A major decision at the time of hearing aid fitting and dispensing is the amount of amplification to provide listeners (both adult and pediatric populations) for the appropriate compensation of sensorineural hearing impairment across a range of frequencies (e.g., 160?10000?Hz) and input levels (e.g., 50?75?dB sound pressure level). This article describes modern prescription theory for hearing aids within the context of a risk versus return trade-off and efficient frontier analyses. The expected return of amplification recommendations (i.e., generic prescriptions such as National Acoustic Laboratories?Non-Linear 2, NAL-NL2, and Desired Sensation Level Multiple Input/Output, DSL m[i/o]) for the Speech Intelligibility Index (SII) and high-frequency audibility were traded against a potential risk (i.e., loudness). The modeled performance of each prescription was compared one with another and with the efficient frontier of normal hearing sensitivity (i.e., a reference point for the most return with the least risk). For the pediatric population, NAL-NL2 was more efficient for SII, while DSL m[i/o] was more efficient for high-frequency audibility. For the adult population, NAL-NL2 was more efficient for SII, while the two prescriptions were similar with regard to high-frequency audibility. In terms of absolute return (i.e., not considering the risk of loudness), however, DSL m[i/o] prescribed more outright high-frequency audibility than NAL-NL2 for either aged population, particularly, as hearing loss increased. Given the principles and demonstrated accuracy of desensitization (reduced utility of audibility with increasing hearing loss) observed at the group level, additional high-frequency audibility beyond that of NAL-NL2 is not expected to make further contributions to speech intelligibility (recognition) for the average listener.

People with hearing loss (HL) often express a desire for the particular hearing device that will yield the best speech recognition. The problem with fulfilling that desire is that a vast number of hearing devices are available from which to choose. In recent years, medical device regulatory agencies have generally viewed hearing devices (i.e., hearing aids), particularly the hardware and even the software, as substantially equivalent. The purpose of this manuscript is to: 1) Synthesize a number of variables about the person, environment in which hearing occurs, as well as characteristics of the hearing aids that can impact speech recognition. 2) Describe a created tool entitled Realistic Expectations 2 (RE2), which has application to the clinical needs of estimating expected speech recognition with and without hearing aids. RE2 is available as a supplemental file to this manuscript and may be useful for comparing estimates against measures of speech recognition ability in addition to assisting with the explanation of the operation and limitations of hearing aids. When expected speech recognition is achieved, subsequent development of speech and language can continue based on circumstance, cognitive status, and cultural-specific learning, as well as personal and societal betterment efforts like education, rehabilitation, and therapy.