Remote hearing-aid delivery and support: perspectives of patients and their hearing care providers

Abstract

Objective

To explore the perspectives of patients and hearing care providers (HCPs) about an adult remote hearing-aid delivery service implemented during the COVID-19 pandemic.

Design

Service evaluation via surveys. The patient survey measured satisfaction with the service, perceived hearing-aid handling skills, and preferences for future services. The HCP survey explored the impact of teleaudiology on outcomes compared to in-person care and factors important for successful teleaudiology.

Study sample

378 patients and 14 HCPs.

Results

Patients were highly satisfied with the service and self-reported good hearing-aid handling skills. However, 2 in 3 patients said they would prefer a future hearing-aid fitting to be in-person rather than remote. HCPs thought teleaudiology had positive impacts on convenience, accessibility, and flexibility, but negative impacts on communication, rapport, and the quality of care. HCPs considered computer literacy and individual preferences to be important for successful remote care; the age of the patient was considered less important.

Conclusions

Patients were generally highly satisfied with the service and for 1 in 3 it was their preferred mode of future hearing-aid fitting. Future services should be aware that a one-size-fits-all approach will not satisfy all patients and that teleaudiology should be offered on the basis of individual preference.

Keywords:

• Teleaudiology
• remote care
• remote hearing-aid fitting
• service evaluation

Introduction

Teleaudiology, defined as the delivery of audiology services via telecommunication technologies, has been of growing interest over recent decades. A variety of technologies have been developed that enable a wide range of audiology services to be conducted remotely, including hearing screening and audiometry, otoscopy, hearing-aid fitting and verification and follow-up consultations (Muñoz, Nagaraj, and Nichols 2021). Teleaudiology’s greatest potential is to improve accessibility for communities without local hearing healthcare services and those with mobility issues (Swanepoel et al. 2010). These approaches could help the estimated 83% of the global population that are hearing-aid candidates but do not use them (WHO, 2021).

Successful adoption of teleaudiology into routine clinical practice relies on both the hearing care providers (HCPs) and patients being engaged and trusting of the approach (Pomey et al. 2015; Whitten and Mackert 2005). This might explain why teleaudiology uptake was low until COVID-19 pandemic restrictions necessitated its use (Eikelboom et al. 2022; Parmar, Beukes, and Rajasingam 2022). HCPs’ opinions about teleaudiology are mixed, with acknowledgement that it provides increased flexibility and convenience, and reduced travel for the patient but is accompanied by concerns that quality of care and rapport with patients will be negatively affected (Saunders and Roughley 2020; Singh et al. 2014). Further, HCPs commonly report barriers to the successful implementation of teleaudiology that include a lack of infrastructure, clinical limitations and preferences for in-person care (Saunders and Roughley 2020; Singh et al. 2014). It thus seems that HCPs are aware of the potential benefits of teleaudiology but that they perceive barriers that are inhibiting change (Aggarwal et al. 2022; Eikelboom et al. 2022; Parmar, Beukes, and Rajasingam 2022).

In contrast, patient experiences of teleaudiology across a variety of teleaudiology approaches have shown good satisfaction and outcomes. For example, studies show good outcomes following synchronous teleaudiology care in which hearing aids were programmed and verified remotely using trained facilitators (Ferrari and Bernardez-Braga 2009; Penteado et al. 2012; Pross, Bourne, and Cheung 2016). Studies using a hybrid pathway, in which participants received in-person assessment and hearing-aid fittings combined with remote follow-up appointments, resulted in high participant satisfaction (Arnold et al. 2022; Ratanjee-Vanmali, Swanepoel, and Laplante-Lévesque 2020). In yet another model, renewal hearing aids were remotely issued to patients using hearing thresholds extrapolated from previous audiograms (an approach necessitated by the COVID-19 pandemic) (Kokkonen et al. 2022). In comparison to a control group of patients that attended for an in-person conventional pathway, there were no clinically significant differences between the remote and control group on the IOI-HA, and 4 out of 5 patients in the remote group did not require in-person follow-ups. On the other hand, Tao et al. (2021) reported significantly lower satisfaction for synchronous remote consultations due to technical and human-related difficulties when they compared patient outcomes following a crossover randomised control trial. In terms of preferences for uptake of teleaudiology, patients have shown mixed interest, with just 39.8% of an Australian hearing-aid user sample interested in remote audiological care (Galvin et al. 2022). This study asked patients which audiological services they would be willing to carry out remotely; the communication-based and troubleshooting services were most supported, which is consistent with HCPs’ opinions of teleaudiology services (Singh et al. 2014). Likewise, Saunders and Oliver (2022) found that relative to people without hearing loss, people with hearing loss were more likely to decline the offer of telemedicine appointments in general, rated telemedicine appointments significantly less positively, and had stronger preferences for in person care. The reasons provided were both directly and indirectly associated with the consequences of hearing loss. These included concerns about communication during the appointment, a lack of privacy when an intermediary helped with communication during the appointment, worries that critical information had been misheard/missed, and anxiety/stress associated with using the telephone for communication. These are of course all issues that can arise during in-person appointments since they rely on the provider being ‘deaf aware’ and communicating in a manner that is helpful to the person with hearing loss.

Whilst there is a growing body of evidence in support of teleaudiology, many studies to date have evaluated synchronous pathways in which a facilitator was involved in the hearing-aid fitting process. The COVID-19 pandemic forced audiology services to implement teleaudiology applications without facilitators due to restrictions on physical contact and distancing. There are possible negative consequences to using an unfacilitated approach, including technical difficulties (communication, internet access and digital literacy) and poor hearing-aid handling skills due to limited instruction from a trained practitioner. Good hearing-aid handling skills are critical to successful hearing-aid outcome (Bertoli et al. 2009; Saunders et al. 2018). More research is therefore required to further explore both patient and HCP experiences of care provided remotely.

This paper describes a service evaluation of an adult hearing-aid service pathway implemented during the COVID-19 pandemic that provided hearing aids to patients remotely. The publicly funded UK National Health Service (NHS) Audiology service for Exeter, mid and east Devon (Chime Social Enterprise), which in normal times provides a traditional in-person hearing-aid service (in-person assessment and fitting with in-person or remote aftercare) to around 4500 patients per year, was forced to adapt due to the pandemic. Due to the unprecedented circumstances, service adaptations were implemented rapidly based on feasibility, resources, available guidelines, and above all else, safety.

The aims of the evaluation were to: 1) measure patient satisfaction and reported self-efficacy for hearing-aid handling skills in services users who had recently received hearing aids via the pathway; 2) evaluate patient preferences for future hearing-aid fittings and service models; and 3) evaluate HCPs’ opinions of remote care based on their experience of delivering the hearing-aid service pathway and establish preferences for future care provision.

Methods

Ethics

This study met the UK National Health Service Health Research Authority criteria for a service evaluation and thus did not need ethical approval. Approval for the service evaluation protocol was granted by the local user involvement project committee (Chime Social Enterprise). Participants did not receive payment for taking part.

Service pathway

The service pathway implemented during the COVID-19 pandemic by the publicly funded NHS adult hearing-aid service in Exeter, mid and east Devon (Chime Social Enterprise) was evaluated. The pathway, shown in Figure 1, was designed to be compliant with the guidance published by UK professional audiology organisations (Joint Guidance 2020) which prioritised minimising patient contact wherever possible. Patients entered the pathway following a referral to audiology or were experienced hearing-aid users renewing their aids. Remote patient interviews were carried out by telephone or video conferencing prior to a hearing assessment. Patients were then offered a hearing assessment that could take place either in-person at a clinic or remotely using an online automated audiometer and personal headphones, depending on the patient preference and HCP’s clinical judgement (for example, hearing losses that would likely require masking or bone conduction measurement). Following the assessment, HCPs created an individual management plan for all patients, and explained the hearing-aid delivery procedure for those who wished to proceed with hearing aids. To minimise face-to-face contact, hearing aids were not fit in-person and were instead programmed and mailed to the patient’s home. Patients were issued with Signia Motion 5Nx or Pure 5Nx hearing aids because these hearing aids had Bluetooth connectivity which allowed remote fine tuning via the Signia App (Signia 2022). The hearing aids were programmed to ‘First fit’ using the patient’s acoustic parameters (dome type or ear mould vent if using previous mould) and NAL-NL2 prescription target (experienced user) with Signia Connexx software. The Connexx software allowed a previously measured real-ear-unaided-response (REUR) to be applied to the fitting (rather than an average REUR), which was used if available. A volume control and telecoil programme (where possible) were activated on all hearing aids. The programmed aids were sent by mail to the patient along with literature explaining how to use and maintain the hearing aids and the Signia app, as well as general information about the clinical service. The HCP first contacted the patient 3 weeks after the hearing-aids were programmed by phone or video call to review progress and provide support or adjustments. A further review was conducted 5 weeks later (8-weeks post hearing-aid delivery) or earlier if necessary. When required, hearing aids were adjusted remotely in one of three ways: synchronously using the Signia App, asynchronously using the Signia Telecare Portal, or by having the patient send the hearing aids to the clinic. The justification for the timings of reviews included allowing for postage delays during the pandemic; allowing sufficient time for the patient to thoroughly try the hearing aids so that the limited amount of HCP time available could be as fruitful as possible; and that this was considered feasible for the available resources at the time.

Figure 1. Service pathway schematic.

In order for us to distinguish outcomes from the remote hearing-aid delivery service from that of experiences with a remote hearing evaluation, the data presented here are from those patients who underwent an in-person hearing assessment. The reported data therefore represent a hearing-aid service that includes an in-person hearing assessment, postal delivery of programmed hearing aids (without verification or in-person validation) and remote follow-up care.

Participants

The patient sample was recruited from adult patients that had a remote 8-week review between 1st May 2021 and 31st August 2021. 615 patients agreed to take part, 400 completed the survey (response rate 65%), of whom 378 had an in-person hearing assessment.

All HCPs (n = 17) that had provided adult hearing-aid services during the COVID-19 pandemic were invited to complete the HCP survey; 14 responded (response rate 82.3%). Each HCP had provided the pathway for at least 10 months. The HCPs were a mixture of Hearing Aid Dispensers, Audiologists and Clinical Scientists.

Patient survey

The patient survey assessed satisfaction with the service, perceived hearing-aid handling skills, and preferences for future services (see Supplementary Materials File 1). No identifiable personal data were collected. Respondents were asked to provide information about their age (in 10-year categories), hearing-aid experience, and smart device ownership, ability and usage. They were also asked if, and how frequently, they used the Signia App. The Short Assessment of Patient Satisfaction (SAPS) questionnaire was included to assess satisfaction with the service they received (Hawthorne et al. 2014). It is a seven-item validated scale of satisfaction in healthcare settings. Each item assesses an independent domain of patient satisfaction on a Likert scale of 0–4 giving a total score out of 28, where a higher score indicates higher satisfaction. Hearing-aid handling skills were assessed using 5 items based on the basic and advanced handling factors of the MARS-HA questionnaire (West and Smith 2007). Skills assessed were battery handling, hearing-aid insertion/removal, switching on and off, cleaning and maintenance, and troubleshooting. Respondents rated their agreement with a statement on a 5-point Likert scale ranging from strongly disagree (0), disagree (1), neutral (2), agree (3) or strongly agree (4), giving a total score out of 20, where a higher score indicated better reported handling skills. Finally, respondents were asked about their preference for future hearing-aid fittings (remote or in-person) and future audiology service provision (in-person-only, remote-only or some remote and some in-person) assuming no pandemic-related restrictions remained, and their reasons for this preference.

Hearing care provider survey

The HCP survey included items about the impact and influence on outcomes of teleaudiology compared to face-to-face care, factors important for successful teleaudiology, and opinions about teleaudiology, using a survey based on that used by Saunders and Roughley (2020). Survey items were combination of Likert scales and free text responses (see Supplementary File 2 for HCP survey).

Procedure

Patients were verbally invited to take part in the service evaluation. Those who agreed were either mailed a hard-copy survey (including a prepaid return envelope) or emailed an online link to the survey, depending on their preference. Sixty-three percent chose a hard-copy survey, 37% chose an online survey. HCPs were sent an email with a link to the survey to complete between 21st September 2021 and 25th October 2021.

Online versions of both surveys were administered via Microsoft Forms.

Analysis

Survey responses were exported from Microsoft Forms (or manually inputted for hard-copy responses) to IBM SPSS Statistics 25 and Microsoft Excel. Free text responses were analysed using inductive content analysis (Elo and Kyngäs 2008); Author MB generated initial themes and categories and GS provided feedback until consensus was agreed. Patient satisfaction (SAPS score) and hearing-aid handling skills data were not normally distributed, as assessed by inspection of box plots and significant Kolmogorov-Smirnov test statistics (p < 0.001). Non-parametric statistical analyses were used for inferential statistics.

Results

Patient survey

Demographics, hearing-aid experience, smart device access and competence and app usage

Table 1 shows demographic information about the patient sample broken out by age group. Age was associated with the survey response format selected (hard-copy versus online) (χ² (4) = 31.04, p < 0.001, V = 0.29), and smart device access (χ² (4) = 59.80, p < 0.001, V = 0.40). The proportion of experienced hearing-aid users increased with increasing age (χ² (4) = 41.28, p < 0.001, V = 0.33). Age was associated with smart device competence, with younger respondents reporting higher competency than older respondents, χ² (8) = 68.12, p < 0.001, V = 0.30. Age was associated with app usage, with younger adults reporting higher usage than older adults, χ² (8) = 27.31, p < 0.001, V = 0.21.

Table 1. Proportions (absolute number of respondents shown in parentheses) of users on questionnaire response type, hearing aid experience and smart device variables by age category and for the total sample combined.

Age (years)	n	Questionnaire response		Hearing-aid experience		Access to smart device		Smart device self-assessed competence			Hearing-aid smartphone app usage
		Hard-copy	Online	New	Experienced	Access	No access	Never used a smart device	Beginner	Competent	Never use the app	Occasional use	Frequent use
< 60	6.9%	53.8%	46.2%	69.2%	30.8%	88.5%	11.5%	11.5%	23.1%	65.4%	54.2%	20.8%	25.0%
	26	14	12	18	8	23	3	3	6	17	13	5	6
60 - 69	15.6%	44.1%	55.9%	45.8%	54.2%	79.7%	20.3%	18.6%	32.2%	49.2%	58.9%	23.2%	17.9%
	59	26	33	27	32	47	12	11	19	29	33	13	10
70 - 79	39.4%	57.7%	42.3%	34.2%	65.8%	76.4%	20.3%	22.1%	32.2%	49.2%	66.1%	16.5%	17.3%
	149	86	63	51	98	113	35	32	53	60	84	21	22
80 - 89	29.4%	73.9%	26.1%	18.9%	81.1%	43.2%	56.8%	52.7%	24.5%	22.7%	86.6%	6.1%	7.3%
	111	82	29	21	90	48	63	58	27	25	71	5	6
> 89	8.7%	93.9%	6.1%	6.1%	93.9%	30.3%	69.7%	72.7%	21.2%	6.1%	100.0%	0.0%	0.0%
	33	31	2	2	31	10	23	24	7	2	18	0	0
TOTAL	378	63.2%	36.8%	31.5%	68.5%	63.9%	36.1%	34.3%	30.0%	35.7%	71.3%	14.3%	14.3%
		239	139	119	259	241	136	128	112	133	219	44	44

Note, some items were not answered by all respondents.

Service satisfaction

The SAPS questionnaire was completed by 361 individuals. The median total SAPS score was 25 (interquartile range 22.5 – 27), indicating good overall satisfaction with the services received. SAPS scores were categorised into very dissatisfied (0 – 10), dissatisfied (10–18), satisfied (19–26) and very satisfied (27–28). 32.1% (n = 116) of participants had scores in the ‘very satisfied’ range, 63.7% (n = 230) in the ‘satisfied’ range, 3.9% (n = 14) in the ‘dissatisfied’ range and 0.3% (n = 1) in the ‘very dissatisfied’ range. No significant effects of hearing-aid experience or age on individual SAPS domains or total scores.

Hearing-aid handling skills

The 5-item hearing-aid handling skills questionnaire was completed by 343 participants. The median handling score was 17 (interquartile range 14 – 19), with 60 participants scoring the ceiling score of 20. This indicates that participants felt confident that they were able to manage their hearing aids effectively. The question regarding troubleshooting had the lowest median score (2, interquartile range 2 - 3) versus 4 (interquartile range 3 – 4) for all other items (battery handling, insertion, off/on, cleaning/maintenance). This finding is consistent with several other studies (Desjardins and Doherty 2009; Kelly-Campbell and McMillan 2015; West and Smith 2007). There was no effect of hearing-aid experience (new user vs. experienced user) for any individual handling skill item or total score, with Mann-Whitney tests with Bonferroni corrections not reaching significance. Age had a significant effect on the total handling skill score (H(4) = 12.67, p = 0.013). Post-hoc Mann-Whitney tests, using Bonferroni-corrected significant levels, revealed that the <60 and 80–89 age groups differed significantly (U = 69.74, p < 0.002) such that the 80–89-year-olds had lower scores than the < 60 years group. All other age group comparisons did not reach significance. However, Jonckheere’s test revealed a significant trend whereby increasing age was associated with decreasing median total score, J = 17876.5, p < 0.001, z = −3.22, r = −0.17.

Future hearing-aid fitting preferences

Respondents were asked to state whether they would prefer in-person or remote hearing-aid fittings in the future (assuming COVID-19 restrictions were no longer present). The data showed that 66.2% (n = 233) would prefer an in-person fitting and 33.8% (n = 119) a remote fitting (see Figure 2 with data broken out by age group and hearing-aid experience). There was a significant association between hearing-aid experience and fitting preference, χ² (1) = 9.54, p = 0.002, V = 0.165. The odds of experienced hearing-aid users preferring an in-person fitting were 2.0 times higher than for new users. There was no significant association between age and fitting preference, χ2 (4) = 7.99, p = 0.09. Chi-square independence tests comparing fitting preferences between new and experienced for each age group (excluding > 89 years due to insufficient new hearing-aid users) did not reveal any significant differences, suggesting no interaction between age and hearing-aid experience on fitting preferences.

Figure 2. Preferences for future hearing-aid fitting, either in-person (dotted) or remotely (solid), by age category and hearing-aid experience (new (blue) or experienced (exp, orange)) user).

Factors impacting hearing-aid fitting preferences

Participants were asked to explain their fitting preferences. Unique open-ended responses were received from 50.8% (n = 179) of respondents that stated a fitting preference; most provided a single reason. Content analysis was used to analyse the responses into themes and categories. Table 2 shows the themes, categories and exemplar quotes. Preferences for in-person fittings were explained by the input a HCP has on the fitting, the communication benefits of an in-person visit and a general preference for face-to-face care. Those preferring remote fittings cited reasons relating to convenience, the ease and simplicity of it, and that an in-person visit appears unnecessary.

Table 2. Content analysis of explanations given by patients to support future hearing-aid fitting preferences (in-person or remote), including exemplar quotes, based on 179 responses.

Fitting preference	Themes	Categories	Exemplar quotes
In-person	HCP input	Explanation and demonstration from HCP	As hearing aids become more bespoke it is good to have an expert tell you what the range of opportunities are and to demonstrate. I lean towards being a visual learner
		Immediate checking, adjustments, and troubleshooting	Should there be a problem it would be sorted there rather than having to post them back
		Confidence in fitting if seen by HCP	Having my hearing aids fitted in hospital or clinic means I know they are correct
	Communication	Ability to ask questions	You have an immediate contact for questions and answers
		Face-to-face communication is easier than remotely	I prefer to talk to staff face to face. For anyone deaf telephone is not the ideal medium
	Patient preference	General preference for face-to-face	It is impossible to better a face to face appointment. This goes with all life interactions and appointments” and “Prefer personal experience
Remote	Convenient for patient	Reduced travel	It is a challenge to get to hospital/clinic - living on my own I rely on help from my home support assistant
		Time saving	Easier when fitting around work hours
		Learn at own pace	After the initial physical consultation/hearing test, the aids coming through the post was ideal so that I could learn how to use them at my own pace. It feels like they are happy to take calls when there is a need
		Generally convenient	More convenient, assuming it follows personal assessment.
		Safety during pandemic	In a post Pandemic situation I could get to the hospital via public transport. Until it is all over I would not like to visit the hospital as I am considered vulnerable due to my medications
	Ease and simplicity		I am happy to have my hearing aids being sent to me, I think I can cope easily with that, especially as I know that if I have a problem I can make an appointment
			The instructions are clear. I have no difficulty in carrying them out
	Face-to-face appears unnecessary	Saves professionals’ time	The hearing aids are easy to fit so no need to take a professional’s time when it can better spent on other matters
		Remote fitting acceptable if face-to-face support available if required	I am happy to receive future hearing aids by post, as I know that if I had any problems that the hospital/clinic are always there to help, if needed
		Seems unnecessary	It does not seem necessary to have a hospital appointment
		Previous experience with hearing aids so remote is satisfactory	Having had hearing aids before and being shown the hearing aids I would receive, it would have been a waste of everyone’s time to attend the [clinic], even though I live within seeing distance of it
Neutral	No preference		I'm happy either way

(Hearing care provider = HCP).

Hearing care provider survey

Impacts of remote care

Figure 3 shows the results of the survey. Respondents considered remote care to have positive impacts on convenience, flexibility, and efficiency but to have negative impacts on communication, confidence and quality of care. The highly positive rating for safety is probably because the survey was completed within the context of COVID-19.

Figure 3. Impact of remote care relative to face-to-face care on various factors, ranked from negative to positive.

When asked to explain their answers HCPs noted that in-person care was preferred due to difficulties associated with telephone communication and building rapport with patients, the inability to conduct hearing-aid verification and troubleshooting, the unreliability and lack of knowledge of the IT systems, and because the success of remote care depended on patient factors, such as computer literacy and age. However, they also noted that remote care enabled highly personalised care such as the possibility of adjusting hearing-aid settings whilst a patient is in a setting of their choosing.

Facilitators and barriers

HCPs were asked about the facilitators and barriers to successful provision of remote care. Over 75% strongly agreed or agreed that a patient’s individual preference, access to smart devices, and computer literacy (that of the patient and the HCP) were important for successful remote care. There was no clear consensus apparent for whether age was an important factor (43% disagreed or strongly disagreed, 29% were neutral and 28% agreed or strongly agreed).

Impact on patient outcomes

When asked to rate how remote care might influence patient outcomes on a 5-point scale (‘greatly improve’ to ‘be much poorer’), 43% (n = 6) thought outcomes would improve, 36% (n = 5) thought outcomes would not change and 21% (n = 3) thought outcomes would be poorer. No respondents thought outcomes would greatly improve or be much poorer.

Attitudes towards remote care

To explore attitudes towards remote care, respondents were asked to describe the main advantages and disadvantages of remote care. The data are shown in Supplementary File 3. Respondents thought the advantages of remote care were its efficiency, accessibility, and its safety relative to face-to-face care within the context of COVID-19. The disadvantages were the clinical factors, which included limitations in the ability to verify, check and troubleshoot hearing-aid fittings, as well as difficulty building a rapport, the infrastructure, and attitudes of patients and HCPs. Another disadvantage, accessibility, focussed on how not all patients find remote care accessible due to communication difficulties and poor digital literacy.

Discussion

This paper reports on patient and HCP opinions about an adult hearing-aid audiology service delivered remotely during the COVID-19 pandemic. We assessed service-user satisfaction, reported hearing-aid handling skills and preferences for future care, as well as HCPs’ opinions about the impacts of remote care on various aspects of service provision.

Patient survey

Satisfaction with the remote care pathway was good, as reflected in high SAPS questionnaire scores. Of course, the fact that any service was being provided during the COVID-19 pandemic when in-person care was unavailable could have led to higher satisfaction than would be seen in less unusual circumstances. However, our findings cannot be entirely driven by COVID-19 pandemic, since 1 in 3 (33.8%) of respondents said they would prefer remote fittings in the future, citing convenience, simplicity and not needing in-person fitting as reasons why. Ratanjee-Vanmali, Swanepoel, and Laplante-Lévesque (2020), who also used the SAPS questionnaire to measure satisfaction with a hybrid hearing care pathway reported similar mean SAPS scores (26 versus 27). Interestingly, lower SAPS scores (values around 23) have been reported in other healthcare disciplines (e.g. maternity care and thrombosis clinics) for both remote and in-person services (Futterman et al. 2021; Young et al. 2022), with slightly lower scores for remote care. While this evaluation did not evaluate in-person care, HCPs should nonetheless be encouraged by these findings as they indicate that patients feel positively about audiology services and hearing aid delivery services.

There was a significant interaction between age and SAPS scores, such that older individuals had lower SAPS scores than younger individuals. Without scores from in-person care, we cannot conclude from this that older individuals are dissatisfied with remote care per se, it might be that older individuals are generally less satisfied with healthcare they receive. However, a 2018 survey of a nationally representative sample of 2,926 people in the UK showed that older patients were more satisfied with their care in general through the NHS than younger patients (Appleby et al. 2020), suggesting that the lower SAPS scores reported by older individuals here might reflect their opinions about remote care, rather than care in general. Indeed, other studies show that relative to younger individuals, older individuals prefer in person care and/or are less satisfied with remote care (Greenfield et al. 2022; Jones, Arif, and Rai 2021).

In terms of patient access and use of smart devices, which are necessary for using many of the remote care apps, the older participants had less access to, and felt less competent in using, smart devices relative to the younger participants. This is consistent with UK Office for National Statistics data, which shows approximately that 53% of over-64-year-olds use smartphones compared to the national average of 84% (ONS, 2020). Smart device access, however, is increasing with time (Eurostat, 2021). About 1 in 3 participants in our sample did not have access to a smart device. This is important in that many of today’s hearing-aid manufacturers integrate smart phone apps into hearing care and encourage the use of remote hearing-aid adjustments using these apps. The lack of access to smart technology likely explains why so few individuals (less than 1/3) reported using the Signia smartphone-connected app frequently or even occasionally. This must be considered when providing and planning future services.

Survey respondents generally felt confident in their ability to manage their hearing aids, with new and experienced hearing-aid users reporting similar scores. This is somewhat surprising because the new users had to learn to manage their hearing aids without in-person instruction and demonstration from a HCP. It might be that the training materials provided here were particularly effective, or that while respondents reported being able to manage their hearing aids, an objective measure would reveal otherwise. Without conducting an objective evaluation, we cannot know which the case is. Nonetheless, once again, HCPs should feel reassured that fittings without direct input from a HCP or facilitator, even for new hearing-aid users, can result in success.

As noted above, 33.8% of respondents said they would prefer a remote fitting in the future, meaning that 66.2% said they would prefer an in-person fitting because, among other reasons, they wanted direct and immediate input from the HCP regarding hearing-aid instruction, explanations, and resolution of issues, and they considered in-person communication to be beneficial. Note that with the hearing aid delivery pathway employed here, the HCP did not provide any direct support until 3 weeks after the hearing aids were programmed. It might be that had the fitting been conducted using some form of facilitator-assisted synchronous fitting (Pross, Bourne, and Cheung 2016), even more patients might have preferred a remote fitting in the future. Age was not associated with fitting preference, but experienced hearing-aid users were 2.0 times more likely to select an in-person fitting then new users. This latter finding is interesting because studies have shown that HCPs are very unwilling to conduct remote fittings with new hearing-aid users (Singh et al. 2014), who, based on our survey would be more open to this than experienced hearing-aid users.

Hearing care provider survey

The HCP survey explored opinions about remote care following at least 10 months of routinely providing remote care services. HCPs reported that remote care was convenient, allowed flexibility and reduced preparation and appointment time. However, they said it had negative impacts on the quality of interpersonal interactions, rapport, communication, and overall care, particularly associated with being unable to conduct some clinical procedures such as hearing-aid verification and troubleshooting fit-related issues. Some also lacked confidence in the services they provided through remote care and considered their patients to be less satisfied with remote care than in-person care. These findings are highly consistent with other studies (Aggarwal et al. 2022; Eikelboom et al. 2022; Eikelboom and Swanepoel 2016; Saunders and Roughley 2020; Singh et al. 2014), though it should be carefully considered that the HCPs surveyed in this study were implementing a service which did not allow patient interaction during the hearing-aid programming and fitting; therefore it is entirely possible that the reported negative impacts could be overcome by use of a facilitated approach.

The factors HCPs considered most strongly allowed successful remote care were the HCPs’ own computer literacy (over that of the patient’s computer literacy), and the patients’ preference for type of care received. Interestingly, in other studies HCPs rated the patient’s confidence in use of technology to be a much greater barrier to successful remote care than their own confidence (Eikelboom et al. 2022; Parmar, Beukes, and Rajasingam 2022). Perhaps the difference here is that the HCPs in this study had no experience with remote care until the COVID-19 pandemic while certainly in the study of Eikelboom et al. (2022), many HCPs had used remote care prior to the pandemic. Almost half the HCPs here did not consider age to play a role in success with remote care. This is in contrast to other studies in which HCPs cited age as a factor they would consider (Singh et al. 2014). Age is cited as a factor in remote care because of its association with use of technology. This suggests then, that remote care candidacy decisions should not be based on simple heuristics like the patient’s age, but rather individual preferences and digital literacy.

Limitations

While this service evaluation benefitted from a large patient sample size and responses from HCPs with at least 10 months experience using the pathway, it does of course have some limitations. Most noticeably, the study took place during the height of the COVID-19 pandemic which may have affected patients’ attitudes and expectations about their medical care and responses might reflect behavioural norms at the time and thus may not fully apply to current care even though they were asked to answer with non-COVID restrictions in mind. Additionally, although we have low numbers of patients under age 70 and over age 89, this age distribution is typical of that found in adult audiology patients, thus the findings can be applied broadly to audiology services.

The retrospective survey methods employed by this evaluation are likely to be associated with a degree of recall bias due to the time between the first point of contact and survey completion. Furthermore, we do not directly compare the findings here with a comparison group of patients who had experienced a ‘usual care’ pathway. Due to the COVID-19 pandemic, this was not possible at the time the data were collected. However, 68.5% of the sample were experienced hearing-aid users who presumably considered previous experiences when they responded.

Finally, it must be noted that the service evaluated here is not necessarily representative of an optimal teleaudiology pathway, such as one that employs trained facilitators (Muñoz, Nagaraj, and Nichols 2021; Pross, Bourne, and Cheung 2016). Instead, it is a service that was rapidly designed to operate within the scope of published guidance at the height of the COVID-19 pandemic.

Summary and conclusions

Our data show that patients are generally satisfied with the hearing aid delivery model and that for about one in three is it is their preferred mode of care. However, one in three individuals did not have access to smart technology, limiting the processes that could be conducted via remote care. In contrast, HCPs have concerns about its impact on communication with patients, their confidence with the service they provide, and have concerns that remote care might negatively impact quality of care. This suggests that HCPs could be more confident in the outcomes of remote care but highlights the need to ensure patients have a choice in the form of care they receive. Indeed, as noted by the HCPs surveyed here, a one-size-fits-all approach will not satisfy all patients and remote care options should be offered on the basis of individual preference.

Acknowledgment

This work was supported by the NIHR Manchester Biomedical Research Centre.

Disclosure statement

The authors report no conflicts of interest. The authors alone are responsible for the content and writing of this article.

Correction Statement

This article has been corrected with minor changes. These changes do not impact the academic content of the article.