Excerpt: "Conclusion: In this retrospective cohort of unilateral hearing-aid users, an REM-based fitting pathway was not associated with statistically significant 3-month audiometric or patient-reported outcome differences compared with manufacturer first-fit followed by routine fine-tuning; this does not establish equivalence or isolate the effect of REM. Contralateral-ear hearing was associated with perceived handicap improvement and may be relevant to outcome interpretation and counseling.:
You’re ignoring this member’s posts.
BJBR21 people in this conversation46 min readJump to latest↓
When reading journals, it is important to notice every detail of the study. The study’s n=105, which falls short of statistical significance. It offers useful information, but the sample size is just too small. Plus it only includes unilateral fittings.
Extrapolating a small study to the general population almost never works.
This study only looks at unilateral hearing aid fitting and specifically doesn't isolate the effects of , so no true comparison has been made by it, nor can the conclusion that you've drawn be made from the data.
Half of the participants in the study had "good" hearing in their better ear, so it's probable that some of them would've had normal hearing in one ear. In these circumstances of course the impact of real-ear measurement is going to be reduced because the clients have a solid comparison against which they can provide feedback to balance the acoustic signal between ears using fine tuning.
In addition, the devices used in the study were Phonak, Widex and Starkey, the first two being known to have the most accurate first-fit algorithms on the market. It isn't really a representative sample of every hearing aid manufacturer.
Looking at study results, they found no significant differences in the subjective outcomes of the REM and non-REM groups on subjective questionnaires, but are these measures sensitive enough to detect any differences in the first place, especially in heterogeneous groups where half the samples had normal or near-normal hearing in one ear?
In this case a lack of difference reflects a poor study design overall. They're still using functional gain testing which has been abandoned in any country that is practicing audiology at a good standard because it isn't a reliable measure following the introduction of digital signal processing in hearing aids (more than two decades ago).
In my opinion this study doesn't tell us anything useful, except that the single otolaryngologist who did the work being reviewed in this retrospective study needs upskilling.
If I were on the journal editorial board or one of the reviewers I would've declined to publish this study unless they repeated their analyses separating unilateral losses from bilateral losses.
When I was first fitted, I went back to the audiologist 4-5 times to have her adjust the hearing aids based on my useage/experience. I continue to go back quarterly or as needed for adjustments. I think this is what fine tuning means?
You can tell when an industry is upset with some one that is disrupting the "norm" when they attack them straight on. The cited study may have its own merits but calling out Dr. Cliff in the Hearing Tracker E-mail speaks volumes. The study actually confirms his position that first fit is not accurate by stating that the aids referenced in the study needed "fine tuning" (without defining what that is). The study also states:
**"**this does not establish equivalence or isolate the effect of ."
Not doing REM defies logic. If you not objectively measuring what the aids are putting out for sound how can you possibly know the "first fit" settings are anywhere near the target? BS headline on the part of whom ever wrote the headline for Hearing Tracker!
I've been around here long enough to get that some people get that sort of follow-up from their audiologists. Never happened for me. The vibe I got was that you've got your hearing aids, see you later. I don't think I'm the only one. I was wondering aloud what 'routine followup' actually means because there is seems to be high variability in what happens after the initial fitting.
I am very surprised to see such a poor study on that website. I have read quite a number of articles on their website and I have found their conclusions very interesting. I struggle to understand why they would only use test candidates that need a hearing aid in one ear.
Anyway, yes, they are perfectly correct. If you come back for repeated, multiple adjustments, you can achieve the same result that would do in one fitting. Not quite sure what their point is! Sorry, I am a huge fan of REM when I see how much of a difference it has made to me!
Did you try to make a follow up appointment and the audiologist declined to see you?
Ok. In both cases I'm thinking of I was booked in automatically for follow-up appointments. I left each one wondering why they bothered. I got the impression that the aids were wonderful pieces of technology that should work out of the box. The first lady would give me a questioning look when I said I wasn't understanding people in certain situations. No talk of fine-tuning. The second guy did eventually but only when I asked him to. That improved things but it's the only change he ever made. Partly it's on me for not speaking up but that's also a lot to do with not knowing if things are as good as they're ever going to get.
I appreciate your honest and thoughtful reply. I have found that the tweaks work ok— sometimes it makes things better in certain circumstances yet I still have issues….but hey—I’m hard of hearing and technology can only help so much.
I am at times elated with what it can do to help and enormously frustrated by what it can’t do.
My audiologist recommended I use a Roger On device that I resisted for a while. I finally bought it and then it sat in the box for a while. I recently started to use it and find it’s very helpful in certain situations (yoga class, for example)! And in the car I can finally hear my boyfriend. It’s very pricey though.
well I find it interesting... the study and the replies so far...
True, it's a small-ish study, but I don't think it's fair to say that n=105 is definitely not going to give statistical significance. Sample size depends greatly on the sample methods, what's being sampled, and goals of the study too!
Regardless, with these medical journal studies one of the first things I wonder about is who is paying for the study and why? what is their goal or purpose?
Well I didn't read the full text of the study but I did open it up and quickly skimmed through the introduction. Seems to me that the authors are trying to recognize that is recommended and is considered to be the "gold standard", but that it is underutilized and they presume because of time and resource constraints
I might have the gist wrong here, but I take it that they are looking at unilateral wearers to see if maybe it's OK to bypass REM in the interest of time or resources.
I didn't get into it deep enough to understand if they're unilateral because the other ear is good, or if the other ear is deaf.... seems plausible to me that if the other ear is good, then the patient can do a pretty good job of knowing where the hearing aid needs to be.... I think they are showing that for their particular microset of unilateral clients, that they can effectively treat without REM.
While I think that the idea could extend beyond that target of their particular situation, that's not what they are looking at.
The point of the thread though does point to the question, is REM absolutely necessary?
My original Audiologist didn't do REM. I asked her about it once. My takeaway from her response...REM is more necessary for young kids, or for people that can't effectively communicate if they can understand speech or in which situations they can't understand speech, or if the aids are over amplifying wind or some other sounds, etc... For able minded and able bodied people, you can get to the same place without it. Seems plausible if the goal is speech understanding.
If the goal is to understand speech, then the goal is met when the patient reports that through their normal daily life situations they can understand speech, then the goal is met. If they can't understand the priest in their church but everywhere else things are fine...then the goal has not yet been reached. REM or not, that's the reality.
When I bought my very first set of aids from that Audiologist, no REM. After several return routine visits tweaking this and that, my aids were set up pretty good not only for speech but for the sounds that I needed to hear in my world. It took several visits, and especially in hindsight now I can see that it took more visits because I was also re-training my brain. It wasn't just about getting the aids to target.
Fast forward to my current trial through Costco for new aids. My brain is already "trained" at least to some degree. They did REM. The result was close but not there. They were still absolutely horrible in some situations. After a follow-up visit and some adjustments they were much closer, but still not exactly where they need to be. I'm two post fitting adjustments into the process, and they are maybe good enough, but they are still not where they need to be...partially because they haven't been following "best practices" at the follow-up visits....but still the point is REM doesn't seem to be some magic and necessary fix.
If I were an Audiologist would I routinely do REM for fittings? Almost certainly yes.
however
My n=1 analysis of only two fittings tells me that REM can definitely help speed up the process of getting to the end goal, but it really is not the necessary thing that Dr Cliff and so many others make it out to be.
With or without REM, follow up programming adjustments are de jure. With my provider, they're invited and free; part of the initial cost. Interesting that folks all agree that patients can get to the same place" as REM by having adjusments made in office.
As for REM being "the gold standard": well, that's according to Dr. Cliff and his cohorts. The majority of practitioners don't use REM. People claim those practitioners are all cheap or lazy or ignorant. That seems unlikely. One presumes they don't use REM because they don't think it's needed. They made an informed decision.
As for the magical "one fitting and you're done" using REM...I wonder. Certainly not in my case. I'm a musician. It took several fittings to dial in an excellent music program. REM would have had nothing to do with that.
A study in a medical journal came to a conclusion about REM outcome. One study is not definitive but it is interesting and suggestive. That's it.
When reading journals, it is important to notice every detail of the study. The study’s n=105, which falls short of statistical significance. It offers useful information, but the sample size is just too small. Plus it only includes unilateral fittings.
But if people actually did that, what would become of political posts on social media?
Non-REM approaches are based on empirical averages. Which doesn’t mean they are necessarily wrong, but the outcome isn’t guaranteed. You can use them on the proviso that they are a ‘starting point’, but you verify the outcome with the client.
The ‘weakness’ of REM in my book is that not everyone likes the same levels of loudness or speech intensity growth per the background. This basically means that properly adjusted REM settings are still a ‘starting point’: albeit closer to a nominal target performance.
As for REM being "the gold standard": well, that's according to Dr. Cliff and his cohorts.
It is the scientific consensus across many prospective randomized control trials that better outcomes are achieved for hearing aid users faster and with less guesswork using and the use of an independently validated prescription formula as the starting point for hearing aid fittings.
It isn't a matter of any one group's opinion. This very poorly designed retrospective analysis doesn't in any way diminish the validity of this long-established scientific conclusion.
The majority of practitioners don't use REM. People claim those practitioners are all cheap or lazy or ignorant. That seems unlikely. One presumes they don't use REM because they don't think it's needed. They made an informed decision.
The majority of doctors didn't wash their hands between dealing with dead bodies and delivering babies. It absolutely meant that they were ignorant. Just because a good practice hasn't achieved widespread adoption in the USA doesn't mean that isn't the best practice.
In Australia and New Zealand everyone uses real-ear measurement because it has been emphasized by training programs and has been required by professional standards.
As for the magical "one fitting and you're done" using REM...I wonder. Certainly not in my case. I'm a musician. It took several fittings to dial in an excellent music program. REM would have had nothing to do with that.
No-one is claiming that using REM with an independently validated prescription formula does anything more than provide the best starting point for a fitting: because it confirms good audibility of soft, average and loud speech in an individual user's ear. Your "one fitting and you're done" is a not what is being claimed by proponents of real-ear measurement. Everyone has individual preferences. Quickfit algorithms have been terribly inaccurate in the past and don't predict actual device output across the vast majority of ears. They've gotten better with some, but not all manufacturers.
It is important to note that the problem has historically been that manufacturer's first fit algorithms have been really poor resulting in poor speech audibility of speech for end users and poor outcomes. Some manufacturers, especially Phonak, Oticon and Widex have worked hard to improve their first fit algorithm accuracy. Outcomes with these devices can also be good for many, but not necessarily all ears.
Real-ear measurement is always required for very small, surgically altered ear canals, open fittings and in the presence of grommets or eardrum perforations because first-fit algorithms do not accurately model these scenarios.
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