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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
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Why?
• Current delivery: Assessment (45 mins) + Fitting (60mins)
• Technology allows for it
• Ear mould manufacture necessitates 2 appointments
• No mould needed
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• 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
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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?
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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?
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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
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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)
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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?
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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….
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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%
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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 )
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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.
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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
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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
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Mildness of loss or lack of readiness not given as reason for lack of use.
Severity, Readiness, Use
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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
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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
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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?
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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
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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
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• 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
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• 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
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• 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.”
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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%
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• 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