The tinnitus functional index: development of a new clinical measure for chronic, intrusive tinnitus.

OBJECTIVES: Chronic subjective tinnitus is a prevalent condition that causes significant distress to millions of Americans. Effective tinnitus treatments are urgently needed, but evaluating them is hampered by the lack of standardized measures that are validated for both intake assessment and evaluation of treatment outcomes. This work was designed to develop a new self-report questionnaire, the Tinnitus Functional Index (TFI), that would have documented validity both for scaling the severity and negative impact of tinnitus for use in intake assessment and for measuring treatment-related changes in tinnitus (responsiveness) and that would provide comprehensive coverage of multiple tinnitus severity domains. DESIGN: To use preexisting knowledge concerning tinnitus-related problems, an Item Selection Panel (17 expert judges) surveyed the content (175 items) of nine widely used tinnitus questionnaires. From those items, the Panel identified 13 separate domains of tinnitus distress and selected 70 items most likely to be responsive to treatment effects. Eliminating redundant items while retaining good content validity and adding new items to achieve the recommended minimum of 3 to 4 items per domain yielded 43 items, which were then used for constructing TFI Prototype 1.Prototype 1 was tested at five clinics. The 326 participants included consecutive patients receiving tinnitus treatment who provided informed consent-constituting a convenience sample. Construct validity of Prototype 1 as an outcome measure was evaluated by measuring responsiveness of the overall scale and its individual items at 3 and 6 mo follow-up with 65 and 42 participants, respectively. Using a predetermined list of criteria, the 30 best-functioning items were selected for constructing TFI Prototype 2.Prototype 2 was tested at four clinics with 347 participants, including 155 and 86 who provided 3 and 6 mo follow-up data, respectively. Analyses were the same as for Prototype 1. Results were used to select the 25 best-functioning items for the final TFI. RESULTS: Both prototypes and the final TFI displayed strong measurement properties, with few missing data, high validity for scaling of tinnitus severity, and good reliability. All TFI versions exhibited the same eight factors characterizing tinnitus severity and negative impact. Responsiveness, evaluated by computing effect sizes for responses at follow-up, was satisfactory in all TFI versions.In the final TFI, Cronbach's alpha was 0.97 and test-retest reliability 0.78. Convergent validity (r = 0.86 with Tinnitus Handicap Inventory [THI]; r = 0.75 with Visual Analog Scale [VAS]) and discriminant validity (r = 0.56 with Beck Depression Inventory-Primary Care [BDI-PC]) were good. The final TFI was successful at detecting improvement from the initial clinic visit to 3 mo with moderate to large effect sizes and from initial to 6 mo with large effect sizes. Effect sizes for the TFI were generally larger than those obtained for the VAS and THI. After careful evaluation, a 13-point reduction was considered a preliminary criterion for meaningful reduction in TFI outcome scores. CONCLUSIONS: The TFI should be useful in both clinical and research settings because of its responsiveness to treatment-related change, validity for scaling the overall severity of tinnitus, and comprehensive coverage of multiple domains of tinnitus severity.

A comparison of benefit and economic value between two sound therapy tinnitus management options.

BACKGROUND: Sound therapy coupled with appropriate counseling has gained widespread acceptance in the audiological management of tinnitus. For many years, ear level sound generators (SGs) have been used to provide masking relief and to promote tinnitus habituation. More recently, an alternative treatment device was introduced, the Neuromonics Tinnitus Treatment (NTT), which employs spectrally-modified music in an acoustic desensitization approach in order to help patients overcome the disturbing consequences of tinnitus. It is unknown, however, if one treatment plan is more efficacious and cost-effective in comparison to the other. In today's economic climate, it has become critical that clinicians justify the value of tinnitus treatment devices in relation to observed benefit. PURPOSE: To determine perceived benefit from, and economic value associated with, two forms of sound therapy, namely, SGs and NTT. RESEARCH DESIGN: Retrospective between-subject clinical study. STUDY SAMPLE: A sample of convenience comprised of 56 patients drawn from the Tinnitus Management Clinic at the Cleveland Clinic participated. Twenty-three patients selected SGs, and 33 patients selected NTT as their preferred sound therapy treatment option. DATA COLLECTION AND ANALYSIS: Sound therapy benefit was quantified using the Tinnitus Handicap Inventory (THI). The questionnaire was administered before and 6 mo after initiation of tinnitus treatment. Prior to device fitting, all patients participated in a 1.5 hr group education session about tinnitus and its management. Economic value comparisons between sound therapy options were made using a cost-effectiveness analysis (CEA) and cost-utility analysis (CUA). RESULTS: THI scores indicated a significant improvement (p < 0.001) in tinnitus reduction for both treatment types between a pre- and 6 mo postfitting interval, yet there were no differences (p > 0.05) between the treatment alternatives at baseline or 6 mo postfitting. The magnitude of improvement for both SGs and NTT was dependent on initial perceived tinnitus handicap. Based on the CEA and CUA economic analyses alone, it appears that the SGs may be the more cost-effective alternative; however, the magnitude of economic value is a function of preexisting perceived tinnitus activity limitation/participation restriction. CONCLUSIONS: Both SGs and NTT provide significant reduction in perceived tinnitus handicap, with benefit being more pronounced for those patients having greater tinnitus problems at the beginning of therapy. Although the economic models favored the SGs over the NTT, there are several other critical factors that clinicians must take into account when recommending a specific sound therapy option. These include initial tinnitus severity complaints and a number of patient preference variables such as sound preference, listening acceptability, and lifestyle.

Treatment options for subjective tinnitus: self reports from a sample of general practitioners and ENT physicians within Europe and the USA.

BACKGROUND: Tinnitus affects about 10-15% of the general population and risks for developing tinnitus are rising through increased exposure to leisure noise through listening to personal music players at high volume. The disorder has a considerable heterogeneity and so no single mechanism is likely to explain the presence of tinnitus in all those affected. As such there is no standardized management pathway nor singly effective treatment for the condition. Choice of clinical intervention is a multi-factorial decision based on many factors, including assessment of patient needs and the healthcare context. The present research surveyed clinicians working in six Westernized countries with the aims: a) to establish the range of referral pathways, b) to evaluate the typical treatment options for categories of subjective tinnitus defined as acute or chronic, and c) to seek clinical opinion about levels of satisfaction with current standards of practice. METHODS: A structured online questionnaire was conducted with 712 physicians who reported seeing at least one tinnitus patients in the previous three months. They were 370 general practitioners (GPs) and 365 ear-nose-throat specialists (ENTs) from the US, Germany, UK, France, Italy and Spain. RESULTS: Our international comparison of health systems for tinnitus revealed that although the characteristics of tinnitus appeared broadly similar across countries, the patient's experience of clinical services differed widely. GPs and ENTs were always involved in referral and management to some degree, but multi-disciplinary teams engaged either neurology (Germany, Italy and Spain) or audiology (UK and US) professionals. For acute subjective tinnitus, pharmacological prescriptions were common, while audiological and psychological approaches were more typical for chronic subjective tinnitus; with several specific treatment options being highly country specific. All therapy options were associated with low levels of satisfaction. CONCLUSIONS: Despite a large variety of treatment options, the low success rates of tinnitus therapy lead to frustration of physicians and patients alike. For subjective tinnitus in particular, effective therapeutic options with guidelines about key diagnostic criteria are urgently needed.

Development and psychometric adequacy of the screening version of the tinnitus handicap inventory.

OBJECTIVE: To develop a screening version of the Tinnitus Handicap Inventory (THI-S) and establish its psychometric characteristics. DESIGN: : Prospective clinical study to analyze 1) the level of predictability between THI and THI-S; 2) test-retest reliability of the THI-S; 3) 95% confidence intervals (critical difference scores) for the THI-S; and 4) a THI-S cutoff score used for referral purposes. SETTING: Head and Neck Institute at the Cleveland Clinic, a tertiary care medical center. PATIENTS: : Thirty-three patients reporting tinnitus as their primary complaint. INTERVENTIONS: There was, on average, a 16-day interval between test-retest administrations of the THI-S. MAIN OUTCOME MEASURE: Comparability of scores between the THI and the THI-S and test-retest reliability of the THI-S was assessed using Pearson product-moment correlations. The level of agreement between the 2 administrations of the THI-S was evaluated using Bland-Altman repeatability plots. RESULTS: Comparability between the THI and THI-S was high (r = 0.90). Test-retest reliability of the THI-S was adequate (r = 0.81), as well as the level of agreement between administrations as demonstrated by the Bland-Altman plot. Based on 95% confidence intervals, pretreatment and posttreatment scores would have to differ by more than 10 points for intervention efforts to be considered significant. A 6-point cutoff score was analyzed as an appropriate fence for referral. CONCLUSION: The THI-S is a psychometrically robust screening measure of activity limitation and participation restriction.

A systematic review of health-related quality of life and hearing aids: final report of the American Academy of Audiology Task Force On the Health-Related Quality of Life Benefits of Amplification in Adults.

This is the final report of the American Academy of Audiology Task Force on the Health-Related Quality of Life (HRQoL) Benefits of Amplification in Adults. A systematic review with meta-analysis examined evidence pertaining to the use of hearing aids for improving HRQoL for adults with sensorineural hearing loss (SNHL). Relevant search strings applied to the CENTRAL, CINAHL, Cochrane Reviews, ComDisDome, EBMR, and PubMed databases identified randomized controlled trial, quasi-experimental, and nonexperimental pre-post test designed studies. Sixteen studies met a priori criteria for inclusion in this review. A random-effects meta-analysis showed differential results for generic versus disease-specific HRQoL measures for within- and between-subject designs. Although generic measures used for within-subject designs did not demonstrate HRQoL benefits from hearing aids, mean effect sizes and confidence intervals for within-subject designs and disease-specific instruments suggested that hearing aids have a small-to-medium impact on HRQoL. Further, the between-subject studies supported at least a small effect for generic measures, and when measured by disease-specific instruments, hearing aids had medium-to-large effects on adults' HRQoL. This review concludes that hearing aids improve adults' HRQoL by reducing psychological, social, and emotional effects of SNHL. Future studies should include control groups using randomized controlled trials.

A Speech Perception Test in Simulated Reverberation Conditions.

PURPOSE: This study developed new test materials by applying various reverberation treatments to sentences having high and low contextual redundancy. METHOD: The Speech Perception in Noise-Revised (SPIN-R; Bilger, Nuetzel, Rabinowitz, & Rzeczkowski, 1984; Kalikow, Stevens, & Elliott, 1977) sentences were modified (SPIN-Reverb) with reverberation times (RT60) from simulated environments: unprocessed, RevCond 1 (RT60 = 600 ms), RevCond 2 (RT60 = 1200 ms), and RevCond 3 (RT60 = 3600 ms). Phase 1 investigated list equivalency among 75 listeners with normal hearing; Phase 2 examined the utility of SPIN-Reverb for 15 cochlear implant (CI) recipients. RESULTS: Equivalent lists within each reverberation condition (unprocessed, RevCond 1, 2, and 3) were identified using nonparametric bootstrapping. Analysis of variance (Phase 1) demonstrated significant differences across conditions for high predictability and total scores. Listening performance decreased for both high and low predictability as RT60 increased for listeners with normal hearing and CI recipients. Unprocessed, RevCond 1, RevCond 2, and RevCond 3 conditions were significantly different from each other. Within RevCond conditions, high- and low-predictability sentences were significantly different from each other. CONCLUSIONS: RevCond 1 and RevCond 2 may be useful supplements to the current CI battery. The SPIN-Reverb has potential as a set of clinically feasible materials that are graded in difficulty and representative of real-life acoustic challenges for the evaluation of sensory devices.

Vestibular nerve sectioning for intractable vertigo: efficacy of simplified retrosigmoid approach.

OBJECTIVE: To determine the surgical efficacy of a simplified retrosigmoid approach for vestibular nerve sectioning. STUDY DESIGN: A retrospective analysis. SETTING: Tertiary academic referral center. PATIENTS: Twenty-eight consecutive patients who underwent vestibular nerve sectioning for intractable peripheral vestibular disorders. INTERVENTION: All patients had a simplified retrosigmoid approach for vestibular nerve sectioning. MAIN OUTCOME MEASURES: Functional outcome after vestibular nerve sectioning was analyzed with respect to improvement in patient disability from vertigo and reduction in the frequency of definitive vertigo attacks. Resolution of lightheadedness provided an additional outcome measure. The incidence of surgical complications, including postoperative headache, was determined, and the operative time was reviewed. RESULTS: Twenty-six patients (92.9%) had an improved functional level postoperatively, 21 (75.0%) had excellent improvement, 4 (14.3%) had significant improvement, 1 (3.6%) had limited improvement, and 2 (7.1%) had no change. No patient was worse postoperatively. Eighteen of 23 Ménière's patients (78.3%) had complete control of definitive vertigo attacks after vestibular nerve sectioning. Improvement in lightheadedness was seen in 23 patients (82.1%), 11 (39.3%) of whom reported complete resolution. Postoperative headache developed in 1 (3.6%) patient. No patients experienced infection, facial weakness, or leakage of cerebrospinal fluid. Mild hearing deterioration was seen in 2 patients (7.1%). The mean operative time was 76.3 minutes. CONCLUSION: With excellent efficacy, short operative time, and a low incidence of postoperative hearing loss or headache, this simplified retrosigmoid technique should be considered for vestibular nerve sectioning in patients with intractable peripheral vestibular disorders.

Hearing loss is often undiscovered, but screening is easy.

Screening for hearing loss should be part of the routine physical examination, but it is often not done because of time constraints. We present a quick and easy office screening test that measures the functional impact of hearing loss. We also review the steps of audiologic management that follow referral by the primary care physician.

Assessing outcomes of tinnitus intervention.

BACKGROUND: It has been estimated that as many as 50 million Americans do experience or have experienced tinnitus. For approximately 12 million of these individuals, tinnitus makes it impossible for them to carry out normal everyday activities without limitation. These are the patients that present to audiology clinics for assessment and management. The tinnitus evaluation includes the measurement of acoustical characteristics of tinnitus and the impact that this impairment has on health-related quality of life (HRQoL). Tinnitus is a disorder that often occurs as a result of auditory system impairment. The impairment for some can impart an activity limitation and a participation restriction (i.e., tinnitus-related disability or handicap, respectively). The goal of tinnitus management is to reduce, or eliminate, activity limitations and participation restrictions by reducing or eliminating a patient's perception of tinnitus or their reaction to tinnitus. Implicit in this statement is the assumption that there exist standardized measures for quantifying the patient's tinnitus perception and their reaction to it. If there existed stable and responsive standardized tinnitus measures, then it would be possible to compare a patient's tinnitus experience at different time points (e.g., before and after treatment) to assess, for example, treatment efficacy. PURPOSE: The purposes of the current review are to (1) describe psychometric standards used to select outcome measurement tools; (2) discuss available measurement techniques and their application to tinnitus evaluation and treatment-related assessment within the domains established by the World Health Organization's International Classification of Functioning, Disability and Health; (3) list and briefly describe self-report tinnitus questionnaires; (4) describe how valuation of tinnitus treatment can be assessed using economic models of treatment effectiveness; and (5) provide future directions including the development of a tinnitus outcomes test battery and treatment-related study designs. RESEARCH DESIGN: Retrospective literature review CONCLUSIONS: Although psychometrically robust measures of tinnitus HRQoL do exist, there is no unanimity in, for example, what tests should be included in the tinnitus assessment, and how studies of HRQoL should be conducted. The current authors suggest that future studies employ more rigorous designs and contain (minimally) the following characteristics: (1) utilization of randomized control groups and blinding; (2) appropriate statistical testing including "dropouts" that should be used in an "intention to treat" analysis rather than elimination from the final data set; (3) long-term follow-up assessment to evaluate responsiveness; (4) appropriate inclusion criteria to avoid "ceiling" and "floor" effects; and (5) suitable sample sizes based on the application of power analyses.

Clinical practice guideline: tinnitus.

OBJECTIVE: Tinnitus is the perception of sound without an external source. More than 50 million people in the United States have reported experiencing tinnitus, resulting in an estimated prevalence of 10% to 15% in adults. Despite the high prevalence of tinnitus and its potential significant effect on quality of life, there are no evidence-based, multidisciplinary clinical practice guidelines to assist clinicians with management. The focus of this guideline is on tinnitus that is both bothersome and persistent (lasting 6 months or longer), which often negatively affects the patient's quality of life. The target audience for the guideline is any clinician, including nonphysicians, involved in managing patients with tinnitus. The target patient population is limited to adults (18 years and older) with primary tinnitus that is persistent and bothersome. PURPOSE: The purpose of this guideline is to provide evidence-based recommendations for clinicians managing patients with tinnitus. This guideline provides clinicians with a logical framework to improve patient care and mitigate the personal and social effects of persistent, bothersome tinnitus. It will discuss the evaluation of patients with tinnitus, including selection and timing of diagnostic testing and specialty referral to identify potential underlying treatable pathology. It will then focus on the evaluation and treatment of patients with persistent primary tinnitus, with recommendations to guide the evaluation and measurement of the effect of tinnitus and to determine the most appropriate interventions to improve symptoms and quality of life for tinnitus sufferers. ACTION STATEMENTS: The development group made a strong recommendation that clinicians distinguish patients with bothersome tinnitus from patients with nonbothersome tinnitus. The development group made a strong recommendation against obtaining imaging studies of the head and neck in patients with tinnitus, specifically to evaluate tinnitus that does not localize to 1 ear, is nonpulsatile, and is not associated with focal neurologic abnormalities or an asymmetric hearing loss. The panel made the following recommendations: Clinicians should (a) perform a targeted history and physical examination at the initial evaluation of a patient with presumed primary tinnitus to identify conditions that if promptly identified and managed may relieve tinnitus; (b) obtain a prompt, comprehensive audiologic examination in patients with tinnitus that is unilateral, persistent (≥ 6 months), or associated with hearing difficulties; (c) distinguish patients with bothersome tinnitus of recent onset from those with persistent symptoms (≥ 6 months) to prioritize intervention and facilitate discussions about natural history and follow-up care; (d) educate patients with persistent, bothersome tinnitus about management strategies; (e) recommend a hearing aid evaluation for patients who have persistent, bothersome tinnitus associated with documented hearing loss; and (f) recommend cognitive behavioral therapy to patients with persistent, bothersome tinnitus. The panel recommended against (a) antidepressants, anticonvulsants, anxiolytics, or intratympanic medications for the routine treatment of patients with persistent, bothersome tinnitus; (b) Ginkgo biloba, melatonin, zinc, or other dietary supplements for treating patients with persistent, bothersome tinnitus; and (c) transcranial magnetic stimulation for the routine treatment of patients with persistent, bothersome tinnitus. The development group provided the following options: Clinicians may (a) obtain an initial comprehensive audiologic examination in patients who present with tinnitus (regardless of laterality, duration, or perceived hearing status); and (b) recommend sound therapy to patients with persistent, bothersome tinnitus. The development group provided no recommendation regarding the effect of acupuncture in patients with persistent, bothersome tinnitus.

Clinical practice guideline: tinnitus executive summary.

The American Academy of Otolaryngology--Head and Neck Surgery Foundation (AAO-HNSF) has published a supplement to this issue featuring the new Clinical Practice Guideline: Tinnitus. To assist in implementing the guideline recommendations, this article summarizes the rationale, purpose, and key action statements. The 13 recommendations developed address the evaluation of patients with tinnitus, including selection and timing of diagnostic testing and specialty referral to identify potential underlying treatable pathology. It will then focus on the evaluation and treatment of patients with persistent primary tinnitus, with recommendations to guide the evaluation and measurement of the impact of tinnitus and to determine the most appropriate interventions to improve symptoms and quality of life for tinnitus sufferers.

Evaluation of a customized acoustical stimulus system in the treatment of chronic tinnitus.

OBJECTIVE: The purpose of this study is to evaluate the efficacy of a customized acoustical stimulus (Neuromonics) system in the treatment of chronic tinnitus. STUDY DESIGN: Multi-institutional prospective. SETTING: Nine U.S. Tertiary Otological referral centers; ambulatory. PATIENTS: Fifty-two adults with chronic tinnitus for a minimum of 6 months, with poor or no response to previous treatments, and not undergoing concomitant therapies were enrolled. INTERVENTIONS: Treatment was delivered in 2 stages: Stage 1 consisted of stimulation with the patient-customized musical tracks and white noise masking of the tinnitus for 2 months, 2 to 4 hours a day. Stage 2 consisted of listening to the same tracks, with no tinnitus masking for 4 months. Both phases included education, cognitive therapy, and periodic follow-up. MAIN OUTCOME MEASURES: Treatment response was measured through validated psychometric testing: the Tinnitus Reaction Questionnaire and the Tinnitus Handicap Inventory. Other measures included the Hospital Anxiety Depression Scale and loudness discomfort levels. RESULTS: Patients' responses were recorded from 38 patients at 6 months, 28 patients at 12 months, and 12 patients at 24 months after initiation of treatment. A total of 14 patients withdrew or were lost to follow-up, and the rest had not reached the 12- or 24-month testing interval. The Tinnitus Reaction Questionnaire score was significantly reduced in 74% of patients at 12 months and 84% of patients at 24 months. Tinnitus Handicap Inventory scores were significantly reduced in 77% of patients at 12 months and 50% at 24 months. CONCLUSION: The customized acoustical stimulus system offers a safe and effective means of tinnitus management for patients with chronic tinnitus.

Tinnitus: patients do not have to 'just live with it'.

Tinnitus is distressing and affects the quality of life for many patients. Because primary care physicians may be the entry point for patients seeking help for tinnitus, we urge them to acknowledge this symptom and its potential negative impact on the patient's health and quality of life. Physicians should actively listen to the patient and provide hope and encouragement, but also provide realistic expectations about the course of treatment. The patient must also understand that there may be no singular "cure" for tinnitus and that management may involve multidisciplinary assessment and treatment.

Eye on the elderly. Screening for hearing loss, risk of falls: a hassle-free approach.

Simply asking elderly patients whether they have trouble hearing is an effective start to screening for hearing loss. Refer elderly patients with suspected hearing impairment for audiologic diagnosis and nonmedical rehabilitation treatment, including hearing aids. To assess a patient's risk of falling, review gait, balance disorders, weakness, environmental hazards, and medications.

Longitudinal benefit from and satisfaction with the Baha system for patients with acquired unilateral sensorineural hearing loss.

OBJECTIVE: To analyze the short-, medium-, and long-term benefits from and satisfaction with the Baha for patients with profound unilateral sensorineural hearing loss (SNHL). DESIGN: Prospective clinical study. SETTING: Head and Neck Institute at the Cleveland Clinic. PATIENTS: Eight patients with acquired profound unilateral SNHL. INTERVENTIONS: Patients underwent unaided baseline testing and aided Baha testing using laboratory and self-report measures at 6 postfitting intervals. MAIN OUTCOME MEASURES: Laboratory measures included the revised Speech Perception in Noise test, Hearing in Noise Test, and localization testing. Disease-specific self-report measures included the Abbreviated Profile of Hearing Aid Benefit, Hearing Handicap Inventory for Adults, and Single-Sided Deafness Questionnaire. The Medical Outcomes Study SF-36 Health Survey was used to assess health-related quality of life. RESULTS: Based on 95% confidence intervals for unaided testing, significant improvements on aided revised Speech Perception in Noise, Abbreviated Profile of Hearing Aid Benefit, and Hearing Handicap Inventory for Adults scores were sustained during the 18-month test interval. Variable performance was observed for the Hearing in Noise Test over time and patients. No acclimatization effects were shown for localization testing or the generic health-related quality-of-life measure. Patients reported satisfaction in a variety of situations as quantified by the Single-Sided Deafness Questionnaire in the long-term. CONCLUSION: The Baha is effective in reducing psychosocial consequences of unilateral profound SNHL for the long-term. Improvement in speech understanding occurred when the primary signal was spatially separated from background noise. Localization performance did not improve with Baha use. Overall, patients were satisfied with their Baha and would still elect to have this procedure if given a second chance.

Benefit From, Satisfaction With, and Cost-Effectiveness of Three Different Hearing Aid Technologies.

Clinical decision-making has become more complex as newer, more costly, hearing aid (HA) technologies become available. The expanding array of more expensive HAs demands that clinical researchers continue to justify the value of these instruments relative to the substantial increase in cost to both the provider and consumer.In the present report, 25 current conventional HA users with adult onset of sensorineural hearing loss were fitted with: (a) a one-channel linear HA; (b) a two-channel, nonlinear HA; and (c) a seven-band, two-channel digital signal processing (DSP) HA. All instruments were mini behind-the-ear units with identifying information removed from the cases. Subjects wore each HA for at least a 1-month period.A set of laboratory (Speech Perception in Noise [SPIN] test; audibility index calculated from real-ear measurements) and self-report (Abbreviated Profile of Hearing Aid Benefit; Hearing Handicap Inventory for the Elderly/Adults; Knowles Hearing Aid Satisfaction Survey; preference ratings) outcome measures were used to evaluate the benefit from, satisfaction with, and cost-effectiveness of each test HA. As expected, there were statistically significant differences between unaided and aided conditions across HAs.Although the DSP instrument yielded significantly higher word recognition scores on the SPIN test, no differences were observed among the test HAs for the standardized self-report measures. In contrast, however, more than 75% of the subjects preferred the "higher end" instruments. Yet, 33% of the subjects changed their preference for the "higher end" instruments after being informed of costs. A cost-effectiveness model for evaluating the relationship between HA retail purchase price and improvements in performance/benefit is presented.