Guideline for Audiologic Management of the Adult Patient Michael Valente Hearing Evaluation - Adults Hearing Aids - Adults 966
`12/14/2016
`Copyright © 2016 AudiologyOnline - All Rights Reserved
`
`Guideline for Audiologic Management of the Adult Patient
`Michael Valente, PhD
`
`October 30, 2006
`
`Introduction and Background
`
`Task Force Members
`
`In 2003, Angela Loavenbruck, then President of the American Academy of Audiology (AAA), asked the author to consider chairing a new Task Force whose goal was to
`develop a national guideline for fitting hearing aids to adults. At that time, AAA would soon release a guideline for fitting hearing aids to children, and AAA felt a separate
`guideline was needed for adults. For the adult population, the American Speech-Language-Hearing Association (ASHA) maintained the most recent national guideline that
`was released in 1998, and Angela felt a new guideline was necessary because a) the AAA guideline for children was about to be published; b) as the national organization
`for audiologists, AAA needed to formulate its own guideline; and c) numerous advances have been made in technology since the ASHA guideline was published. Angela
`informed the author that the current Task Force members included Harvey Abrams, Dennis Hampton, Todd Ricketts, and Robert Sweetow. Soon after assuming the chair,
`I asked Theresa Hnath-Chisolm, Darcy Benson, David Citron, and Helena Solodar to join. Please see Appendix A for a list of the members of the Task Force. It is
`important to note that of the ten members of the Task Force, five are in private practice (Darcy, David, Dennis, Angela, and Helena), one is involved in full-time research
`and teaching (Todd) and the others (Harvey, Theresa, Robert, and I) have combined administrative, patient care, research, and teaching responsibilities. As chair, I felt it
`was imperative to have a significant presence of clinicians as members of the Task Force so the content of the guideline would have relevance to the clinicians who would
`be asked to implement its contents. What followed was a three-year journey to develop the guideline. During that journey, there were numerous hurricanes, several
`crashed hard drives, lost files, thousands of e-mails and phone calls, some illnesses, and two face-to-face meetings (Tampa Bay and Washington, D.C.).
`
`Why a New Guideline?
`
`The reader might ask, "Why a new guideline?" There are several answers to this important question. First, as mentioned earlier, the last guideline was published by ASHA
`(Valente et al., 1998). Since 1998, there have been numerous advances in hearing aid technology as well as the methods used to verify and validate hearing aid fittings.
`Thus, the current standard needed to be updated to accommodate these advances. Second, there is increased interest in other professions in using evidence-based
`principles (EBP) when developing a new guideline. It was felt that in order for this guideline to have relevance, it too must use EBP to reinforce its recommendations.
`Third, AAA published a pediatric guideline (2004) and felt an adult guideline was also necessary. Fourth, there is considerable concern regarding the manner in which
`hearing aids are dispensed by audiologists (Mueller, 2003; Kochkin, 2002). That is, current clinical practices implemented "in the field" may do little to differentiate how
`hearing aids are dispensed by audiologists and others and therefore would not be in line with AAA's goal for professional autonomy.
`
`Goals for Developing the Guideline
`
`After recruiting the members, it was decided that a primary goal would be to use EBP to support whatever recommendations were developed. Initially, the decision to
`incorporate EBP into the guideline was not unanimously supported by the Chair and several members of the committee. Initially, the Chair felt the Task Force would make
`a major contribution by taking the current guideline and updating its contents. Harvey and Theresa, however, very diplomatically argued that using EBP to support
`guideline recommendations would be even a greater contribution to our profession. Because using EBP to support guideline recommendations had never been done in
`past or current Audiology-related guidelines, Harvey and Theresa persisted that the final guideline must be supported using EBP. Also, other than Harvey and Theresa,
`few members of the Task Force were exposed or knowledgeable about implementing EBP. To become more knowledgeable, each member was provided Law's (2002)
`textbook on EBP. For several weeks, little was accomplished until the members became more comfortable and knowledgeable about EBP. The author believes it fair to
`state that if Harvey and Theresa were not members of the Task Force, then the final version of the guideline would bear little resemblance to the version currently
`available on www.audiology.org and approved by the Executive Board of AAA.
`
`A second goal was that the guideline must be patient-centered by incorporating a section on auditory and non-auditory needs-assessment. Finally, it was felt that if
`the "spirit" of the guideline (i.e., not every recommendation needs to be implemented; recommendations do not need to be implemented precisely as stated within the
`guideline) were followed then its implementation by audiologists would:
`
`Promote uniformity of care,
`Decrease variability of outcomes,
`Promote better fitting practices,
`Elevate the clinical care to our patients as well as elevate our profession,
`Provide greater patient satisfaction, and,
`Reduce the hearing aid return rate.
`
`How does this Guideline Differ from Previous Guidelines?
`
`The content and organization of this guideline differs significantly from the previously published ASHA guideline in several ways. First, it is the only guideline thus far to
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`Guideline for Audiologic Management of the Adult Patient Michael Valente Hearing Evaluation - Adults Hearing Aids - Adults 966
`12/14/2016
`include a section specifically on auditory and non-auditory needs assessment. Second, it is the first to use EBP to support its recommendations. Within the guideline, EPB
`is also used to point out areas where the evidence may not be sufficient to support implementing some recommendations of the guideline. Finally, it is emphasized that a
`guideline is not static and needs to be re-evaluated every five years to assess the need for revisions as technology and the evidence changes.
`
`How Did the Members Organize the Guideline and Review the Evidence?
`
`First, the group divided the guideline into five major divisions (Introduction; Assessment; Technical Aspects of Intervention; Instruction, Orientation, Counseling
`and Follow-Up Audiologic Rehabilitation; Assessing Outcomes). These divisions follow the sequence patients typically follow when pursuing amplification. The five
`divisions were divided into nine sections. The numbers appearing below in parentheses indicate the number of specific recommendations for each section:
`
`Assessment: auditory assessment (0), auditory-needs assessment (3), and non-auditory needs assessment (6).
`
`Technical Aspects of Intervention: hearing aid evaluation (13), quality control (2), fitting and verification (7), and hearing assistive technology (4).
`
`Instruction, Orientation, Counseling and Follow-Up Audiologic Rehabilitation: hearing aid orientation (2), and counseling and follow-up audiologic
`rehabilitation (6).
`
`Assessing Outcomes (0)
`
`Once the divisions and sections were identified, members within the Task Force volunteered to work on the nine sections of the guideline. Some sections may have had
`one member, while other sections may have had several members working on developing their material for their section. Through their work, specific recommendations
`were developed for most sections. The specific number of recommendations for each section ranged from zero to thirteen. Overall, the guideline contains 43 specific
`recommendations.
`
`Then a systematic search of the literature was conducted using EBP to support each of the 43 recommendations. The search focused on seeking the best available
`evidence to address each recommendation and ensure maximum coverage of studies at the top of the hierarchy of study types (Levels 1-2, see Table 1). Once definitive
`studies providing relevant information were identified at this level, the search stopped. The search extended to studies or reports of lower quality (Levels 3-6) only if higher
`quality studies (Levels 1 or 2) could not be found.
`
`Table 1. Levels of Evidence
`
`1. Systematic reviews and meta-analysis of randomized controlled
`trials (RCT) or other high-quality studies
`
`2. Well designed RCT
`
`3. Non-randomized intervention studies
`
`4. Cohort studies, case-control studies, cross-sectional
`surveys or uncontrolled experiment
`
`5. Case report
`
`6. Expert opinion
`
`Table 2. Grade of Recommendation
`
`A. Level 1- 2 with consistent conclusions.
`
`B. Level 3- 4 studies; extrapolated evidence (generalized to a situation
`where it is not fully relevant from Level 1 - 2).
`
`C. Level 5 studies of extrapolated evidence from Level 3 - 4.
`
`D. Level 6 evidence; inconsistent or inconclusive studies of any level;
`any study having a high risk of bias.
`
`After retrieving the evidence using a wide variety of methods, the members reviewed and graded the evidence using Quality of Evidence Ratings (Levels 1-6; Table 1) and
`Grade of the Recommendation (A-D; Table 2). In addition, it was determined if the evidence was Effective (EV) or Efficacy (EF) - based where EV is evidence measured in
`the "real world" and EF is evidence measured under "laboratory or ideal" conditions.
`
`Table 3 provides an example of a Table of Evidence taken from the guideline. In this example, the first column shows guideline recommendation number(s). The second
`column states the evidence to support the recommendation. On several occasions, more than one statement was presented to support a recommendation. Also, several
`recommendations could be presented to support one statement. Overall, the combined Tables of Evidence contained 108 statements to support the 43
`recommendations. The third column cites the reference(s) used to support the statement of a recommendation (the number is the number of the reference cited to
`support the statement from the Reference section for that section of the guideline). The fourth column is the Level of the Evidence (1-6) and Grade (A-D). When reading
`the entire guideline, the reader will note that of the 108 statements supporting the key recommendations, 4.6%, 25.9%, 14.8%, 35.2%, 4.6%, and 14.8% were judged to
`have evidence at Level 1 through 6, respectively. It is clear that for most recommendations within the guideline, less than 1/3 were judged as Level 1-2. This finding
`should be a major concern because this suggests there may not be strong evidence to support many of the procedures audiologists typically complete
`when dispensing hearing aids to the adult patient! This finding also points to the need for future research to justify the manner in which audiologists provide services
`relative to the sections covered in this guideline.
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`Guideline for Audiologic Management of the Adult Patient Michael Valente Hearing Evaluation - Adults Hearing Aids - Adults 966
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`Table 3. Example of Evidence Table
`
`Organization of Each Section
`
`Each section begins with an Objective that states the purpose for that particular section. This is followed by a Background detailing how the section fits within the
`guideline. The specific Recommendations then follow. Each section then ends with the Table of Evidence and References.
`
`Specific Divisions and Sections of the Guideline
`
`Introduction
`
`Within the "Introduction," the guideline provides several statements outlining some of the essential components. First, services must be provided by a licensed audiologist.
`Second, the combined efforts of the audiologist, patient, significant others, and/or caregivers are essential. Third, assessment must be viewed as a multi-faceted process
`that includes assessment of auditory function to determine the extent of impairment and assessment of activity limitations, as well as participation restrictions through self-
`report of communication needs and performance. Fourth, consideration should be given to assess the typical listening environments using tools such as datalogging or
`self-assessment. This assessment could be useful in helping make decisions regarding hearing aid style and features. A recent example of such a self-assessment tool is
`the "Characteristics of Amplification Tool (COAT)" that was recently introduced by Cleveland Clinic and published on Audiology Online (Sandridge & Newman, 2006).
`Washington University audiologists use this two-page questionnaire daily and have found it to be very beneficial in focusing upon the perceived listening environments of
`the patient, level of motivation for success with amplification, expectations, style, and cost of amplification. I urge readers to pursue this very helpful tool.
`
`Also, consideration needs to be given to how these levels of assessment interact and reinforce each other to improve quality of life (QOL) of the patient. It was felt that as
`a result of the multi-faceted assessment, clear and realistic individualized goals for intervention could be set.
`
`Assessment
`
`Auditory Assessment
`
`This section details the various components of the auditory assessment of the patient. Some of the specific components include:
`
`Comprehensive case history,
`
`Identifying type and magnitude of hearing loss via pure-tone and speech audiometry as well as immittance audiometry (tympanometry and acoustic reflexes),
`
`Measuring loudness discomfort levels (LDLs)
`
`Otoscopic inspection and cerumen management,
`
`Determine need for treatment/referral to physician or need for further tests (ABR; vestibular, etc),
`
`Counsel patient, family, caregiver on the results and recommendations,
`
`Assess candidacy and motivation toward amplification,
`
`Determine medical clearance as determined by FDA (1977).
`
`Auditory Needs Assessment
`
`This section details procedures to develop patient-specific communication needs. This includes providing realistic expectations and creating patient-specific fitting
`goals as the initial stage of the "validation" process. The importance of providing realistic expectations becomes increasingly more important as one reads the
`advertisements appearing in the local media. For example, the author lives in a major city where one major newspaper contains advertisements for hearing aids on a daily
`basis. One advertisement suggested an available hearing aid could "control the noise of 65,000 screaming football fans." Another advertisement used an excellent article
`on dead hair cells published in the Journal of the American Academy of Audiology (JAAA) as support that their hearing aid had the ability to "bypass dead cells" to improve
`speech understanding. It should be easy for the reader to see how advertisements such as these, and others, will create an atmosphere of unrealistic expectations and
`force a dispensing audiologist to dismiss these claims and provide his/her patient with more realistic expectations.
`
`Also involved in this process is determining which hearing aid "features" may be appropriate for the patient. These features may include:
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`Guideline for Audiologic Management of the Adult Patient Michael Valente Hearing Evaluation - Adults Hearing Aids - Adults 966
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`Directional microphones
`
`Direct auditory input (DAI)
`
`Noise management
`
`Frequency Modulation (FM) devices
`
`As part of the needs assessment, the patient may respond to a variety of questionnaires. Examples of such validation questionnaires may include:
`Abbreviated Profile of Hearing Aid Benefit (APHAB) (Cox and Alexander, 1995).
`
`Client Oriented Scale of Improvement (COSI) (Dillon et al., 1997).
`
`Hearing Handicap Inventory for the Elderly (HHIE) (Ventry and Weinstein, 1982).
`
`Expected Consequence of Hearing Aid Ownership (ECHO) (Cox and Alexander, 2000)
`
`Glasgow Hearing aid Benefit Profile (GHABP) (Gatehouse, 2000)
`
`International Outcome Inventory-Hearing (Cox et al., 2003)
`
`Non-Auditory Needs Assessment
`
`This section deals with the non-auditory aspects of the patient that may interact to determine success with amplification. These aspects may include cognition, patient
`expectations, motivation, willingness to take risks, assertiveness, manual dexterity, visual acuity, prior experience with amplification, general health, tinnitus, occupational
`demands, and the presence of support systems.
`
`Technical Aspects of Intervention
`
`Hearing Aid Selection
`
`This section relates to the decisions needed to select the appropriate hearing aid(s) and hearing assistive technology (HAT) based on the results of the hearing
`assessment and the auditory and non-auditory needs assessment. The outcome of this process is an attempt to match the appropriate style and features to the patient.
`These decisions may include:
`
`Style (CIC ; ITE ; ITC ; BTE)
`
`Occlusion management
`
`Volume control
`
`Bilateral versus monaural
`
`Direct auditory input (DAI); telecoil (programmable)
`
`Type of signal processing
`
`Capacity for frequency shaping (number of bands)
`
`Selection of output and SSPL90
`
`Number of memories
`
`Number of channels of compression and feedback management
`
`Digital noise reduction
`
`Switchable or adaptive directional/omnidirectional microphones
`
`Frequency compression or transposition
`
`Bone anchored devices
`
`CROS/BICROS/Transcranial CROS
`
`Quality Control
`
`The objective of this section is to ensure that hearing aids meet reasonable and expected quality standards prior to scheduling for hearing aid fitting and verification. A
`small percentage of instruments and earmolds may be defective upon receipt. In addition, hearing aids and earmolds may arrive in good working order, but with the
`incorrect configuration/features. Quality control (QC) measures are necessary to limit patient and clinician frustration and inconvenience. Examples of QC may be:
`
`Verification of directional microphone performance using either coupler or real-ear measurement
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`Electroacoustic analysis of new and repaired aids to ensure compliance to national standards and clinician satisfaction
`
`Electroacoustic analysis at final fit to provide base for measures at semi-annual or annual checks
`
`Verification of features to include confirmation of earmold/shell style, vent, color, type, processing (memories, automatic switches, etc.) and mechanical (directional
`microphones, t-coil, integrated FM, etc) features,
`
`Listening check for features not verifiable through physical examination or electroacoustic analysis. These may include operation of the volume control, directional
`microphones, FM, t-coil, etc.
`
`Fitting and Verification
`
`The objective of this section is to assure the fitting and verification procedure is viewed as a process that culminates in the optimal fitting. Verification procedures also
`serve as a benchmark against which future hearing aid changes can be compared.
`
`Verification procedures should be based on validated hearing aid fitting rationales and are expected to yield a comfortable fit of hearing aids including all desired features.
`In the fitting and verification process a signal must be presented to the hearing aid whether in the test chamber or with a probe microphone in the real ear. The clinician
`must select signals ensuring accurate verification of prescriptive methods to target, which are based on speech inputs and therefore a speech-like signal should be used.
`Examples of aspects of the fitting requiring verification may include:
`
`A comfortable physical fit
`
`Gain/output using validated fitting rationales.
`
`Correction for monaural/bilateral conditions
`
`Correction for type of HL
`
`RESR90 measurement below the individually measured LDL using pure-tone signal, when possible.
`
`Aided sound-field thresholds for audibility of soft sounds.
`
`Function of features such as telecoil and directional microphone
`
`Absent or minimal occlusion effect
`
`Hearing Assistive Technology (HAT)
`
`The objective of this section is to promote the use of Hearing Assistive Technology (HAT) to ensure communication needs are met as hearing aids alone may not address
`all the needs of the patient. HATs can either be used alone or combined with hearing aids to supplement performance in difficult listening conditions. HATs can address
`four communication needs:
`
`1. Face-to-face communication.
`
`2. Broadcast and other electronic media.
`
`3. Telephone conversation.
`
`4. Sensitivity to alerting signals and environmental stimuli.
`
`HAT is available as personal systems or large area listening systems. The most common HATs are:
`
`a. Personal FM system
`
`b. Infrared
`
`c. Induction loop
`
`d. Hardwired systems
`
`e. Telephone amplifier, telecoil, TDD (telecommunication device for the deaf)
`
`f. Situation specific devices (e.g., television)
`
`g. Alerting devices
`
`Instruction, Orientation, Counseling and Follow-Up Audiologic Rehabilitation
`
`Hearing Aid Orientation
`
`The objective of this section is to ensure patients obtain the desired benefits from amplification as easily and efficiently as possible. The hearing aid orientation process
`begins with the initial hearing aid fitting and may continue over several visits. Hearing aid orientation is complete only when all appropriate information has been provided
`and the patient (or family member/caregiver) is competent to handle the instruments or declines further post-fitting care.
`
`Orientation information can be device or patient-related. Device-related is specifically about the care and use of hearing instruments. Patient-related includes helping the
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`patient understand the nature of hearing loss, adjust to amplification, have realistic expectations of the benefits and limitations of amplification, and take advantage of
`other sources of help (such as better communication strategies, HATs and speechreading). Topics addressed in orientation may include:
`
`Use and care of aids such as instrument features; insertion/removal; battery use; care and cleaning; comfort; feedback, use with telephone; warranty.
`
`Wearing schedule; goals and expectations; adjustment to amplification; speechreading; post-fitting.
`
`Counseling and Follow-Up Audiologic Rehabilitation
`
`The objective of this section is to provide patients who have received hearing aids a comprehensive understanding concerning the effects of hearing impairment and the
`implementation of strategies to mitigate those effects. The members view the fitting of hearing aids as the beginning of the treatment process. Successful management
`requires comprehensive counseling to help the patient adjust to his/her hearing aids, as well as instruction the patient and his/her primary communication partners
`concerning the development of appropriate communication strategies to maximize and augment the assistance he/she receive from the hearing aids. Counseling is often
`required to help the patient learn new strategies to help ensure success. In addition, emotional factors concerning hearing loss must be addressed in a comprehensive
`audiologic rehabilitation program. Counseling can be provided on an individual basis, but is often delivered in small group settings.
`
`Topics addressed in these sessions should include:
`
`Anatomy and physiology of hearing process
`
`Understanding the audiogram
`
`Problems associated with understanding speech in noise
`
`Appropriate/inappropriate communication behaviors
`
`Communication strategies
`
`Listening and repair strategies
`
`Ways in which to control the environment
`
`Assertiveness training
`
`Realistic expectations from amplification
`
`Stress management
`
`Speechreading skills
`
`HATs
`
`Community resources
`
`Assessing Outcomes
`
`This is the part of the patient management process that assesses how well intervention reduced activity limitations, decreased participation restrictions, and improved
`QOL. This is referred to as validation. Validating the choices made as part of the assessment, selection, and fitting processes, to the extent that the patient's needs have
`been met, is accomplished through the administration of outcome measures. Many outcome measures, described in the auditory and non-auditory needs assessment
`section, have been developed to assess the impact of a hearing impairment on the individual in the areas of communication functioning, activity limitation and participation
`restrictions.
`
`As critical as it is to measure the benefits of hearing aid intervention at the level of the patient, the measurement of treatment outcomes is assuming greater importance on
`the national health care stage. Through the routine use of clinically applied outcome measures and carefully controlled clinical trials, audiologists can build a foundation for
`evidence-based clinical practice guidelines. Clinical practice guidelines, in turn, minimize variability in outcome, maximize treatment efficacy, reduce risks, decrease waste,
`and improve patient satisfaction. In addition, the guideline should elevate the profession of Audiology among third party payers, other health care providers as well as
`current and future patients. As audiologists continue to compete in the health care marketplace, they must demonstrate that treatments reduce activity limitations,
`decrease participation restrictions, and improve health-related quality of life. Only by measuring the outcomes of treatment can audiologists be assured that interventions
`make a difference and patients have benefited from their care.
`
`Personal Thoughts on Some Possible Limitations of EBP
`
`Integrating EBP to develop this guideline and implying that clinicians should routinely use EBP to critically analyze the evidence (literature) to determine whether to include
`new procedures or treatments into the clinical care of their patients is a logical step. One would be hard pressed to argue against this. The author, however, believes that
`strict reliance on EBP to help clinicians make these decisions may not be without some problems and these potential problems need to be, at least, mentioned. This is not
`to minimize the importance of integrating EBP into the daily clinical practice of audiologists. Rather, this section serves to point out some concerns the author has about
`the reality of strict integration of EBP within the current clinical environment. These potential concerns include:
`
`Reviewing the evidence is subjective. Anyone experiencing the peer review process as either a reviewer or author knows of the rather common outcome of
`reviewers having significantly different views on the quality of the submitted manuscript. In fact, in the experience of the author, it is quite rare when the reviewers
`arrive at the same recommendation concerning acceptance/rejection or specific concerns about the quality of the submitted manuscript. Further, members of the
`Task Force, when using EBP, were not always in agreement as to whether a particular article was a Level 1 or Level 2 or some other level of evidence. Thus, if the
`"experts" are not in agreement, is it realistic to expect the "non-experts" among us to agree on the quality and level of the research he/she has just read? That is,
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`the EBP process also appears to be a balance between art and science.
`
`The application of clinical care needs be a balance between art and science. That is, clinician experience/intuition should not simply be written off as having little or
`no value. Clinical experience does have significant value and this experience must be balanced with the conclusions a clinician might draw as he/she reads and
`analyzes the evidence. The clinician, for example, should be able to judge if the results of a published project have relevance to the "real world." For example, is a
`reported improvement of 6.5 dB obtained in a sound suite with noise arriving from a single loudspeaker from 180 degrees is going to result in the same magnitude
`of improvement in the real-world? No, and hopefully most clinicians would be able to make the connection between research completed in the laboratory and its
`application in real world experiences and expectations of their patients.
`
`This is extremely difficult for the author to state, but do most audiologists actually read the evidence? Unfortunately, my experience would suggest that the answer
`may be "no." Thus, if a profession relies on the use of EBP to advance the quality of care, is its value being maximized if the members of the profession do not
`routinely read the evidence?
`
`On a more positive note, the author believes there is a significant shift within the profession to embrace EBP. This shift is observed by the increased number of
`presentations on EBP at professional meetings. In fact, there are now entire conferences dedicated specifically to the implementation EBP in Audiology. Also, there
`are increased requests on the part of conference organizers asking presenters to use EBP in their presentations to support the ideas being expressed. Finally, a
`casual review of the curriculum of residential four year Au.D. programs appears to show a significant increase in courses pertaining to statistical analysis and
`research design that is required in order to be awarded the degree.
`
`It is also extremely difficult for the author to suggest that most audiologists are not typically trained to critically analyze the evidence. Thus, even if the evidence is
`being read, is the typical audiologist trained to critically analyze the merit of the evidence? Again, the author believes there is a significant shift in direction with the
`residential four year Au.D. programs offering courses on statistical analysis and research design. In addition, many programs appear to be mandating that students
`use EBP in the review of the literature and discussion sections of their Capstone Projects. It does appear as if the current graduates from Au.D. programs are being
`better trained in EBP. The hope, of course, is that this will continue in the years after graduation.
`
`Technology is rapidly changing and it may take more than two years from the time data collection and the peer-review process is completed before the benefits/risks
`of this new technology to appear in the literature. Can a clinician afford to wait more than two years before learning if a new treatment or procedure has greater
`benefit than a current treatment or procedure before implementing it into the daily clinical care for their patients? If clinicians followed this time line, with the current
`explosion in technology, the advances would pass their patients by and audiologists would remain stagnant.
`
`As noted earlier, there appears to be little Level 1 or Level 2 evidence to support the practices clinicians typically practice when dispensing hearing aids to adult
`patients on a daily basis. Hopefully, one of the greatest contributions of incorporating EBP to formulate this guideline is pointing out the "holes" or "weaknesses" in
`our collective research and "force" our profession to generate better research.
`
`Strict use of EBP would seem to minimize the contribution of information published in non-peer reviewed "trade" journals. The reader probably realizes that in an
`environment where technology is changing so rapidly, it may well be that the information contained within these journals may be the best source of current
`information on the capabilities and limitations of these new advances. The reader simply needs to be reminded of the obvious conflict of interest (bias) that may be
`contained within the information provided. The reader should be further reminded that some of the most often cited work in our field has been contained within the
`pages of these journals.
`
`Finally, and related to some of the prev