Remote cochlear implant programming in real-life listening environments: a feasibility and acceptability study

Introduction

Remote care in cochlear implants (CIs) has been developed and applied over the last two decades as a telehealth strategy to reduce travel burden and increase access to specialized care (Muñoz et al., 2021). Several studies across different implant manufacturers have demonstrated that remote fitting is technically feasible and safe, and that fitting parameters and speech perception outcomes are generally comparable to those obtained during conventional in-clinic fitting (Eikelboom et al., 2014; Hughes et al., 2012; Ramos et al., 2009; Schepers et al., 2019; Wesarg et al., 2010). In addition to remote fitting, there have been remote evaluation methods developed and validated to measure performance with CI (de Graaff et al., 2018; Maruthurkkara et al., 2022; van der Mescht et al., 2022), which were shown to be feasible at any time when administered in a quiet place (Wasmann et al., 2024). Schepers et al. (2019) applied remote fitting both in adult and pediatric CI users, demonstrating that it leads to equivalent results as in-clinic fitting, although with slightly more time required for the remote fitting. In some clinics, remote fitting has been implemented in routine practice for selected CI users via satellite clinics, so called outreach centers (Luryi et al., 2020; Polovoy, 2008; Slager et al., 2019; Trueheart and Hildrew, 2025).

It is estimated that currently there are around one million CI users worldwide (Zeng, 2022). The group of CI users that need aftercare, that is all long-term CI care including processor upgrades, performance monitoring and refitting, is growing on a yearly basis leading to a growing burden on clinical capacity. Therefore, clinics will face challenges to meet the rising need in CI care, particularly to keep CI care as accessible as possible. Additionally, CI users living in remote areas or facing logistic challenges (e.g., child-care, work, transportation, etc.) might decline CI care because of the substantial effort required to visit a CI clinic (Hughes et al., 2012; Polovoy, 2008; Slager et al., 2019; Wesarg et al., 2010).

Remote CI programming is a promising approach to meet this increasing demand, offering potential advantages such as reduced clinic load, shorter visits, more accessible support by partners and relatives without having to take the day off, fewer travel-related emissions, and improved access for users in remote or underserved areas (Bush et al., 2013; Homans et al., 2025; Maruthurkkara, 2025; Wasmann and de Laat, 2022). Yet large-scale implementation attempts, such as the UK CHOICE program, show persistent adoption challenges—limited perceived value, technology gaps, and poor workflow integration (Cullington et al., 2022; Liles et al., 2021). International data echo this: in the Netherlands only ~14% of users report being offered remote care despite high willingness to try it; similar trends appear in Australia (Sucher et al., 2025; Wasmann, 2025). Inconsistent reimbursement also limits uptake, and willingness to pay out-of-pocket is modest (Galvin et al., 2023; Lin and Chen, 2024). Collectively, equivalence to in-clinic care alone is insufficient for widespread adoption.

To support sustainable implementation, it may be necessary to clarify the additional benefits that remote fitting can provide. A novel and underexplored potential benefit of remote CI fitting is to perform remote fittings in real-life contexts—such as at the workplace, during family visits, at home, or at social gatherings—allowing clinicians to tailor settings to everyday listening environments. Here, we consider remote fitting not as a replacement for conventional care, but as a valuable component of a hybrid model that combines remote and in-clinic sessions. The present study therefore aimed to explore the potential advantages and feasibility of remote programming in real-life listening situations, and to identify benefits, challenges, and recommendations for clinical practice.

Materials and methods

Ethics

The study was conducted according to the principles of the Declaration of Helsinki (October 2013). The research protocol was submitted to the Medical Research Ethics Committee at the Radboud University Medical Center Nijmegen, and they considered the study not subject to the Medical Research Involving Human Subjects Act (WMO). The study was performed in accordance with good clinical practice and signed informed consent forms were obtained from all participants. Potential candidates were informed about the study by either the investigator or by clinicians from the Radboudumc CI team. They received the patient information letter and were able to ask questions related to the research project via an online patient platform or by phone before deciding to participate. Candidates were informed they could withdraw from the study at any moment.

Remote programming devices

The latest Advanced Bionics Target CI programming software (version 1.5) was used to program the Naída CI Marvel sound processor and the Phonak Naída Link M hearing aid (HA). Together with the AB Remote Support mobile application, the software also allows for remote programming (Advanced Bionics, 2023) as illustrated in Figure 1.

The clinician initiates the fitting session while the CI user connects their hearing devices to the mobile application via Bluetooth. Adjustments made during the fitting process are transmitted over a secure, peer-to-peer connection established between the clinician and the CI user. A camera is used on both ends to enable visual communication, and the clinician may use a headset to ensure optimal sound quality.

Study design

This explorative study evaluated feasibility, the functionality, and benefits of remote fitting in real-world locations and situations chosen by the participant. Outcomes such as system stability, potential camera and sound issues, and subjective satisfaction of the participant and clinician were recorded. In addition, the Client Oriented Scale of Improvement (COSI questionnaire (Dillon et al., 1997) was used to determine what issues to address via remote fitting and to evaluate the degree of improvement due to the programming changes made during the remote fitting sessions. It was beyond the scope of this feasibility study to objectively evaluate the effectiveness of the remote fitting intervention other than based on the feedback from the participants. The primary reason to assess aided speech intelligibility in quiet in this study was to prevent that the remote fittings would (unintentionally) lead to inferior aided speech intelligibility. In this way, we minimized the risk for the participants in line with the requirements from the Medical Research Ethics Committee. A secondary reason to use aided speech intelligibility was to have a first-order impression of how well a participant could communicate without body language.

An uncontrolled open design with within-subject comparisons was used. Each of the 12 participants visited the clinic twice over the course of the study period, approximately 2–4 months per participant and underwent two remote fitting sessions. Study activities took approximately 5 h per participant in total. There was approximately 60 min reserved per remote fitting session but no strict time limitation per session.

Figure 2 shows the study workflow including programming and evaluation methods. During the first visit to the clinic (session 1) the candidates were enrolled in the study and tested with their preferred MAP. Aided hearing thresholds were measured per side (i.e., CI-only and HA-only) at session 1 and repeated at session 4 if relevant fitting changes were made. The participants were counseled on the use of the AB Remote Support mobile application and the procedure of remote fitting. After a take-home phase of about 2 weeks, the first remote fitting session was performed with the participant in a quiet listening situation at home. Subjective feedback was collected via questionnaires on the handling, video and audio quality. Approximately 3–4 weeks later, a second remote fitting session was performed with the participant being in an individually chosen challenging listening situation. The same questionnaires were completed. During session 4, which was the second visit in the clinic, best-aided speech intelligibility was repeated using the settings created during the remote fitting session before the study ended for the participant.

Study group

Participants had to be using an AB implant system with the Naída CI Marvel sound processor, have at least 6 months post-implantation experience, and be motivated for remote fitting. It was expected that communication during remote fitting sessions would be more challenging than during in-clinic sessions. Therefore, the recruitment focused on CI users with relatively good, aided speech intelligibility, who were comfortable making phone calls. Exclusion criteria were CI users with prelingual onset of hearing loss and those with variable hearing; meaning large changes in CI aided speech intelligibility outcomes after the rehabilitation phase was completed, or low results on speech intelligibility scores (Speech intelligibility score best-aided at 65 dB SPL < 50 %). The study included 12 experienced unilateral CI users. All participants used a contralateral Phonak Naída Link M hearing aid, except for Participant 03, who did not use any contralateral hearing device. Four out of 12 participants were female. The mean age was 62 years old (range 36–78 years) and participants had an average of 8 years of experience with their CI (range 0–21 years). More details about the subjects can be found in Table 1.

Table 1. Overview of participant characteristics.

Yrs, years; F, female; M, male; CI, cochlear Implant; HA, hearing aid; HL, hearing loss; DFNA, nonsyndromic deafness, autosomal dominant; DFNB, nonsyndromic deafness, autosomal recessive.

Speech perception

Aided speech intelligibility was measured with the Dutch NVA CVC test (Nederlandse Vereniging voor Audiologie woordenlijst, NVA) at 45, 55, and 65 dB SPL in session 1 (conditions: best-aided, CI-only, HA-only; one list per level). In session 4 we repeated best-aided. Testing followed the local protocol, starting at 65 dB SPL and aborting lower levels when scores fell below 50%. The primary comparison was best-aided at 65 dB SPL before and after remote fittings, to verify that speech intelligibility did not deteriorate.

Subjective feedback

Subjective feedback was collected orally during the sessions, and through multiple questionnaires. At the start of the study, each participant was asked to fill in the COSI questionnaire. The audiologist assisted the participant in order to define clear and straightforward goals. In each session, one or two goals would be addressed, depending on how much time and effort was needed to address a goal. In the last session, the individual COSI goals were evaluated.

After each remote fitting session, participants completed a video and audio quality survey, which was a Dutch translation from the questionnaire used by Eikelboom et al. (2014). The audio and video quality survey was provided at the start of the trial and collected during the last session. After the final session, participants completed an eleven-item Remote Fitting Experience Survey addressing their satisfaction with remote fitting, perceived benefits, and suggestions for improvement. All responses were collected in Dutch. To make the results accessible for an international audience, a translation of the Dutch responses to English was made using ChatGPT (version 4.5, OpenAI, Enterprise) and manually verified by two authors (CS & JW); see Supplementary material Remote Fitting Experience Survey Template for the items and response options.

Statistical analysis

Given the subjective outcomes of this study, the use of the COSI questionnaire, and the importance of describing the context in order to interpret the results, a more qualitative approach for presenting our outcomes was used. Not all COSI goals had equal importance and only a subset could be addressed per participant, making a systematic quantitative analysis less suitable for this feasibility study.

Results

COSI goals

Participants articulated individualized, context-specific COSI goals (Table 2). Most goals were aimed at improving speech understanding in noisy environments (e.g., restaurants, office, classroom), in specific 1-on-1 situations, better music perception, enhanced localization and balance (left-right, front-back), filtering environmental noise (wind, traffic), streaming performance (phone and music), reduced switching sensitivity between sound environments, and soft sound management (e.g., air conditioning, utensils).

Table 2. Overview of COSI goals.

At the end of the study, goals were rated according to the categories: no improvement, a little better, better, much better, or other. Every participant reported at least a little improvement on one or more goals. Across 37 goals: twelve with no improvement; four a little better; eight better; ten much better; three were not evaluated (changes not yet tested by the participant), see Supplementary Table S2 COSI PROGRAMMING LOG.

Example cases

Here, we share two detailed examples. Example 1 (Participant 12)— Industrial workplace and office. A participant wished to hear apprentices more clearly near running machinery and to cope with office conversations disrupted by nearby talkers. This participant found it very helpful that we were able to experience and assess his situation in real-life (e.g., get an impression of the room acoustics, lighting conditions, actual group interactions and voices, etc.) and therefore fully understand it, even while being present online. Different microphone directionality modes and various levels of noise-reduction could be fully experienced in the actual usage situation, allowing for a very short feedback loop and create the most effective combination of settings for both situations. Colleagues present at the participant's office were able to create the desired listening situations. This is something he would not have done as thoroughly, or not have done at all, when given the program in the clinic and having to test it by himself. In addition, the participant appreciated the real-time suggestions and advice on how to use different settings and what the impact was on his speech understanding. Furthermore, in general, participants reported that because they were in a non-clinical, real-life situation, their focus shifted from very specific sound details to real-life “all-round” hearing, which helped them to fully understand their needs and which changes were actually effective and impactful on their communication skills and hearing.

Example 2 (Participant 11)—Traffic noise near home. Whenever this participant left his home for a walk or to ride his bike, traffic noise irritated him and drowned out other sounds. We set up a remote fitting session near the road. At the beginning of the session, communication was very difficult due to weak 4G signal and the traffic noise. After increasing the aggressiveness of the noise-reduction (including NoiseBlock) to the maximum level and enabling the forward-directionality of the microphone to StereoZoom, the interaction improved, and traffic noise was reduced. The participant needed to reconnect a couple of times during the session due to the poor internet connectivity, but said it was worth the effort. Later, he reported that without the traffic noise, he could hear birds more clearly. The only disadvantage was that wind noise became more apparent now that traffic noise was reduced. We should note that in theory, our approach is not different from what is commonly done in clinic, but the feedback loop is much shorter, more effective, and clinically feasible. For instance, when setting the noise-reduction to reduce traffic noise, the noise reduction feature in the CI programming software could be changed on a scale from 1 to 16 (e.g., going from low to high noise-reduction). During our study, it turned out that participants sometimes reported subjective differences between noise-reduction level 14, 15, or 16. Alternative, one can make 16 programs in the clinic and give them consecutively to the participant, however, this is very time-consuming and not clinically feasible.

Fitting intervention

We compared speech intelligibility in quiet per individual between baseline (session 1) and the final follow-up (session 4) per presentation level to evaluate whether best-aided speech intelligibility (CI and if available contralateral HA) had deteriorated. Individual results and median and mean scores at group level are displayed in Supplementary material Aided Speech Intelligibility Scores. At 65 dB SPL, mean scores are 4 percentage points higher across most participants. At 55 dB SPL, median and mean scores remained essentially unchanged, indicating stable performance at this level. At 45 dB SPL, mean scores increased by approximately 7 percentage points, although individual variability was larger at this presentation level. Overall, changes in median and mean scores across levels were small ( ≤ 4 percentage points for medians), suggesting that group-level speech intelligibility in quiet remained largely stable. Larger changes were observed in some individuals and were communicated to participants as part of their clinical feedback.

Most fitting interventions were focused on parameters or features settings, respectively, such as noise-reduction and microphone directionality mode. Assessing M-levels and T-levels remotely was possible for all participants. To accommodate loudness scaling, a visual loudness scale was provided on paper at session 1. Participants were instructed that during the M-level assessment they could provide oral feedback to rate the loudness, but that the audiologist could not reply due to muted CI microphones. In most cases, the M-levels and T-levels were kept stable since most participants were long-term CI users. We only deliberately changed M-levels when it served to address a COSI goal such as reducing audibility of low-frequency sounds or to improve the loudness balance between the CI and HA.

Detailed programming changes per COSI goal are summarized in Supplementary Table S2 COSI PROGRAMMING LOG. This per-goal log documents what feature(s) were adjusted (e.g., directionality mode, noise-reduction strength, T/M-levels, CI–HA balance, streaming/other) and if applicable how the changes were made. Across all goals, the most frequently logged items were CI–HA balance (n = 11), T/M-levels (n = 8), UltraZoom (n = 7), SoundRelax (n = 7), and ClearVoice (n = 6); among improved goals (n = 22), CI–HA balance (n = 7) and SoundRelax (n = 6) were most common, followed by increases in WindBlock/ClearVoice (n = 4 each).

The mean duration of the remote fitting sessions decreased between session 2 and session 3. At session 2, the average appointments lasted about 1 h (Mean = 59.6 min, SD = 26.8, range 30–120 min), while session 3 appointments were shorter and more consistent (Mean = 44.5 min, SD = 10.4, range 30–60 min).

Questionnaires

Remote Fitting Experience Survey

All participants completed a Remote Fitting Experience survey after the four sessions (see Supplementary material Remote Fitting Experience Survey Results, for the full results). Most participants reported being satisfied (4/10) or very satisfied (6/12) with remote fitting and found it equally (5/12), slightly (3/12) or much more effective (3/12) than in-clinic fitting.

Perceived benefits and disadvantages

The most frequently cited benefits from multiple choice question 3 (Q3), see Figure 3, were time and cost savings (9/12), improved fitting in the user's daily context (8/12), and scheduling flexibility (7/12). These results align with the greatest advantages of remote fitting that the participants could provide in the free-text responses (Q11), where participants emphasized travel and cost savings (4/12), quicker problem solving (4/12), adjustments in real-world listening environments (4/12), and scheduling flexibility (2/12); see Table 3).

Table 3. Open responses from participants to the question: Q11: “What do you consider the greatest advantage of remote fitting for your cochlear implant?” Listed are categorization, frequencies, participant responses, and coding rationale.

Seven participants (7/12) reported technical issues (Q4), most commonly unstable connection or audio-video synchronization issues. Six (6/12) noted reduced communication due to the loss of non-verbal cues, and two (2/12) described difficulties such as poor video visibility and one participant (1/12) had privacy concerns when using their smartphone speakers for communication with their audiologist. Two participants (2/12) explicitly indicated no disadvantages.

Preferred settings for remote vs. clinic fittings

When asked under which circumstances they would prefer an in-clinic fitting (Q5), almost all respondents selected more complex fittings (9/12) and unsolvable technical problems or the ability to handle technology as a barrier (11/12). Five (5/12) preferred an in-clinic fitting in cases when direct interaction with their audiologist is important. One participant (1/12) mentioned always preferring a remote fitting as first choice, while others preferred in-clinic visits for specific scenarios such as receiving a new processor (1/12) or undergoing hearing performance tests (1/12).

Audiologist communication and perceived importance

Communication with the audiologist (Q6) was rated positively overall: eight (8/12) described it as very good, while only one reported it as poor (1/12); three (3/12) gave neutral or mixed ratings. The option to use remote fitting in the future (Q7) was considered important or very important by ten participants (10/12), with two (2/12) remaining neutral.

Willingness to invest time and recommendations

The majority of participants (Q8) were willing to invest more time in preparation and execution of a remote fitting if needed: six (6/12) indicated they would absolutely do this and five said they would in some situations, while only one participant (1/12) preferred faster in-clinic visits. All respondents (Q9) would recommend remote fitting: four (4/12) strongly, six (6/12) conditionally depending on circumstances, and two (2/12) depending on digital skills of the CI user.

Suggestions for improvement

Question 10 asked participants what should be improved in the remote fitting process. The most frequent suggestions concerned technical stability and usability (8/12), including stable connection, clearer video, and better interface design. Other requests included more flexibility for patient self-adjustment (2/12), clearer communication and visibility of audiologist actions (3/12), digital consultation days (1/12), and one participant (1/12)had no suggestions for improvement. These findings are detailed in Table 4.

Table 4. Open and closed responses from participants to the question: Q10: “What should be improved in the remote fitting process to make it better for you?” Listed are categories, frequencies, explicit participant responses, and coding rationale.

Audio and video quality

Results from the audio and video quality survey are shown in Figures 4, 5. Eight out of twelve (8/12) participants completed the questions after the first remote fitting (session 2), and ten (10/12) completed the questionnaire after the second remote fitting (session 3). Despite some technical issues during the remote fitting, more than 80% of the participants were neutral or (very) satisfied with how the appointment went. The improvement seen between session 2 and 3 is most likely due to the fact that the goal of session 2 was primarily to solve technical difficulties that might occur during a remote fitting. In session 3, participants were more informed about what to expect, as well as more experienced and more focused on the specific listening situation. Most participants reported lip-synchronization issues. Occasional issues with volume (too soft or too loud) and audio interruptions were noted. Video performance was generally acceptable, though face visibility and camera positioning showed room for improvement. As for the difference between both sessions, we see that there were slightly more issues with lip-synchronization, camera position and audio interruptions in session 3. This might be due to connectivity loss due to the use of 4G/5G instead of Wi-Fi.

Discussion

This study explored the possible advantages of remote fitting in real-life situations versus fitting in the clinic, by using the Advanced Bionics Remote Support Programming App. Twelve (eleven bimodal) CI users participated in this study. All participants had good to excellent speech intelligibility scores on the CVC-word test in quiet (≥70% best-aided) at study inclusion. Overall, participants reported high satisfaction of remote fitting in real-life situations, with most rating it as having equivalent or superior effectiveness compared to traditional in-clinic sessions. All participants would recommend remote fitting to other CI users, which is in line with the feedback collected in previous remote fitting studies, where 35 of 39 participants (Slager et al., 2019) and 8 of 10 participants (Homans et al., 2025) would recommend remote fitting to other CI users. The perceived benefits of remote fitting in this study are consistent with those from a larger international survey including real-world data from 57 CI users, in which the majority also identified time savings, convenience, and reduced travel costs as main benefits of remote care (Maruthurkkara, 2025). In addition to this, our participants placed emphasis on the benefits of making adjustments in real-world listening environments, suggesting that incorporating daily-life experiences may further enhance the perceived value of remote fittings.

Patient-centered goals and clinical impact

The use of the COSI framework facilitated addressing the highly individualized needs of CI users, including improvements in speech understanding in noise, more effective one-on-one conversations, enhanced music perception, reduced annoyance from distracting sounds, and optimization of device settings. According to our per-goal programming log (Supplementary Table S2 COSI PROGRAMMING LOG), we most often changed the microphone directionality and (incrementally) increased noise-reduction for speech-in-noise scenarios, whereas modest T/M-level adjustments and CI–HA balance refinements, predominated for 1-on-1, streaming and music goals. For nuisance reduction (e.g., wind, sudden sounds), improvements most frequently involved WindBlock and SoundRelax. Because features were commonly used in concert, it is important to record before and after values to support reproducibility and to collect more evidence of what the most optimal finetuning steps are with impact beyond the clinic.

Notably, all participants reported at least a small improvement in at least one of the addressed COSI goals after remote fitting. This demonstrates that remote sessions can target CI user-specific concerns in real-world listening environments, potentially improving ecological validity of their settings compared to adjustments made in a clinical (artificial) environment.

However, we observed that some COSI goals improved even though they were not specifically addressed in a given session. We hypothesize that because many goals are closely related—either as situational contexts or through overlapping settings or features—addressing one goal may directly influence other (overlapping) goals. Another explanation for improved COSI goals could be the very specific counseling provided to the CI users in their daily usage context, which may have made them more adept and confident in using all available CI features.

Speech intelligibility outcomes

Our findings align with previous work demonstrating the feasibility and safety of remote CI fitting. Schepers et al. (2019) showed that remote and in-clinic fittings yield equivalent audiological outcomes, with no adverse events and high satisfaction among CI users and professionals. Similarly, Wesarg et al. (2010) reported in a large multicenter randomized trial that program settings obtained remotely were similar to those programmed in-clinic, with high CI user acceptance and only slightly longer session times. In line with previous results, we also observed relatively stable best-aided speech intelligibility across sessions, supporting the applicability of remote fittings. However, one needs to be cautious how clinically meaningful these speech intelligibility measurements in quiet were since they are not representative for the specific real-life listening situation in which the remote fittings were evaluated. It remains a challenge to better objectify the perceived benefits in these real-life situations. The speech intelligibility outcomes can be influenced by the acoustics of the test environment, including reverberation effects and the smartphone's speaker quality (Goehring et al., 2012). Alternatively, the acoustics can be fully circumvented when speech intelligibility tests are directly streamed (Rootlieb et al., 2025), with the advantage that it can be compared to best-aided in-clinic results, but ignoring the specific listening situation that was targeted.

Technical feasibility

The participants reported a relatively high rate of technical issues. However, they were motivated and capable of solving these minor difficulties. It should be mentioned that participants valued it very much to be more in control over their CI care. For instance, participants preferred to conduct the remote fitting sessions without help from a significant other, even though we routinely advised to also ask for help from a partner and use a second screen to facilitate easier communication. No insurmountable technical hurdles were found, even though neither the participants nor the clinicians had prior experience with remote fitting. However, participants frequently mentioned issues such as unstable internet connections, audio-video desynchronization, and reduced visibility of non-verbal cues. These limitations align with prior teleaudiology studies (Eikelboom et al., 2014; Kuzovkov et al., 2014). Overall, participants indicated to be satisfied or very satisfied with the video and audio quality during the remote fittings.

Study limitations

This feasibility study relied primarily on subjective outcomes. We recognize the potential for acquiescence bias during clinician-guided remote sessions (e.g., participants may feel inclined to report improvement after a focused interaction), and no blinding or sham conditions were used. We did not collect objective measures in the specific real-life settings, nor did we systematically analyze all programming changes, because COSI goals and corresponding strategies varied widely. Furthermore, program changes often included multiple features, the problem solving strategy may have differed between clinicians and changes for one COSI goal may have been incorporated into the next COSI goal, which makes it more difficult to disentangle which features were the most impactful on each of the single COSI goals. Speech in quiet was primarily collected to avoid that the remote fittings would lead to inferior aided speech intelligibility but are not a suitable measure to evaluate the COSI objectives.

In hindsight, we should have considered adding a sentence-in-noise test in the clinic. Many of the top-identified COSI goals relate to speech-in-noise (category 1 and at least a portion of category 2), therefore for follow-up research we would recommend including a measure of speech-in-noise performance using spatially separated sound sources similar to the method used by Gazibegovic et al. (2024). However, this does not resolve the problem of the lack of objective measures available to fully evaluate the effect of e.g. changing microphone settings or other processing features. Also, the appreciation of counseling during a remote fitting session is difficult to capture.

Another limitation of this study is the small sample size which does not cover the full variety of experienced CI users and their remote fitting needs. In addition, we limited this study to CI users with an AB implant system since the AB remote fitting app is currently the only commercially available app that allows full control of CI fitting parameters comparable to in-clinic adjustments. Remote fitting would become easier to implement clinically if more remote fitting features become available across CI brands. In addition, especially for remote assessments, interoperable systems, which allow the comparison and optimization between different CI's and hearing aids or other assistive devices would benefit both clinicians and CI users to bring remote fitting on par with clinical care.

Participants were mainly approached directly by members of our CI implant team. This might have further biased the variety in participant characteristics. Presumably, this group of participants were extra motivated to experiment and have digital skills that are higher than average in the CI user population. Moreover, the applicability of this study outcomes to poor performing CI users should be made with caution, since only candidates with good speech intelligibility were approached, which may also have positively affected the good communication outcomes during the remote fittings. It is possible that if we had included lower performing participants, they might have weighed technical issues that hamper communication as a further disruption to care and therefore report lower satisfaction with remote fitting service delivery.

Clinical recommendations

Remote fitting enabled more detailed fine tuning compared to in-clinic fitting and provided the opportunity to collect real-time subjective feedback. The more detailed fine tuning included the incremental adjustment of parameters or features settings that the audiologist expected to be relevant to address the COSI goal. Typically these were the noise-reduction and microphone directionality mode or adjusting the audibility of specific sounds, which are not routinely addressed or hard to determine to what extent to adjust during an in-clinic fitting. Practical clinical recommendations are summarized in Appendix A. Participants expressed that experiencing changes immediately in a specific situation helped to understand the effect of a feature or a parameter change. There was also an effect of more targeted counseling. Participants reported they were more likely to explore new programs and follow up the advice when there was someone to guide them, e.g. understanding how microphone directionality mode and noise-reduction works in combination with the position of the CI user in relation to the noise-source. Moreover, they reported a better understanding of the functions of different features. This improved understanding can likely be attributed to the clinician's individualized guidance and the opportunity to experience the effect in actual listening situations. Lastly, because they were in a non-clinical, real-life situation, their focus shifted from specific sound details to real-life “all-round” hearing, which helped them to fully understand their needs and which changes were actually effective.

Although the majority of participants rated communication with the audiologist as very good, we would not recommend the current tool for use with CI users with limited speech intelligibility who (fully) rely on lip-reading and visual cues. One difficulty was that the dialogue turn-taking during remote sessions went less smoothly than in the clinical environment. In addition, body language was mainly lost due to the small video frame and could be misinterpreted during the assessments of technical settings; for example clinicians may not realize that a focused facial expression could be interpreted as a reason for concern by the CI user. Addressing these issues is essential for the further improvement of the system, given the additional burden that hearing loss places on communication during video consultations, including listening effort and anxiety to miss important information (Saunders and Oliver, 2022). Over the years, and especially after COVID, this phenomenon of experienced mental and physical stress during and after videoconferencing, referred to as “Zoom/videoconferencing fatigue”, has been described and studied (Riedl, 2022). Factors such as lack of shared attention due to less eye contact, lack of body language and asynchrony in communication cause extra mental effort and could reduce audiovisual compensation mechanisms that many people with hearing loss employ (Fleming and Winn, 2025; Lasfargues-Delannoy et al., 2021; Meister et al., 2025; Puschmann et al., 2019). In addition, there are indications that people with hearing loss, and especially CI users, require more listening effort (Philips et al., 2023), and thus are likely to experience zoom fatigue more profoundly than people with normal hearing.

Initially, remote fitting sessions were longer and varied widely in duration. This may be caused by a learning curve from participants and clinicians in the remote fitting process, and also because session 3 was mostly focused on a single COSI goal. These observations suggest that efficiency and sustained focus on the goal of the appointment improves with experience and should be accounted for when implementing remote fittings within CI care pathways. Therefore, to keep fatigue within acceptable limits, we recommend focusing on one COSI goal per remote appointment, or at most two small goals. This yields shorter, simpler sessions and makes it easier to guide the CI user through every fitting step with appropriate context. Shorter remote follow-up appointments seem feasible, as demonstrated in a study by Homans et al. (2025) comparing remote fittings and traditional fittings within the first-year post-implantation. They found that remote fittings tend to take less time than traditional in-clinic fittings.

We would also recommend a trial in-clinic session with the app before the actual remote session, which can help to reduce mental exhaustion during the real session. Technical recommendations we could make are the option to include a chat function and live subtitles, an adjustable position of the video screen on the users' phone, screen sharing by the clinician, and the possibility to contact the participant when in the waiting room for pre-appointment instructions or to report delays. Lastly, we recommend evaluating each remote appointment carefully (such as video and audio quality, listening effort, overall satisfaction on achieved goals during the appointment for CI user as well as clinician, etc.) with every patient, as lessons can be learned to improve future remote programming sessions.

Conclusion

The AB remote fitting app provides a ready-to-use method remotely in real-life situations for fitting CI users who have a relatively good aided speech intelligibility and who are comfortable having video calls. All twelve participants, with no prior remote fitting experience, completed two remote fitting sessions without significant communication problems or technical issues.

Furthermore, problem-solving appears to be more accurately addressed by the clinician and subjectively assessed by the participant within realistic listening environments, leading to higher rated subjective outcomes. Clinicians had a clearer understanding of which parameters needed (incremental) adjustment and participants reported clearer understanding of feature effects (e.g., directionality) in specific listening situations. Additional technical improvements are needed to improve the ease of communication, and we recommend keeping remote fitting appointments short and simple.

Generative AI statement

The author(s) declared that generative AI was used in the creation of this manuscript. This work made use of a large-language model, ChatGPT (v4.5, OpenAI, Enterprise), for two purposes: (1) translating the Dutch questionnaires and responses into English, and (2) assisting with the manuscript's readability and flow while preserving the scientific content.

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Supplementary material

The Supplementary Material for this article can be found online at: https://www.frontiersin.org/articles/10.3389/fauot.2026.1730079/full#supplementary-material

Table S2 COSI Programming log Supplementary material at the source

Aided Speech Intelligibility Scores Supplementary material at the source

Remote Fitting Experience Survey Template Supplementary material at the source

Remote Fitting Experience Survey Results Supplementary material at the source

Footnotes

Edited by: Nicola Quaranta, University of Bari Aldo Moro, Italy

Reviewed by: Saji Maruthurkkara, Cochlear, Australia

Jonathan Neukam, Vanderbilt University, United States