a lot from our conversation. So I'll start asking some questions. Now, both of you have spent a significant amount of time of your career working on research addressing hearing healthcare disparities. What motivated you to do work in this area?

SPEAKER_02 2:32

Well, with me, what really uh tugged at my heart was with my work at the University of Oklahoma Health Campus in the John W. Key Speech and Hearing Center, and working as the faculty coordinator of the United Way Hearing Aid Bank. As Dr. Gilla's research has shown with regard to affordability of hearing aids, the average cost of a hearing aid is $2,500. And so working with these patients and then also working with Dr. Gilla and her passion for health disparities and trying to give us the information we need in health economics. It's really been something that is important to me. And now I'm hoping to look from the patient to the population level in public health.

SPEAKER_00 3:22

I had a really similar journey. So during my time at the University of Oklahoma as a student, I got to be a part of this interprofessional group. It was like a pilot program. And we got to provide services alongside PTs, OTs, dentistry, you know, future physicians, physicians assistants, social work, et cetera. And what ended up coming out of that interprofessional practice experience was an opening of a free clinic in Oklahoma City to do diagnostic assessments for hearing and make sure that we could connect them to places like the United Way Hearing Aid Bank to get low-cost amplification. And that was when I really started to see the amount of the disparity. I don't know that I had seen it until I actually, you know, was in that realm in a free clinic to see, you know, how many comorbidities these people had and how poor access actually was. So that was the beginning of my journey there. And as part of my PhD program, I got to really dig in deep on some of these public health-related issues and start looking at this from a population level. We had some really interesting findings, some maybe unsurprising and others perhaps surprising. And I know we'll talk more about that today.

SPEAKER_01 4:40

Absolutely. And so kind of moving into some of those findings and some of that work that both of y'all have been doing, as we mentioned in the introduction, you recently worked with the Academy Writing Group to perform a systematic review of hearing aid use and health-related quality of life for adults with sensory neural hearing loss. Why do you feel it was important to revisit the evidence on hearing aids and health-related quality of life?

SPEAKER_02 5:04

Well, back about 25 years ago, then President Angela Lovenbruck commissioned the first task force on the non-acoustic benefits of amplification. At that time, we were chaired by Dr. Terry Chisholm, Dr. Craig Newman, Dr. Harvey Abrams, and our team really did the first evidence-based systematic review with meta-analysis under the leadership of Terry and Harvey because they've always pushed the field forward with evidence-based practice. And at that particular time, we there was no roadmap. There was no uh integration platform like Covidence. Uh, we didn't have a library scientist. But the group persevered, and that we found that the evidence was uh a recommended the recommendation that hearing aid use enhances health-related quality of life, um, was at a grade B, meaning that most of the studies were before and after studies, and there was only one randomized clinical trial. And so also at that time, it was only analog hearing aids. And I was um the youngest one at that time, and everyone else has uh gone into semi, semi or full retirement. And so in 2022, um the American Academy of Audiology tapped myself and Dr. Gilla to lead this group, and it it kind of makes me uh chuckle a little bit when we read the recommendations that um we need to keep these period periodically updated. Well, 25 years goes by pretty quickly, and so uh now we were really uh with our group uh excited to go ahead and uh tackle this problem. And things have changed. And so hopefully uh Dr. Jill and I will be able to share those results.

SPEAKER_00 7:04

Yeah, absolutely. And I yeah, I want to underscore Dr. Johnson's comments that you know, even though this has been, you know, a couple of decades since the update, um, I think that this was the right time for the update. Um, I know Dr. Johnson, Carol, you'd agree with me that we still had a whole bunch of randomized controlled trials coming through in the pipeline, like for instance, Frank Len's achieve trial results were published, you know, 2023, some of them in 2024. And so in order to get that grade A recommendation, you really need those randomized controlled trials. And so, you know, 20 years sounds like a long time, but I think that we were really just, you know, moving forward in our research design step by step, and this was the right time to update it. So I, you know, now I'm not gonna reveal anything, no spoilers quite yet, but uh, we're doing a lot better now than what we were in terms of graded evidence.

SPEAKER_03 8:03

All right. Well, now it's time for the spoilers. Tell us about the results of the study. We're really interested to hear.

SPEAKER_02 8:10

Well, and and as we embarked upon this, we realized that the definition of health-related quality of life has expanded, certainly with maybe public health initiatives such as Healthy People 2030, and uh also certainly with um the rigor and the interest that hearing aid use has in multiple areas. And so Dr. uh Gilla and I and the group really worked hard to try to identify some specific aims. And so, specific aim one, we really wanted to see how we moved the ball forward to a grade A recommendation. And um, because as we know, the United States Preventative Health Task Force does not recommend hearing screening for those 50 and older, partly because of the efficacy level of treatment. And so um we have numerous randomized control trials, and basically following the same outcome measures that we found in large effect size for disease-specific outcome measures, the hearing handicap inventory and the short form of the hearing handicap inventory, and also some generic measures. But what I'm really excited about now is that uh we've moved to grade A, but um, we're now going to go forward with a specific aim two that Dr. Jella um is going to tell us about right now.

SPEAKER_00 9:42

Yeah, so a specific aim two, I think, is again in that vein, like Dr. Johnson was saying, of that expanded definition of quality of life, that once upon a time we defined health-related quality of life as like the absence of disease. And we know that that's not the best way to define that. And we've, you know, added a lot of things to that definition. And now I think we're including more holistic aspects of wellness and health. And for us, we, you know, in our search when we were doing the systematic review, we wanted to exhaust a lot of those options. So we know that this may have impacts in terms of mental health or cognition and maybe perhaps balance. And so those were three areas that we identified as very meaningful as it relates to hearing health-related quality of life and wanted to add those in for our specific aim too. But like Dr. Johnson said, you know, that aim one, we have moved the ball forward. We are in a grade A territory now, and we're able to, you know, basically take that forward to places like the United States Preventative Task Force as part of the supporting evidence for screening of asymptomatic adults at ages 50 and older. Um, and I think that you know a lot of people maybe don't realize that the the evidence was maybe lacking on the screening side. But in order to have the United States Preventative Task Force give it the thumbs up, you know, and say, hey, everybody should do this, there has to be a good treatment available. And because we were sitting at that grade of B, you know, we weren't able to make a great argument to say that, you know, hearing aids do help. And, you know, a side example of that would be, you know, if you're uh right now we don't have a lot of good, you know, drugs or treatment for things like Alzheimer's and related dementias. And so, you know, a universal screening for that wouldn't make sense because if we screen for it, then what are we gonna do about it? Um, so now we have that great evidence that we can take to the USP STF. And the other things that I think are gonna be helpful for these findings too is um influencing things like payer policy, um, that you know, we deal with insurance with hearing aids all the time. And this is, you know, part of an argument that can be made through payer advocacy that these things aren't luxury devices. Um this is not something that's you know extra. Um, it's something that's integral to health and well-being and improves overall quality of life well beyond audibility.

SPEAKER_02 12:19

And to chime in a little bit about sound practice, um, that most of these randomized controlled trials did not focus specifically on health-related quality of life. Those were secondary or tertiary outcomes, but the vast majority of those randomized control trials did recommended care and fitting of hearing aids and follow-up services according to best practices that we currently have. For example, uh Valenti's work on management of adult hearing loss.

SPEAKER_00 12:53

I think that's a great point to underscore, Dr. Johnson, that um, you know, the findings that we have in terms of this grade A, it's very difficult to disentangle the device itself from the supportive rehabilitative services that were provided in most all of these randomized controlled trials. Um, if you look at the manual procedures, you know, available on the NIH website and government websites about the Achieve trial. I mean, we're talking real probe microphone measures, we're talking counseling orientation, et cetera. So, I mean, all of that Valente guideline from 2006, 2007, they hit all of those aspects. And so when we talk grade A here, it's not just the widget, it's not just the device, it's the professional services associated with that. And I think that when we think about pair policy and advocacy, that's an important point to underscore.

SPEAKER_02 13:44

And also, Dr. uh following up on Dr. Gilla's uh point is that uh, and Dr. Jilla, correct me if I'm wrong, but both of the meta-analyses for generic measures that measure multiple areas of health functioning, the SF-36, the SF-12, the EQ5D, um, and the disease-specific um hearing handicap inventory and its short form. Um, those were based on seven randomized trials, but there are several that are ongoing, and um we can start to feel more secure about our meta-analytic meta-analytic results in multiple domains with regard to heterogeneity, differences among these studies, um, prediction interval of what would future studies affect sites, where would it fall for 95% of those studies with comparable comparable populations, uh, and also publication bias, uh, which is an assessment that says, is there a study missing? Is it are these results on balance? Really start to stabilize around 10 randomized controlled trials, and we we hope that that we're there. Um, and these trials are being done all around the world. And the difficult part is is that when a a group reports um findings and something looks unusual, we need we need to contact those investigators. And that's been a little difficult. Um, Dr. Jilly, do you want to say anything more about that?

SPEAKER_00 15:21

Yeah, I think that your point, so again, in the meta-analysis, and you know, this is basically a statistical synthesis across all studies. Um, so instead of you know your typical study where you have an N equals however many participants in our systematic review, our unit of study is a study. And um, what we found in that um, because what when we looked in our search, we wanted to dig deep on the available evidence, clearly, but what was also coming? So if the study protocols that were published actually met our inclusion and exclusion criteria for the systematic review, we dug in to see kind of whether that would actually fit. And what we found is that there were several ongoing studies that, you know, when we revisit this topic and periodically update the systematic review, um, I think that we'll be at a critical mass. And like Dr. Johnson was saying, that, you know, once you get up to around 10 studies, you know, it's almost like your central limit theorem from your statistics class. You get enough here, you get a good average. And uh I think we're gonna be there, you know. We're clearly most of the way there because I feel like our statistics look really nice, really clean, that we're very well centered around a mean. Um, but we'll have a lot more to throw into the pot the next time. So I think that that's really exciting to see that people are continuing to study this topic. Because sometimes we can be prone in research that, you know, when's the last time somebody did a study on pure tone audiometry, for instance, that, you know, once we hit it, we abandon it. But I think that there's a lot more going on here. And what we found in a lot of those protocols that are, you know, yet to be published in terms of their results is that they're looking into these specific areas of mental health and cognition, et cetera. So, you know, our our inkling that we needed to go a little bit further with that aim too, I think is uh definitely spot on.

SPEAKER_01 17:12

And I think all of these topics are really important, especially when you think about the patients that we see in clinic and what matters to them. I mean, um, we all have patients who are very hesitant to proceed with amplification, where we can feel like we're trying to talk them into doing what is best for their health. Um, and trying to find things that matter to them when, you know, maybe hearing, quote unquote, is not the factor that's ultimately going to drive their decision to purchase hearing aids can be difficult. And so thinking through sort of the systematic review that you've done, um, what do you feel like these findings really mean for audiologists who are counseling those patients in clinic and trying to, you know, convince them that hearing aids really are going to improve their quality of life overall and not just improve their hearing, so to speak.

SPEAKER_02 18:10

You know, um, and that's one of the critical differences also in terms of the language, because first task force said hearing aids, but we're saying hearing aid use, because it's one thing to get the hearing aid and it's another thing to use it. But I think that audiologists can be more confident in that. And our history with the hearing aid industry, we've some several times the FDA has kind of slapped our wrists because of the recommendations that have come from maybe manufacturers or so forth about the benefits of hearing aid use. But, you know, a grade A-level recommendation that hearing aid use enhances health-related quality of life is something you can take to the bank.

SPEAKER_00 18:53

Yeah, I agree. I think, you know, in Clinic, there you get all of these questions about hearing aids. Like, is this one that's a higher level of technology going to help me? And, you know, we know that we only have a couple of studies on that topic. And so, you know, whenever I talk to patients about that, I'll say, well, you know, according to the the small body of literature on the topic, you know, this is what they found. Um, but I think for this systematic review, you don't really have to kind of temper what you're saying, that you can say with really good confidence, we anticipate that this is going to improve not just the audibility and the hearing pieces, you know, Sarah, like you were saying, this is gonna improve your general functioning as a human. You know, you're gonna be able to be more social, perhaps more active. Um, you might find yourself happier, less lonely. And again, we didn't dig into each one of those specifically, but a lot of that is encompassed in the measures that we use. So we know the hearing handicap inventory um measures have more kind of social and emotional aspects to them. We know a lot of the measures that we used for the generic piece and just overall health-related quality of life, that these are cross-cutting measures that can be used, you know, regardless of what the disorder is or disability is, um, physical functioning and mental functioning. And so I think that those are some key points to think about when we're counseling patients and taking this evidence and not necessarily giving them the paper because that would be a sure cure for insomnia. Um, it's incredibly lengthy. However, I think that when we're talking about it, we can lay that out to say, you know, what we can say with good confidence is this is going to help you across multiple aspects of your life, not just related to hearing, but other, you know, aspects in terms of physical and mental functioning as well.

SPEAKER_01 20:50

And I think that's all super helpful for the clinical audiologist. And um, Carol, I loved what you said there about the clarification about hearing aid use versus just hearing aids. I know um when I was in grad school, I always had a supervisor that used to say the worst type of hearing aid is an ITD hearing aid, an in-the-drawer hearing aid. Um, you've got to wear it if you're really going to get anything out of it.

SPEAKER_03 21:12

All right, I have a question. So your work really does highlight the importance of using quality of life outcome measures for patients in clinical settings. We're audiologists. We all know the day-to-day, in and out, not enough time with each patient. How would you recommend we incorporate that into clinical practice to be able to get that value to our patients?

SPEAKER_00 21:38

Well, the first thing that I would say is um just in case you missed the last episode of Sound Practice, I'll give a plug. Um, there was a task force that was put together by the National Academy of Science, Engineering, and Medicine, and they did this whole review of all of our outcome measures, both clinical and kind of the questionnaire types. And Um, we found out that, you know, there's this revised hearing handicap inventory available. And, you know, I think it got published in 2020. It probably got buried in, you know, the COVID fog. Um, but here we are on the backside of that, you know, and I want to give it its time in the light. And that revised hearing handicap inventory and the work of Casterly and colleagues shortened the measure and made it more sensitive and more specific. And that's also going to save you time, right? And it's going to be more specific. It's going to be more useful to your clinical practice. And I know that there's a lot of, you know, large medical centers, et cetera, that are putting these measures in things like Epic to speed up, you know, that it's part of a check-in process, et cetera. So we don't need to sit there and watch them with our own two eyeballs with a piece of paper and a pencil, that integrating this into health systems, I think, is going to be very helpful as we start to see a lot of this really build out in those medical record systems like Epic.

SPEAKER_02 23:02

And I think also, too, experimentally, it's important for these randomized, these teams conducting these randomized control trials to get on the same page. And that if there's just some way that we can leverage the effort going on around the globe in these clinical trials, it could bode well for moving things forward. And as I said, um, with these with the uh RCTs that uh have been done, they're not looking at health-related quality of life, but it's a secondary or tertiary area. Um, but certainly if an expensive clinical trials during done being done, why not look in multiple areas? And uh with the new uh revised hearing handicap inventory, shorter, more sensitive, and specific is the way to go because you know they've made the AFAB, the Saddle, the Echo, but they're you know 24 items long, and we know that our pay our older patients can't even fill out their case history forms. So and the only thing that when an outcome measure is going to be used, it's that the time worth doing it is gonna give you the information that you need to uh contribute to a better outcome for your patient. And um I recently attended the American Auditory Society meeting, and there is now a new COSI2 that uses AI, which is super exciting. And Dr. Um Katie Keese and Harvey Abrams are doing that work because we know that the that the COSI really is the star of outcome measures because it's patient specific and it really gets at what we're trying to do, and that is being our boots on the ground for specific situations for our patients.

SPEAKER_03 24:52

Yeah, and so it's important to have that model and really to have that conversation starter. I think those outcome measures just help audiologists build the relationship and answer the questions that the patients really want to talk about.

SPEAKER_00 25:06

I just wanted to give a little plug out to anybody who's designing studies out there as it relates to the generic health-related quality of life measures in our work on the systematic review. And I think that this was hinted at in the previous one by Chisholm and colleagues and Dr. Johnson here many moons ago, that some of these generic health-related quality of life measures don't have things that load specifically onto hearing. Like there are zero questions specific to hearing. Um, sometimes we get it tangentially via, you know, questions about communication or interacting in society, et cetera. So we found some of these measures are perhaps a little bit more sensitive to our world in audiology than others, um, those being the RAND short form, either, you know, 12 or 36. And we're also huge fans of the Health Utilities Index 3, the Huey 3, um, because that one is pretty much the only one that has a hearing-specific question. Um, so you know, if anybody's out there listening right now and you're designing a study, I'd encourage you to look at those measures as opposed to other ones because I think we're gonna find that they're more sensitive to the impacts of amplification and um and rehabilitation.

SPEAKER_01 26:28

And so, sort of thinking about all of the many studies that you look at when you're doing this type of systematic review, I know it's thousands. Um, it includes a wide range of different technologies, fitting models, service delivery approaches. Um, were there any patterns that really emerged about what works best? Or is it really just as simple as wearing some type of hearing device is going to improve your quality of life?

SPEAKER_02 26:53

What we wanted to do for specific game one, though, it was was we were looking for that graded recommendation. Did we move the ball forward? So we opened up the possibility of different amplification options, um, different models, uh, randomized trials looking at different things like health workers and so forth, helping individuals um get used to amplification. So one of the studies had body hearing aids. So it was wide open. So for that first day, uh, we were really looking for the experimental level as to drive this and our PICO um rubric of what was included and not included. And so uh we really didn't look specifically because it was so broad and heterogeneous, because again, it was the level of evidence that was going to drive the recommendation. But I think Dr.

SPEAKER_00 27:44

Gillis got some insights into this is a can that we kicked around the yard quite a bit while we were drafting the manuscript. And um, when we started this project, we were very optimistic that we would be able to do these meta-analyses in subgroup analyses to see, like, oh, well, what's the difference in effects between analog and digital? Or what's the difference in effects between this service delivery model and that service delivery model? And um, like we had said earlier, you really need a good group, uh good number of studies in order to be confident in what your your synthesis results are in meta-analysis. And unfortunately, those subgroup analyses were um not in the cards this time, but I think that um, you know, as these you know protocols come to fruition in terms of completed studies in the next go round, hopefully we'll be able to you know put some more science to this to answer some of those clinical questions. But I think that that's well posed, Sarah. And I know that your professors would be proud. Previous.

SPEAKER_02 28:52

And some of the RCTs had like we included the one RCT that was in the last systematic review, it was all analog, as well as McCardle's work, uh, her randomized control trial, um, had digitally programmable hearing aids and some early digital hearing aids. But for the most part, Dr. Jill, and most of the rest of them were digital, correct?

SPEAKER_00 29:14

Correct. Yeah. And so then when you're trying to make a comparison, you don't have a large enough sample in one of the boxes to, you know, do a comparison. So, but we're hopeful though, I think in the next round, go round, that we'll have enough studies to answer some of those questions because those were not the only areas that we wanted to look into for subgroup.

SPEAKER_03 29:34

So, along that line, the landscape in audiology is clearly changing, and we're seeing a lot more OTC hearing aids on the market and on our patients, some with really good benefits to our patients. Um, how would you um how might these findings apply to the new models of care that we're seeing with these patients who have OTC versus prescription hearing aids?

SPEAKER_00 29:59

Yeah, I think that there's definitely some implications there. I, you know, can't really state that this is all going to be applicable to the population who's using OTC hearing aids. Um, but all things being equal, you know, it may stand to reason that you know we may see uh benefits reaped from these OTC hearing aids, um, given that we saw good benefits in the 2007 systematic review, which included primarily the analog, digitally programmable, et cetera. So, you know, thinking that we had a grade B even with you know older technology, it stands to reason that people will still be able to reap some benefits from that. But as far as you know, the numbers, we we don't really have that yet. But you know, logic might say.

SPEAKER_02 30:50

And and it's really hard to to at this point to say anything about over-the-counter, just in my work in the United Way Hearing Aid Bank, uh where we had a lot of students doing capstone projects, um, our patients were 170% of the Fed US federal poverty level and lower, accounting for household size. And about four out of ten of them had tried over-the-counter hearing aids before they found finally found their way to us. And um, our pay our patients have multiple comorbidities like diabetes and so forth. Um, but I guess you know the main thing is is it do they get the hearing aid on? Um, have they been able to self-fit the device to the point where they are wearing it? And I think wearing is is the again is the underlying common denominator. Because like that you said, the in-the-drawer hearing aids, um, so many of those end up there, and many over the counters do.

SPEAKER_00 31:55

And I think um, you know, most recently the new market track uh data came out, and shout out to my one of my co-authors on a paper that we wrote um for that, Lindsay Jorgensen. Hi. Um we were really interested to find that um, you know, the population who's you know purchasing OTC hearing aids is very inherently different from the typical patient population that we see in prescription hearing aids. They're younger, they're more diverse, et cetera. And then when you get to purchase intent for their next set of hearing aids, the vast majority of the people who responded to the market track survey said, you know, for my next set, really thinking about a prescription hearing aid. So I think that that's exciting to hear because, you know, we were in a very uncertain time when the FDA, you know, said, hey, you're gonna need to create a new classification of OTC hearing aids. Um, but I think that, you know, access was what the underpinning for that decision was the entire time. And I think that that's been wildly successful. And um, for people who maybe were not as successful as they hoped they would be, um they're planning on seeking care um with an audiologist and obtaining those prescription hearing aids in the future. So I think that that's you know, really, really great news in terms of the market moving forward.

SPEAKER_01 33:17

Yeah, absolutely. I I think that is great news, and I think that's really a relief for a lot of audiologists who have been worried about OTCs, you know, hurting the prescription hearing aid market to know that if anything, hopefully this is going to drive more people to seek out our services in the future, which is really what we all could have hoped to get from the OTC model of care. Um, I think, you know, one of the things that's great about this um systematic review and about both of y'all getting to collaborate together on it is that you have really worked together for um a while on many different projects. Um, and one of those projects was back in 2024. You published in the American Journal of Audiology a benefit cost analysis of hearing aids, over-the-counter hearing devices, and hearing aid services, which really ties in to a lot about what we've been discussing today. Um, what links really do you see between the project that was published back in 2024 and the systematic review that we've been discussing today?

SPEAKER_00 34:22

Yeah, I think that there's there's plenty of links there. Um, in terms of clinical applications, you know, the health-related quality of life piece is really just getting at, you know, what are the outcomes with these things? But the benefit cost analysis is similar yet different. And it has as this extra layer to it, um, where not only are we worried about outcomes, we're worried about outcomes per dollar spent, basically. And um, you know, it's all linked together. You know, we've got outcomes baked into it. The benefit cost analysis was uh definitely kind of a paradigm shift. We don't have a lot of examples of those in audiology. Um we were reviewing the literature on the topic, but come to find out, benefit cost analyses are very useful, particularly when advocating at state legislative, federally legislative, and just you know, general budgetary hearings. Because, you know, you go in front of you know your state legislature and you're like, guys, we should really cover this stuff. It will give a two-point increase on the revised hearing handicap inventory per dollar spent. That doesn't help them understand what those impacts are. And so the cool thing about the benefit cost analysis is that everything is in dollars. That, you know, the actual quote unquote benefits are measured, at least in our study, as willingness to pay. And we, you know, kind of equate that with outcomes and utility in the same way that, you know, if I ask you how much you would be willing to pay for a new cell phone, I imagine that it would be quite a large amount because you see great benefit in that, right? Um, and so being able to talk in dollars and cents to these policymakers, we felt was very, uh, very important. And, you know, I'm looking forward to doing more work in this area, um, that it's not just hearing aids that we need to be able to communicate about. It's diagnostic testing, it's vestibular, it's auditory processing, it's tenetists, it's everything. Um, so I think that that was kind of the link there is that outcomes are baked in everywhere, but um, benefit cost analysis is really getting us into the policy leagues. And I think that that's where the academy has been, you know, a great shining star in getting us in front of, you know, the legislature and having really good, solid advocacy, um, strategic plans and just functioning so that as this evidence continues to grow, we will have um more to say in those meetings that meets the needs and the language of um the people that we're talking to in those rooms who are making the decisions.

SPEAKER_02 37:02

And in working with health equity, it and this is Dr. Gilla forging her way into new frontiers for our field. And um, I was so fortunate for her to be able to have her apply some of her health economics to our patients in the United Way Hearing Aid Bank. Um, and how much would they be willing to pay for a prescription fit hearing aid? And most of our patients had an annual or monthly income of $1,100. So they would have been ready, uh, willing to pay $250 for a hearing aid, which for them is a lot. But uh out of 50 respondents, only two would be willing to spend anything on an over-the-counter hearing aid. And that that bodes well for how important our services is because in the United Way Hearing Aid Bank, um, the services are bundled in with the hearing aid, and we have you know fitting a two-week and a four-week follow-up because many of our patients need a little bit more help to be successful. So that indicates for me when we talk about health equities, that uh the prescription fit model and follow-up services is so important, and that the over-the-counter sometimes for those patients that have are just extra challenged may not be appropriate because that support's not there and they're not necessarily good with technology.

SPEAKER_00 38:32

Yeah, I think that that scores are great, underscores a great point, Dr. Johnson. That, you know, in the not the United Way Hearing Aid Bank, you know, low-income individuals study, but the, you know, kind of broader study that we did. Um, this was the first time that we had teased out what people would be willing to pay for hearing aids and services separately. And what we found is that those services have an inherent value and people are willing to pay for those. And so um, you know, bundled versus unbundled versus itemized is a whole other episode uh, you know, that could be, you know, done for this podcast. But um, you know, for those of you who are thinking, well, I don't know that people would pay for this, our research is indicating that it would, and um or they would. And anecdotally, any clinics who have kind of split these things out have not seen major issues with that um in terms of you know office visit fees, et cetera, um, you know, payment for relayer measures out of pocket.

SPEAKER_02 39:36

And to take it back to the health-related quality of life systematic review, um, that again, those services were so important and they were embedded with the majority of the clinical trials. So that any gains that we've seen, this grade A recommendation, it's the hearing aid, using the hearing aid in addition to the services and follow-up care. So that bodes well. But your questions to us are so well put in terms of looking at what the future holds, and hopefully, as more studies are done, that we'll be we'll be able to have answers to um different technologies and things like that.

SPEAKER_03 40:17

Yeah, and that goes right into my next question. So as we get close to wrapping up, what unanswered questions remain about the broader health impacts of hearing aid use? Dr.

SPEAKER_02 40:29

Gilla um has great visions for cognition balance and mental health. Would you like to say a little bit about specific aim two?

SPEAKER_00 40:42

Sure. I think that those are the primary unanswered questions coming out of the systematic review. Um, because you know, we talked about how you talk to patients about the findings of you know, the systematic review that's you know working in in-press right now. Um, you know, we can say with good certainty that you'll reap these benefits and hearing and just general quality of life. But what a powerful thing to, you know, if we could say that, you know, hearing aids can improve your mental health, hearing aids can improve your cognition, hearing aids can improve your balance. Because those are, you know, some of the things, A, that are, you know, big ticket items for insurers to begin with. We're talking about falls, you know, mental health concerns, you know, cognition, just downstream effects and cost for the care. Um, and so if we're able to mitigate those things through hearing aid use, I think that that's great. The other, you know, thing that I would love to see coming out of AM2 is that we'll be able to get on the interprofessional team with some of these discussion points. We can get in the room with neurologists, we can get in the room with physical therapists, we can get in the room with psychiatrists and say, hey, you know, let's think about a screening procedure or triage system so that, you know, you can get those patients to us so that we can get them the care that we need to help these other things. Um, so those I think are you know big unanswered questions. Sarah, you brought up one earlier about, you know, what are the differential effects, you know, across these device types and service delivery models. We definitely want to see that as well.

SPEAKER_02 42:17

And some of the RCTs that are finishing up are focusing specifically, for example, on mental health, and but the majority really are focusing on cognition. So there should there should be a lot there. And you know, I think that uh with regard to um you know specific areas. We we had a the the academy was able to secure for us some coaches, mentors for this project. And one of them said, you know, why aren't you looking at all of these side areas? Why are you going back? But we really do do and need it, we we needed to have planted that flag on the high peak of a grade A uh recommendation that hearing aid use enhances quality of life from where we were. Otherwise, we're not gonna have our seat at the table for third, you know, recommendations for screening of hearing for adults 50 and over and 30 party payers. So that was really the first step. Um but these other areas and how Dr. Jilla has mentioned that, you know, it's gonna expand our role on holistic and interprofessional care. And we're excited about embarking on that immediately.

SPEAKER_03 43:39

So I'm looking forward to that as well.

SPEAKER_01 43:42

So, future researchers, I think we've given you several projects that you can hopefully take on and run with as we hopefully seek to continue to show how important audiology services and hearing aid services are to the patients that we show. Um So to wrap up, um, our show is called sound practice, um, and we love to end our podcast with a little bit of a fun question. So outside of the clinic, what is one sound practice, um, maybe habit, hobby, mindset that helps you stay balanced and focused?

SPEAKER_02 44:19

I've discovered swimming. I love swimming. Uh try to swim a mile three times a week, and um something I did as a kid, and you just have to keep reinventing yourself.

SPEAKER_00 44:30

I take my cat on leashwalks. No, that's the that's actually true, but that's not you know, that's not the true source of grounding. Um, there's a really great exercise program called Pure Bar. I'm a retired gymnast and it speaks to me, and that is definitely something that gives me, you know, I can look forward to that at the end of the day. Um, exercise the mind and body. And I think about, you know, the vestibular side of my learning and how important it is for body awareness and preventing falls in the future. So I feel like not only am I grounding myself, um, but I'm also making sure that I don't end up on the ground later.

SPEAKER_01 45:09

I think those are both great ways to improve your own um health-related quality of life.

SPEAKER_03 45:15

Yes, and Dr. Jilla, I hope I do see you on a walk with your cat because that sounds like that would make my evening for sure, and be a wonderful story to tell. Well, thank you both, Dr. Gilla and Dr. Johnson, for sharing your experience about the cost-benefit of our important services. Um, I know I took a lot away from this conversation. It's really exciting to see the profession move in this direction. And I think it's going to have a huge impact on the patients we see as well as the clinical practice. It's going to open up a whole different opportunity for us to engage our patients at a different level and get them excited about the hearing health care in front of them. So I took so much from this hour with you and greatly appreciate it. Sarah?

SPEAKER_01 46:05

Yeah, I agree. I mean, I think the work that y'all are doing is just so important to how we counsel our patients, how we, like you said, Anna, talk to legislators about why these services are important to cover, why we need to better support this for um all of the people that we see with hearing loss. And then I know I'm always thinking Maggie and I are both pediatric audiologists, I'm at heart, and maybe some of the other pediatric folks listen to this podcast and they hear about these studies that are focusing on adults and wonder, like, eh, does it really matter? And it does, because we're still talking to parents about why it's important for them to consider hearing devices for their child, because those children are going to become adults. And we know that it's going to be important for their quality of life from birth through adulthood to have access to that language, to help with their cognition, to help with their overall um quality of life, socialization, everything like that. So I really appreciate all of this work you're doing, and I love that you were able to come on the podcast and share with us today.

SPEAKER_03 47:10

Thanks for having us. And thank you to our listeners for listening to Sound Practice, sponsored by the AAA Foundation. We hope today's discussion provided clinically relevant insight that you can apply to your practice and professional development. For references, additional resources, and future episodes, be sure to follow the American Academy of Audiology to stay connected. If you found this episode valuable, consider sharing it with an audiology colleague, a friend, students. Until next time, this is Sound Practice, translating research into better patient care.