a test of change. one-stop hearing aid fittings: you only need to … · hcs national conference...

A test of change.

One-stop hearing aid fittings: You only need to come “hear” once.

Michael Osborne, Senior Audiologist

HCS National Conference June 24th

Why?

• Current delivery: Assessment (45 mins) + Fitting (60mins)

• Technology allows for it

• Ear mould manufacture necessitates 2 appointments

• No mould needed

• Advantages of one-stop: ❖ Only one visit for the patient ❖ Only one appointment to schedule within 18 weeks ❖ At 90 mins saves 15 mins over standard delivery

Disadvantages?

• Down-time where aid not issued (45 mins spare) or where DNA.

• Appointment too long for patient….and audiologist? • But not long enough to cover all necessary steps?

One-stop trial

• Conducted from October 2015 to January 2016 • Using products already being issued - test of service

delivery change, not technology change. • Key questions:

1. Can >75% be issued at first appointment? 2. Can same level of service be delivered in

shorter appointment time? 3. Does hearing aid use differ between

different service delivery models?

One-stop trial

•2 additional patient criteria for Direct Referral to one-stop appointment:

1. <80 years old (based on literature search and adequate coverage of pending population)

2. No significant visual impairment • 48 patients appointed. • 4 excluded (3 patients >79 years old. 1 patient had hearing aids

issued by another service.) • Allocation not randomised • Results from 44 one-stop appointments considered • And the results …….

….64% issued at first appointment

Not magic 75% one-stop issue rate. Why not?

Difference in age between those issued and those not?

Issued Not Issued

Age range (years) 49-79 34-79

Average (years) 66 62

No statistical difference in age between groups (t-test, p= 0.29)

Reasons for failure to fit

1

3

2

3

7

WNLRejectedWaxOutwithTransport

7% of sample population with measured hearing loss rejected a free hearing aid.

Patient or Audiologist factors?

The wider Direct Referral Population

•Currently measure footfall but not rejection (conversion)

•Looked at wider DR population <80 years old during same time period as one-stop trial.

•32% did not go on to a hearing aid issue appointment.

•Rejected offer? Referred on to another department? Thinkers?

Or….

Reasons for failure to fit

1

3

2

3

7

WNLRejectedWaxOutwithTransport

16% of sample population had normal hearing

If could triage these patients to more appropriate assessment appointment one-stop success rises to 76%

One-stop patient reviews

• Of 28, one handed aids back, 7 DNA, 20 seen, incomplete data on 3

• Single blinded. Could have been double blinded • 7 questions (Strongly agree to Strongly disagree) assess:

❖patient opinion on level of service ❖perception of hearing loss severity ❖readiness

Plus ❖Hearing aid use ❖Competence - directly ❖Competence - indirectly (open-access clinic )

Level of service • Appointment length: nobody has found too long (1 uncertain?)

• 88% “strongly agreed” and 12% “agreed” that results were explained clearly and concerns addressed

• 88% “strongly agreed”/“agreed” that the purpose was made clear and sufficient instruction was provided. While 12% were uncertain in each case.

• From audit of appointments all key elements (diagnostics, fittings, verification) were covered in all one-stop appointments.

• No extra pressure on Open Access clinic ❖ 2 patients have used, each on 1 occasion.

Self-rated severity – [None] [Mild] [Moderate] [Severe]

Readiness:

Use:

Severity, Readiness, Use

• 50% rated as mild

• 5 point Likert scale • 86% felt that they were ready for hearing aids

(45% “strongly agreed”, 41% “agreed”) • 14% were uncertain

• Hours/day • 39% wearing for 1 hour or less on average per day

Correlated?

Severity/ Hours use r = 0.186 p= 0.491 Not significant

Readiness/ Hours use r = -0.397 p= 0.128 Not significant

Severity/Readiness r = -0.310 p = 0.242 Not significant

Severity, Readiness, Use

No

•Small sample size? •Every patient “ready” •Finer scale needed, e.g.: “Readiness” 0 I I10

Mildness of loss or lack of readiness not given as reason for lack of use.

Severity, Readiness, Use

How does severity, readiness and usage compare with patients from usual two stage journey?

• 30 patients from usual two appointment journey ✤ Same age criteria (range 48-78, m=67, p=0.691) ✤ Assessed during same period ✤ Randomly selected, single blinded ✤ 53% female (46% female one-stop) ✤ 23 attended

Control group

How does severity, readiness and usage compare with patients from usual two stage journey?

• Usage

• But, must look at full distribution of use…..

Control group

1 hour or less

0%

10%

20%

30%

40%

One Stop Usual Journey

22

39

How does severity, readiness and usage compare with patients from usual two stage journey?

• Usage

Control group

0

2

3

5

6

<1 1 2 3 4 5 6 7 8 9 10 11 12 13

one stop usual journey

“Usual Journey”: bimodal. Two sub pop.s?

How does severity, readiness and usage compare with patients from usual two stage journey?

• Usage

Control group

0

2

3

5

6

<1 1 2 3 4 5 6 7 8 9 10 11 12 13

one stop usual journey

5.35.8

Means meaningless in this analysis

How does severity, readiness and usage compare with patients from usual two stage journey?

• Usage - analysis of distribution

• Kolmogorov-Smirnov test suggests that 1. “Usual Journey” usage does not follow normal distribution curve - is bimodal

2. The usage distributions of each group do not significantly differ.

Control group

• 5 point Likert scale • No one selected “Disagree” or Strongly disagree”

p = 0.556, not significant

Control group - Readiness

%

17.5%

35%

52.5%

70%

Strongly Agree Agree Uncertain

14%

41%45%

25%

6%

69%

One StopUsual Journey

• 5 point Likert scale

p = 0.51, not significant

Control group - Severity

%

17.5%

35%

52.5%

70%

None Mild Moderate Severe

5%

66%

29%

0%

12%

35%

47%

6%

One StopUsual Journey

• No significant difference between hearing aid user groups on ✦ Patterns of hearing aid usage ✦ judged hearing loss severity ✦ readiness

•No patients from one-stop group objected to the 90 minute appointment

•Would the control group have preferred a one-stop appointment?

The Final Question

Final statement:

“ I would have preferred to have had my hearing aid(s) issued at the same time as my hearing test, even if the appointment had to be 90 minutes long.”

The Final Question

“ I would have preferred to have had my hearing aid(s) issued at the same time as my hearing test, even if the appointment had to be 90 minutes long.”

%

7%

14%

21%

28%

Strongly agree Agree Uncertain Disagree Strongly disagree

9%

18%

27%27%

18%

• Cannot yet fit >75% of patients at a one-stop appointment.

• Level of service does not suffer as a result of one-stop appointments.

• Patterns of hearing aid use do not differ between groups.

Conclusions

✤ But could do further work on normal hearing triage and hearing aid rejection.

✤ But could work on improving hearing aid use and our understanding of patterns of use.

• Study limitations: ✤ Low patient numbers, especially in review ✤ Partial randomisation ✤ Single blinded ✤ Unvalidated questionnaire