Evaluating the health-related quality of life effects of cochlear implants: a prospective study of an adult cochlear implant program

Teledelivery of Aural Rehabilitation to Improve Cochlear Implant Outcomes

OBJECTIVE(S)

This randomized controlled study evaluated the effectiveness of a Telehealth Aural Rehabilitation (TeleAR) training protocol to improve outcomes for adult cochlear implant (CI) users.

METHODS

This was a multisite clinical study with participants randomized to either an AR treatment or active control group. The AR protocol consisted of auditory training (words, sentences, and speech tracking), informational counseling, and communication strategies. The control group participants engaged in cognitive stimulation activities (crosswords, sudoku, etc.). Each group completed 6 weekly 90-min individual treatment sessions delivered remotely. Twenty postlingually deafened adult CI users participated. Assessments were completed pretreatment and 1 week and 2 months posttreatment.

RESULTS

Repeated-measures ANOVA and planned contrasts were used to compare group performance on AzBio Sentences, Hearing Handicap Inventory (HHI), Client Oriented Scale of Improvement (COSI), and Glasgow Benefit Inventory (GBI). The two groups were statistically equivalent on all outcome measures at pre-assessment. There was a statistically significant main effect of time for all measures. Improvement over time was observed for participants in both groups, with greater improvement seen for the AR than the CT group on all outcome measures. The AR group showed medium to large effect sizes on all measures over time, suggesting clinically significant outcomes.

CONCLUSION

This randomized controlled study provides evidence of improved speech recognition and psychosocial outcomes following 6 weeks of TeleAR intervention. For adult post-lingually deafened CI users, including those >3 months post-activation, AR treatment can leverage neuroplasticity to maximize outcomes.

LEVEL OF EVIDENCE

2 Laryngoscope, 134:1861-1867, 2024.

Evaluating Listening Effort in Unilateral, Bimodal, and Bilateral Cochlear Implant Users

OBJECTIVE

Evaluate listening effort (LE) in unilateral, bilateral, and bimodal cochlear implant (CI) users. Establish an easy-to-implement task of LE that could be useful for clinical decision making.

STUDY DESIGN

Prospective cohort study.

SETTING

Tertiary neurotology center.

METHODS

The Sentence Final Word Identification and Recall Task, an established measure of LE, was modified to include challenging listening conditions (multitalker babble, gender, and emotional variation; test), in addition to single-talker sentences (control). Participants listened to lists of sentences in each condition and recalled the last word of each sentence. LE was quantified by percentage of words correctly recalled and was compared across conditions, across CI groups, and within subjects (best aided vs monaural).

RESULTS

A total of 24 adults between the ages of 37 and 82 years enrolled, including 4 unilateral CI users (CI), 10 bilateral CI users (CICI), and 10 bimodal CI users (CIHA). Task condition impacted LE (P < .001), but hearing configuration and listener group did not (P = .90). Working memory capacity and contralateral hearing contributed to individual performance.

CONCLUSION

This study adds to the growing body of literature on LE in challenging listening conditions for CI users and demonstrates feasibility of a simple behavioral task that could be implemented clinically to assess LE. This study also highlights the potential benefits of bimodal hearing and individual hearing and cognitive factors in understanding individual differences in performance, which will be evaluated through further research.

Effect of Cochlear Implantation on Social Life

OBJECTIVE

Explore the effects of hearing loss on social life and identify residual social life deficits that remain after cochlear implantation.

STUDY DESIGN

Retrospective review of prospectively obtained data.

SETTING

Tertiary care adult neurotology center.

PATIENTS

Adults between the ages of 35 and 83 years were included with either normal hearing (NH) or a cochlear implant (CI).

INTERVENTIONS

CI and non-CI-specific quality-of-life (QOL) surveys focused on social and overall QOL.

MAIN OUTCOME MEASURES

(1) The difference in QOL survey responses between NH and CI participants. (2) The relationship between CI-specific global and social QOL responses and non-CI-specific social QOL responses in CI users.

RESULTS

A total of 51 participants were included: 31 CI users and 20 NH participants. Of the social QOL questionnaires, CI users reported significantly poorer scores on Self-Efficacy in Social Interactions than NH peers ( p = 0.049). Both Self-Efficacy in Social Interactions scores and Social Isolation Questionnaire scores were significantly correlated with the CI-specific social domain of QOL ( r = 0.64 and -0.58, respectively). Only the Self-Efficacy in Social Interactions scores had a moderate association with global CI QOL ( r = 0.47).

CONCLUSIONS

CI users self-report similar social life outcomes as their NH peers with the exception of poorer self-efficacy in social situations. Moreover, self-efficacy in social interactions and social isolation were associated with social QOL in CI users, and self-efficacy in social interactions was associated with broader CI-related QOL. Findings support the relevance of individuals' perception of social life to their overall QOL with a CI.

Cochlear implantation impact on health service utilisation and social outcomes: a systematic review

BACKGROUND

Hearing loss can have a negative impact on individuals' health and engagement with social activities. Integrated approaches that tackle barriers and social outcomes could mitigate some of these effects for cochlear implants (CI) users. This review aims to synthesise the evidence of the impact of a CI on adults' health service utilisation and social outcomes.

METHODS

Five databases (MEDLINE, Scopus, ERIC, CINAHL and PsychINFO) were searched from 1st January 2000 to 16 January 2023 and May 2023. Articles that reported on health service utilisation or social outcomes post-CI in adults aged ≥ 18 years were included. Health service utilisation includes hospital admissions, emergency department (ED) presentations, general practitioner (GP) visits, CI revision surgery and pharmaceutical use. Social outcomes include education, autonomy, social participation, training, disability, social housing, social welfare benefits, occupation, employment, income level, anxiety, depression, quality of life (QoL), communication and cognition. Searched articles were screened in two stages ̶̶̶ by going through the title and abstract then full text. Information extracted from the included studies was narratively synthesised.

RESULTS

There were 44 studies included in this review, with 20 (45.5%) cohort studies, 18 (40.9%) cross-sectional and six (13.6%) qualitative studies. Nine studies (20.5%) reported on health service utilisation and 35 (79.5%) on social outcomes. Five out of nine studies showed benefits of CI in improving adults' health service utilisation including reduced use of prescription medication, reduced number of surgical and audiological visits. Most of the studies 27 (77.1%) revealed improvements for at least one social outcome, such as work or employment 18 (85.7%), social participation 14 (93.3%), autonomy 8 (88.9%), education (all nine studies), perceived hearing disability (five out of six studies) and income (all three studies) post-CI. None of the included studies had a low risk of bias.

CONCLUSIONS

This review identified beneficial impacts of CI in improving adults' health service utilisation and social outcomes. Improvement in hearing enhanced social interactions and working lives. There is a need for large scale, well-designed epidemiological studies examining health and social outcomes post-CI.

Health State Utility Values Associated with Cochlear Implants in Adults: A Systematic Review and Network Meta-Analysis

OBJECTIVES

The cost-effectiveness of bilateral cochlear implants in adults remains uncertain despite established clinical benefits. In cost-effectiveness studies, benefit is often measured by change in health state utility value (HSUV), a single number summary of health-related quality of life anchored at 0 (state of being dead) and 1 (perfect health). Small differences in bilateral cochlear implant HSUV change conclusions of published models, and invalid estimates can therefore mislead policy and funding decisions. As such, we aimed to review and synthesize published HSUV estimates associated with cochlear implants.

DESIGN

We included observational or experimental studies reporting HSUV for adult patients (age ≥18 years) with at least moderate-profound sensorineural hearing loss in both ears who received unilateral or bilateral cochlear implants. We searched MEDLINE, EMBASE, PsycINFO, and Cochrane Library databases up to May 1, 2021. Study and participant characteristics and HSUV outcomes were extracted. Narrative synthesis is reported for all studies. A Bayesian network meta-analysis was conducted to generate pooled estimates for the mean difference in HSUV for three comparisons: (1) unilateral cochlear implant versus preimplant, (2) bilateral cochlear implants versus preimplant, (3) bilateral versus unilateral cochlear implants. Our principal measure was pooled mean difference in HSUV.

RESULTS

Thirty-six studies reporting unique patient cohorts were identified. Health Utilities Index, 3 (HUI-3) was the most common HSUV elicitation method. HSUV from 19 preimplant mean estimates (1402 patients), 19 unilateral cochlear implant mean estimates (1701 patients), and 5 bilateral cochlear implants mean estimates (83 patients) were pooled to estimate mean differences in HUI-3 HSUV by network meta-analysis. Compared with preimplant, a unilateral cochlear implant was associated with a mean change in HSUV of +0.17 (95% credible interval [CrI] +0.12 to +0.23) and bilateral cochlear implants were associated with a mean change of +0.25 (95% CrI +0.12 to +0.37). No significant difference in HSUV was detected for bilateral compared with unilateral cochlear implants (+0.08 [95% CrI -0.06 to +0.21]). Overall study quality was moderate.

CONCLUSIONS

The findings of this review and network meta-analysis comprise the best-available resource for parameterization of cost-utility models of cochlear implantation in adults and highlight the need to critically evaluate the validity of available HSUV instruments for bilateral cochlear implant populations.Protocol registration: PROSPERO (CRD42018091838).

A Novel Automatic Audiometric System Design Based on Machine Learning Methods Using the Brain's Electrical Activity Signals

This study uses machine learning to perform the hearing test (audiometry) processes autonomously with EEG signals. Sounds with different amplitudes and wavelengths given to the person tested in standard hearing tests are assigned randomly with the interface designed with MATLAB GUI. The person stated that he heard the random size sounds he listened to with headphones but did not take action if he did not hear them. Simultaneously, EEG (electro-encephalography) signals were followed, and the waves created in the brain by the sounds that the person attended and did not hear were recorded. EEG data generated at the end of the test were pre-processed, and then feature extraction was performed. The heard and unheard information received from the MATLAB interface was combined with the EEG signals, and it was determined which sounds the person heard and which they did not hear. During the waiting period between the sounds given via the interface, no sound was given to the person. Therefore, these times are marked as not heard in EEG signals. In this study, brain signals were measured with Brain Products Vamp 16 EEG device, and then EEG raw data were created using the Brain Vision Recorder program and MATLAB. After the data set was created from the signal data produced by the heard and unheard sounds in the brain, machine learning processes were carried out with the PYTHON programming language. The raw data created with MATLAB was taken with the Python programming language, and after the pre-processing steps were completed, machine learning methods were applied to the classification algorithms. Each raw EEG data has been detected by the Count Vectorizer method. The importance of each EEG signal in all EEG data has been calculated using the TF-IDF (Term Frequency-Inverse Document Frequency) method. The obtained dataset has been classified according to whether people can hear the sound. Naïve Bayes, Light Gradient Strengthening Machine (LGBM), support vector machine (SVM), decision tree, k-NN, logistic regression, and random forest classifier algorithms have been applied in the analysis. The algorithms selected in our study were preferred because they showed superior performance in ML and succeeded in analyzing EEG signals. Selected classification algorithms also have features of being used online. Naïve Bayes, Light Gradient Strengthening Machine (LGBM), support vector machine (SVM), decision tree, k-NN, logistic regression, and random forest classifier algorithms were used. In the analysis of EEG signals, Light Gradient Strengthening Machine (LGBM) was obtained as the best method. It was determined that the most successful algorithm in prediction was the prediction of the LGBM classification algorithm, with a success rate of 84%. This study has revealed that hearing tests can also be performed using brain waves detected by an EEG device. Although a completely independent hearing test can be created, an audiologist or doctor may be needed to evaluate the results.

The Impact of Hearing Loss and Its Treatment on Health-Related Quality of Life Utility: a Systematic Review with Meta-analysis

BACKGROUND

Hearing loss significantly impacts health-related quality of life (QoL), yet the effects of current treatments on QoL utility remain uncertain. Our objective was to describe the impact of untreated and treated hearing loss on QoL utility to inform hearing healthcare policy.

METHODS

We searched databases for articles published through 02/01/2021. Two independent reviewers screened for articles that reported elicitation of general QoL utility values for untreated and treated hearing loss health states. We extracted data and quality indicators from 62 studies that met the inclusion criteria.

RESULTS

Included studies predominately used observational pre/post designs (61%), evaluated unilateral cochlear implantation (65%), administered the Health Utilities Index 3 (HUI3; 71%), and were conducted in Europe and North America (84%). In general, treatment of hearing loss improved post-treatment QoL utility when measured by most methods except the Euro-QoL 5 dimension (EQ-5D). In meta-analysis, hearing aids for adult mild-to-moderate hearing loss compared to no treatment significantly improved HUI3-estimated QoL utility (3 studies; mean change=0.11; 95% confidence interval (CI): 0.07 to 0.14) but did not impact EQ-5D-estimated QoL (3 studies; mean change=0.0; 95% CI: -0.03 to 0.04). Cochlear implants improved adult QoL utility 1-year post-implantation when measured by the HUI3 (7 studies; mean change=0.17; 95% CI: 0.11 to 0.23); however, pediatric VAS-estimated QoL utility was non-significant (4 studies; mean change=0.12; 95% CI: -0.02 to 0.25). The quality of included studies was limited by failure to report missingness of data and low survey response rates. Our study was limited by heterogeneous study populations and designs.

FINDINGS

Treatment of hearing loss significantly improves QoL utility, and the HUI3 and VAS were most sensitive to improvements in hearing. Improved access to hearing healthcare should be prioritized. SYSTEMATIC REVIEW REGISTRATION: PROSPERO: CRD42021253314.

Cognition and Cognitive Reserve in Cochlear Implant Recipients

At present, dementia is a hot topic. Hearing loss is considered to be a modifiable risk factor for cognitive decline. The underlying mechanism remains unclear and might be mediated by socioeconomic and psychosocial factors. Cochlear implantation has been shown not only to restore auditory abilities, but also to decrease mental distress and to improve cognitive functions in people with severe hearing impairment. However, the promising results need to be confirmed. In a prospective single-center study, we tested the neurocognitive abilities of a large group of 71 subjects with bilateral severe hearing impairment with a mean age of 66.03 (SD = 9.15) preoperatively and 6, 12, and 24 months after cochlear implantation using a comprehensive non-auditory computer-based test battery, and we also assessed the cognitive reserve (CR) [Cognitive Reserve Index (CRI)], health-related quality of life (QoL) (Nijmegen Cochlear Implant Questionnaire), and depression (Geriatric Depression Scale-15). Cognitive functions significantly increased after 6 months in attention (p = 0.00004), working memory (operation span task; p = 0.002), and inhibition (p = 0.0002); and after 12 months in recall (p = 0.003) and verbal fluency (p = 0.0048), and remained stable up to 24 months (p ≥ 0.06). The CR positively correlated with cognitive functions pre- and post-operatively (both p < 0.005), but postoperative improvement in cognition was better in subjects with poor CR (p = 0.003). Depression had only a slight influence on one subtest. No correlation was found among cognitive skills, quality of life, and speech perception (each p ≥ 0.05). Cochlear implantation creates an enriched environment stimulating the plasticity of the brain with a global positive impact on neurocognitive functions, especially in subjects with poor preoperative cognitive performance and low cognitive reserve.

Health-related quality of life in adults with profound postlingual hearing loss before and after cochlear implantation

Purpose

In clinical trials and everyday medical practice, health-related quality of life (HRQoL) measures are increasingly being used. That is, in addition to the usual biological health assessment, the impact of disease and treatment on the patient’s functioning in the physical, mental, and social areas is an important parameter. The aim of this study was to assess HRQoL before and after using a cochlear implant (CI) in adults with profound hearing loss.

Methods

There were 104 patients who qualified for the study. All gave informed and free consent. The study involved adults with bilateral hearing loss above 81 dB HL and rated according to the World Health Organization (WHO) classification scheme as having profound hearing loss (which includes deafness). In each participant, the hearing loss was postlingual, that is, it occurred after speech and language had developed. The assessment of quality of life (AQoL-8D) questionnaire was used to assess the health-related quality of life in the study participants.

Results

Quality of life significantly increased (p < 0.001) after cochlear implantation in almost all domains (except the pain dimension). The mean increase in overall quality of life was 0.16, the greatest improvement was found in the dimensions senses (mean change of 0.17) and self-worth (mean change of 0.16).

Conclusion

Cochlear implantation improves the health-related quality of life of the postlingually deaf.

Cost-Utility Analysis of Bilateral Cochlear Implantation in Adults With Severe to Profound Sensorineural Hearing Loss in Poland

OBJECTIVE

The aim of the study was to develop a Markov model and apply it for the evaluation of three different treatment scenarios for adult patients with severe to profound bilateral sensorineural hearing loss.

STUDY DESIGN

Prospective Observational Study.

SETTINGS

Hospital.

PATIENTS

A clinical group of 22 adult patients (59.1% men, 40.9% women) aged from 59.13 ± 8.9 years were included in the study. The study comprised two arms: patients in group 1 received the second cochlear implant one to three months after the first implant; while patients in group 2 got the second cochlear implant approximately one year after the first implant.

MAIN OUTCOME MEASURES

All participants were first asked to complete an AQoL-8D questionnaire. For the cost-effectiveness analyses, a Markov model analyzed as microsimulation was developed to compare the different treatment options.

RESULTS

The analyses show that bilateral cochlear implantation strategies are cost-effective compared to the 'no treatment' alternative when having a 10-year model time horizon. When all three model scenarios are compared, the bilateral simultaneous cochlear implantation strategy (Scenario 3) compared to the 'no treatment' option is even more cost-effective than the Scenarios 1 and 2, compared with the 'no treatment' alternative.

CONCLUSIONS

The model results summarize that bilateral (sequential and simultaneous) cochlear implantation that are represented in the model scenarios, are cost-effective strategies for Polish adult patients with bilateral severe to profound sensorineural hearing loss.

Maximizing Cochlear Implant Outcomes with Short-Term Aural Rehabilitation

BACKGROUND

 Increasing numbers of adults are receiving cochlear implants (CIs) and many achieve high levels of speech perception and improved quality of life. However, a proportion of implant recipients still struggle due to limited speech recognition and/or greater communication demands in their daily lives. For these individuals a program of aural rehabilitation (AR) has the potential to improve outcomes.

PURPOSE

 The study investigated the effects of a short-term AR intervention on speech recognition, functional communication, and psychosocial outcomes in post lingually deafened adult CI users.

RESEARCH DESIGN

 The experimental design was a multisite clinical study with participants randomized to either an AR treatment or active control group. Each group completed 6 weekly 90-minute individual treatment sessions. Assessments were completed pretreatment, 1 week and 2 months post-treatment.

STUDY SAMPLE

 Twenty-five post lingually deafened adult CI recipients participated. AR group: mean age 66.2 (48-80); nine females, four males; months postactivation 7.7 (3-16); mean years severe to profound deafness 18.4 (2-40). Active control group: mean age 62.8 (47-85); eight females, four males; months postactivation 7.0 (3-13); mean years severe to profound deafness 18.8 (1-55).

INTERVENTION

 The AR protocol consisted of auditory training (words, sentences, speech tracking), and psychosocial counseling (informational and communication strategies). Active control group participants engaged in cognitive stimulation activities (e.g., crosswords, sudoku, etc.).

DATA COLLECTION AND ANALYSIS

 Repeated measures ANOVA or analysis of variance, MANOVA or multivariate analysis of variance, and planned contrasts were used to compare group performance on the following measures: CasperSent; Hearing Handicap Inventory; Nijmegen Cochlear Implant Questionnaire; Client Oriented Scale of Improvement; Glasgow Benefit Inventory.

RESULTS

 The AR group showed statistically significant improvements on speech recognition performance, psychosocial function, and communication goals with no significant improvement seen in the control group. The two groups were statistically equivalent on all outcome measures at preassessment. The robust improvements for the AR group were maintained at 2 months post-treatment.

CONCLUSION

 Results of this clinical study provide evidence that a short-term AR intervention protocol can maximize outcomes for adult post lingually deafened CI users. The impact of this brief multidimensional AR intervention to extend CI benefit is compelling, and may serve as a template for best practices with adult CI users.

Prospective study on health-related quality of life in patients before and after cochlear implantation

Purpose

Assessing cochlear implant (CI)-associated patient outcomes is a focus of implant research. Most studies have analyzed outcomes retrospectively with low patient numbers and few measurement time points. In addition, standardized CI-specific health-related quality of life (HRQoL) instruments have not been used. To address this, we prospectively assessed HRQoL in patients before and after implantation.

Methods

We assessed HRQoL using the Nijmegen Cochlear Implant Questionnaire (NCIQ), Abbreviated Profile of Hearing Aid Benefit (APHAB), Hearing Participation Scale (HPS), and the Visual Analogue Scale (VAS) in 100 deaf or severely hearing-impaired patients (57 unilaterally deaf and 43 bilaterally deaf) before and 3, 6, and 12 months after cochlear implantation. We compared the results of unilaterally and bilaterally hearing-impaired patients and patients with or without a hearing aid. Principal component (PCA) and exploratory factor analyses (EFA) were also conducted.

Results

The NCIQ measured improvements in all 6 domains after CI and correlated well with other QoL instruments. The PCA revealed that the NCIQ can be better explained by physical, physical advanced, and socio-psychological components. The APHAB score ameliorated over time, except for the background noise domain. The overall HPS score improved over time, but the hearing handicap subscore significantly decreased. Sociodemographic influences on the questionnaire scores were relatively weak.

Conclusion

Assessing HRQoL is essential for quantifying the patient outcome after CI. NCIQ scores in our patient cohort showed improved HRQoL in all domains and we recommend that the NCIQ be used as a first-line questionnaire for assessing QoL in hearing-impaired patients after CI.

The effect of cochlear implantation on autonomy, participation and work in postlingually deafened adults: a scoping review

Purpose

This scoping review examines the available evidence on the effect of unilateral cochlear implantation (CI) in adults with postlingual bilateral hearing loss on societal-related outcomes in terms of work, autonomy and participation.

Methods

Five databases were searched (Pubmed, Web of Science, Embase, PsycINFO and Cochrane Library). Publications were screened in three steps on inclusion criteria. Of the 4230 screened publications, 110 met the inclusion criteria and were assessed for data extraction regarding outcomes “work”, “autonomy”, “participation”. Study characteristics and key findings are presented and narratively described.

Results

Twenty-seven publications were included and categorized into retrospective (n = 3), cross-sectional (n = 18) or prospective (n = 6) study designs. Measurement or identification of number of outcomes (no) were related to work (no = 20), participation (no = 9) and autonomy or independency (no = 10). Most studies indicated benefits of CI on these outcomes. However, some studies did not or indicated additional barriers for benefits. Eleven publications primarily aimed to study one or more of our primary outcomes.

Conclusion

In this literature search, scientific databases are reviewed. The results indicate that there is a relatively small body of evidence regarding the effect of CI on the outcomes “work”, “autonomy” and “participation”. Even though there are some limitations of the current study including some overlap in outcome definitions, most included studies indicate a beneficial effect of CI on work, autonomy and participation. The lack of consensus in definitions and the small body of evidence indicates a need for additional prospective studies investigating the societal outcomes of CI in postlingually deafened adults.

Electronic supplementary material

The online version of this article (10.1007/s00405-020-06490-x) contains supplementary material, which is available to authorized users.

The effect of tinnitus on hearing-related quality of life outcomes in adult cochlear implant recipients

OBJECTIVE

To describe the effect of tinnitus distress on the hearing-related quality of life (QoL) outcomes over time in adult cochlear implant (CI) recipients.

DESIGN

A retrospective, longitudinal study of adult CI recipients was conducted. Hearing-related QoL and tinnitus distress were assessed using the Abbreviated Profile of Hearing Aid Benefit (APHAB) and the Tinnitus Reaction Questionnaire (TRQ) preoperatively and at 6-months, 12-months and >24-month postoperatively. The association between tinnitus distress and hearing-related QoL outcomes over time was investigated. Furthermore, 13 potential predictive factors were identified from the retrospective dataset. Multiple regression analyses were performed to identify variables that influence hearing-related QoL outcomes over time.

STUDY SAMPLE

The study sample included 210 adult (≥18 years) CI recipients implanted between 2001 and 2017.

RESULTS

Lower tinnitus distress and younger age at implantation were significant predictors of better hearing-related QoL in adult CI recipients. A significant reduction in tinnitus distress up to two years post-implantation was found, as well as greater tinnitus distress correlating with poorer hearing-related QoL outcomes.

CONCLUSION

Tinnitus distress negatively affects the hearing-related QoL outcomes of adult CI recipients. Tinnitus distress and age at implantation were found to be significant predictors of hearing-related QoL when controlling for other predictive factors.

Visual Speech Benefit in Clear and Degraded Speech Depends on the Auditory Intelligibility of the Talker and the Number of Background Talkers

Perceiving speech in background noise presents a significant challenge to listeners. Intelligibility can be improved by seeing the face of a talker. This is of particular value to hearing impaired people and users of cochlear implants. It is well known that auditory-only speech understanding depends on factors beyond audibility. How these factors impact on the audio-visual integration of speech is poorly understood. We investigated audio-visual integration when either the interfering background speech (Experiment 1) or intelligibility of the target talkers (Experiment 2) was manipulated. Clear speech was also contrasted with sine-wave vocoded speech to mimic the loss of temporal fine structure with a cochlear implant. Experiment 1 showed that for clear speech, the visual speech benefit was unaffected by the number of background talkers. For vocoded speech, a larger benefit was found when there was only one background talker. Experiment 2 showed that visual speech benefit depended upon the audio intelligibility of the talker and increased as intelligibility decreased. Degrading the speech by vocoding resulted in even greater benefit from visual speech information. A single “independent noise” signal detection theory model predicted the overall visual speech benefit in some conditions but could not predict the different levels of benefit across variations in the background or target talkers. This suggests that, similar to audio-only speech intelligibility, the integration of audio-visual speech cues may be functionally dependent on factors other than audibility and task difficulty, and that clinicians and researchers should carefully consider the characteristics of their stimuli when assessing audio-visual integration.

Meta-analysis of quality-of-life improvement after cochlear implantation and associations with speech recognition abilities

OBJECTIVES

Determine the impact of cochlear implantation on quality of life (QOL) and determine the correlation between QOL and speech recognition ability.

STUDY DESIGN

Two authors independently searched PubMed, Medline, Scopus, and the Cumulative Index to Nursing and Allied Health Literature to identify studies reporting hearing-specific or cochlear implant (CI)-specific QOL outcomes before and after cochlear implantation, and studies reporting correlations between QOL and speech recognition after cochlear implantation. Data from the included articles were obtained independently by two authors. Standardized mean difference (SMD) for each measure and pooled effects were determined to assess improvement in QOL before and after cochlear implantation.

RESULTS

From 14 articles with 679 CI patients who met the inclusion criteria, pooled analyses of all hearing-specific QOL measures revealed a very strong improvement in QOL after cochlear implantation (SMD = 1.77). Subset analysis of CI-specific QOL measures also showed very strong improvement (SMD = 1.69). Thirteen articles with 715 patients met the criteria to evaluate associations between QOL and speech recognition. Pooled analyses showed a low positive correlation between hearing-specific QOL and word recognition in quiet (r = 0.213), sentence recognition in quiet (r = 0.241), and sentence recognition in noise (r = 0.238). Subset analysis of CI-specific QOL showed similarly low positive correlations with word recognition in quiet (r = 0.213), word recognition in noise (r = 0.241), and sentence recognition in noise (r = 0.255).

CONCLUSIONS

Using hearing-specific and CI-specific measures of QOL, patients report significantly improved QOL after cochlear implantation. However, widely used clinical measures of speech recognition are poor predictors of patient-reported QOL with CIs. Laryngoscope, 128:982-990, 2018.

Meta-analysis of Cochlear Implantation Outcomes Evaluated With General Health-related Patient-reported Outcome Measures

OBJECTIVE

Determine the change in general health-related quality of life (HRQOL) after cochlear implantation and association with speech recognition.

STUDY DESIGN

Meta-analysis.

METHODS

Search was performed following the PRISMA statement using PubMed, Medline, Scopus, and CINAHL. Studies on adult cochlear implant (CI) patients measuring HRQOL before and after cochlear implantation were included. Standardized mean difference (SMD) for each measure and pooled effects were determined. A meta-analysis of correlations was also performed between all non-disease-specific patient-reported outcome measures (PROMs) and speech recognition after cochlear implantation.

RESULTS

Twenty-two articles met criteria for meta-analysis of HRQOL improvement, but 15 (65%) were excluded due to incomplete statistical reporting. From the seven articles with 274 CI patients that met inclusion criteria, pooled analyses showed a medium positive effect of cochlear implantation on HRQOL (SMD = 0.79). Subset analysis of the HUI-3 measure showed a large effect (SMD = 0.84). Nine articles with 550 CI patients met inclusion criteria for meta-analysis of correlations between non-disease specific PROMs and speech recognition after cochlear implantation. Pooled analysis showed a low correlation between non-disease-specific PROMs and word recognition in quiet (r = 0.35), sentence recognition in quiet (r = 0.40), and sentence recognition in noise (r = 0.32).

CONCLUSION

Although regularly used, HRQOL measures are not intended to measure nor do they accurately reflect the complex difficulties facing CI patients. Only a medium positive effect of cochlear implantation on HRQOL was observed along with a low correlation between non-disease-specific PROMs and speech recognition. The use of such instruments in this population may underestimate the benefit of cochlear implantation.

Quality of Life and Cost-Effectiveness of Cochlear Implants: A Narrative Review

OBJECTIVES

To review evidence regarding the health-related quality of life (HRQoL) and cost-effectiveness of unilateral and bilateral cochlear implantation (CI) among children and adults with severe-to-profound hearing loss.

STUDY DESIGN

Narrative review.

METHODS

Publications related to quality of life (QoL) and costs of care in CI were acquired through searches in English-language databases. Studies were included if they had identified the HRQoL attainment, cost of care, cost-utility, or cost-effectiveness associated with CI.

RESULTS

57 studies were critically reviewed. The QoL outcome metrics used in these articles were divided into 2 categories - generic and condition specific. In studies investigating children, many reported no significant difference in QoL attainment between CI recipients and normal-hearing peers. In adults, significant improvements in QoL after implantation and higher QoL than in their nonimplanted (hearing-aided) peers were frequently reported. Studies involving an older adult cohort reported significant improvement in QoL after implantation, which was often independent of audiological performance. Overall, the calculated cost-utility ratios consistently met the threshold of cost acceptance, indicating acceptable values for expenditures on CI.

CONCLUSIONS

Considerable work has been done on the QoL attainment and health economic implications of CI. Unilateral CI across all age groups leads to reported sustained benefits in the recipients' overall and disease-specific QoL. With increased cost associated with bilateral CI, further study is needed to characterize its costs and benefits with respect to the recipients' health, well-being, and contributions to society.

Perceived Quality of Life Among Adults With Hearing Loss: Relationships With Amplification Device and Financial Well-Being

The current study explored the relationship between perceived quality of life and financial well-being among adult cochlear implant (CI) users as compared with hearing aid (HA) users. Participants were 66 adults: 30 CI users and 36 HA users. They completed the Perceived Quality of Life for Deaf and Hard-of-Hearing (DHH) scale, the In Charge Financial Distress/Financial Well-Being scale, and a background questionnaire. Significant differences were found between the two study groups in two perceived quality-of-life factors: participation, t(58) = 1.71, p < .05, and perceived stigma, t(58) = −1.80, p < .05. CI users reported higher levels of participation and lower levels of perceived stigma as compared with HA users. In addition, financial well-being was a significant predictor of participation (β = .32, p < .05), and CI users who used their device for a longer time reported higher levels of financial well-being ( r = .35, p < .05). Research findings emphasize the possible contribution that both CIs and financial well-being may have on the perceived quality of life of DHH adults. In addition, time since implantation may be an important variable when measuring improvements after cochlear implantation, especially when evaluating long-term processes, such as changes in financial well-being.

Use of Adult Patient Focus Groups to Develop the Initial Item Bank for a Cochlear Implant Quality-of-Life Instrument

Importance

No instrument exists to assess quality of life (QOL) in adult cochlear implant (CI) users that has been developed and validated using accepted scientific standards.

Objective

To develop a CI-specific QOL instrument for adults in accordance with the Patient Reported Outcomes Measurement Information System (PROMIS) guidelines.

Design, Setting, and Participants

As required in the PROMIS guidelines, patient focus groups participated in creation of the initial item bank. Twenty-three adult CI users were divided into 1 of 3 focus groups stratified by word recognition ability. Three moderator-led focus groups were conducted based on grounded theory on December 3, 2016. Two reviewers independently analyzed focus group recordings and transcripts, with a third reviewer available to resolve discrepancies. All data were reviewed and reported according to the Consolidated Criteria for Reporting Qualitative Research. The setting was a tertiary referral center.

Main Outcomes and Measures

Coded focus group data.

Results

The 23 focus group participants (10 [43%] female; mean [range] age, 68.1 [46.2-84.2] years) represented a wide range of income levels, education levels, listening modalities, CI device manufacturers, duration of CI use, and age at implantation. Data saturation was determined to be reached before the conclusion of each of the focus groups. After analysis of the transcripts, the central themes identified were communication, emotion, environmental sounds, independence and work function, listening effort, social isolation and ability to socialize, and sound clarity. Cognitive interviews were carried out on 20 adult CI patients who did not participate in the focus groups to ensure item clarity. Based on these results, the initial QOL item bank and prototype were developed.

Conclusions and Relevance

Patient focus groups drawn from the target population are the preferred method of identifying content areas and domains for developing the item bank for a CI-specific QOL instrument. Compared with previously used methods, the use of patient-centered item development for a CI-specific QOL instrument will more accurately reflect patient experience and increase our understanding of how CI use affects QOL.

Quality of life in adult cochlear implant users

Objective To evaluate the quality of life (QOL) of adult cochlear implant users (CI) and compare it with the QOL of adults with normal hearing; and study the influence of the variables socioeconomic status, education, age at assessment, auditory sensory deprivation time, device usage time and performance in auditory speech perception tests in the QOL of adult cochlear implant users. Design The QOL was assessed using the World Health Organization Quality of Life (WHOQOL-BREF) generic assessment questionnaire. Study sample Seventy adult CI users formed the experimental group (EG) and 50 adults with normal hearing formed the control group (CG). Results The EG scores were close to the maximum score in satisfactory quality of life for all domains of the WHOQOL-BREF and there were similar results between the EG and CG. The variables age at assessment, duration of auditory sensory deprivation, duration of CI use and performance in auditory speech perception did not influence the results of the QOL of adult cochlear implant users. Conclusion Evaluating the QOL should be a concern of interdisciplinary teams in CI for an intervention with humanized care.

Long-term follow-up of spinal cord stimulation to restore cough in subjects with spinal cord injury

OBJECTIVE

To determine the long-term effects of the cough stimulation system.

DESIGN

Nonrandomized clinical trial of subjects using the study device well beyond the period of close follow-up.

SETTING

Use of the study device in the home setting.

PARTICIPANTS

Subjects (N = 10) implanted with the device for a minimum of 2 years (mean 4.6 ± 0.6 years).

INTERVENTIONS

Application of daily stimulation.

OUTCOME MEASURES

Airway pressure generation and other clinical assessments including ease in raising secretions, life quality, caregiver support, and incidence of respiratory tract infections were measured at 1 year and mean 4.6 years after implantation.

RESULTS

Each subject continued to use the device on a regular basis. During SCS, mean maximum airway pressures were 103.1 ± 20.4 and 107.7 ± 23.0 cm H₂O at the 1-year and mean 4.6-year follow-up points, respectively (P < 0.05 compared with pre-implant and not significantly different (NS) compared with 1-year follow-up). Benchmarks related to ease in raising secretions and improvements in life quality related to respiratory care were maintained at the mean 4.6 year follow-up. The need for trained caregivers to provide other means of secretion management remained significantly below the pre-implant values (P < 0.05). The incidence of acute respiratory tract infections remained low at 0.2 ± 0.1 events/year, which is significantly below the pre-implant value of 1.4 ± 0.3 events/year (P < 0.05).

CONCLUSION

Subjects continued to use the system on a long-term basis beyond the period of close follow-up and to continued derive significant clinical benefits.

Differences in perception of hearing handicap between cochlear implant users and their spouses

OBJECTIVES/HYPOTHESIS

To examine the relationship between patient and proxy ratings of health-related quality of life (HRQL) in patients with cochlear implants.

STUDY DESIGN

Prospective survey.

METHODS

Eighty-two adult cochlear implant recipients and their spouses/partners were asked to complete the Nijmegen Cochlear Implant Questionnaire (NCIQ) and the Hearing Participation Scale (HPS) that were mailed to them.

RESULTS

For the NCIQ, there were 38 useable responses from recipients and 31 useable responses from the partners. There were 27 paired and useable questionnaires (i.e., from both the recipient and his/her partner). For the HPS, there were 42 useable responses from recipients and 36 useable responses from the partners. Of these, there were 35 paired questionnaires. There was good agreement between partners and patients with both the HPS (r = 0.62) and the NCIQ (r = 0.80). There was a significant statistical difference in the scoring of the Basic Sound Perception subscale between the two groups (P = .039), with spouses under-rating performance in this subscale.

CONCLUSIONS

For patients with cochlear implants, patients' partners corroborate patients' self-reported HRQL. In cases in which patients have sensory impairment, there may be an additional role for proxy ratings of HRQL to give a more complete assessment of functional limitations.

Quality of life measures in otitis media

Disabling hearing impairment is the world's most common disability. Traditionally, hearing levels measured by pure tone audiometry have been used to define and quantify hearing loss. The effects of disabling hearing loss on patients' quality of life can be profound, and audiometric data alone may not correlate with quality of life measures. Generic measures of quality of life can be used to compare different diseases, and as such are useful in resource allocation and burden of disease studies. Their disadvantage is that they are not disease-specific and can therefore under-estimate the effects of a disease on patients' quality of life. Disease-specific measures are more sensitive. In chronic otitis media, additional factors such as discharge augment the effect of hearing loss alone on quality of life. Many of the quality of life measures developed for chronic otitis media have been used to assess improvement following reconstructive surgery. Quality of life measures have also been used to assess the effect of paediatric otitis media. Quality of life measures also have utility in the developing world, where hearing impairment is a huge burden.

Unilateral multi-channel cochlear implantation results in significant improvement in quality of life

OBJECTIVES

To investigate the effects of unilateral multi-channel cochlear implant surgery on health-related quality of life and to determine if there is an age-related impact of cochlear implantation on these effects.

DESIGN

Prospective study.

SETTING

Tertiary health-care center.

METHODS

The Short Form-36 survey (SF-36) was administered to determine the health-related quality of life of 283 age-stratified patients before and after cochlear implant surgery.

MAIN OUTCOMES

Precochlear to postcochlear implantation changes in health-related quality of life as determined by the SF-36 questionnaire.

RESULTS

There were significant increases in precochlear and postcochlear implantation scores for 5 of the 8 SF-36 survey domains: vitality, physical role functioning, mental health, emotional role functioning, and social functioning. Significant differences were found between age groups in the domains of social functioning, emotion role functioning, and mental health.

CONCLUSION

Cochlear implant surgery significantly improves health-related quality of life as categorically stratified by the SF-36 questionnaire. These improvements were most evident in the mental health, emotional and social functioning, and physical functioning at work questions of the survey. Cochlear implant recipients younger than 65 years perceive a greater improvement in their level of energy, mental health, and social function compared with those older than 65 years.

Validation of a quality-of-life measure for deaf or hard of hearing youth

OBJECTIVE

Quality-of-life (QOL) measures targeting youth with hearing loss are useful in population needs assessment, educational placement, and program design and evaluation. This study assesses the cross-sectional validity of the Youth Quality of Life Instrument-Deaf and Hard of Hearing Module (YQOL-DHH). STUDY DESIGN. Instrument development and cross-sectional survey.

SETTING

Recruitment through schools, professional organizations, clinics, and programs for youth who are deaf or hard of hearing. SUBJECTS AND METHODS. Thirty-five candidate items were administered to 230 adolescents aged 11 to 18 years: 49% female, 61% white, 11% mild hearing loss, 20% moderate/moderate-severe, 41% severe/profound, and 28% with cochlear implants. Participants completed individual or group-administered questionnaires by paper and pencil (58%), Web-based English (29%), American Sign Language (ASL) or Pidgin Signed English (PSE) (9%) on DVD, or interviewer-supervised ASL or PSE DVD (4%). The Children's Depression Inventory (CDI-S) was also completed. Factor structure, reliability, construct validity, and respondent burden were assessed.

RESULTS

Thirty-two items were retained in the final instrument covering 3 domains: self-acceptance/advocacy (14 items, Cronbach α = 0.84), perceived stigma (8 items, Cronbach α = 0.85), and participation (10 items, Cronbach α = 0.86). QOL was not significantly associated with hearing level. One-week test-retest coefficients were acceptable: self-acceptance/ advocacy (0.70), perceived stigma (0.78), and participation 0.92). As predicted, the total CDI-S score was associated in the appropriate direction (P < .0001) with all YQOL-DHH domains. Time to complete the paper-and-pencil version was 12 minutes.

CONCLUSION

The YQOL-DHH shows good reliability and validity for assessing hearing-specific QOL in adolescents.

Access to New Zealand Sign Language interpreters and quality of life for the deaf: a pilot study

PURPOSE

This paper aims to: (1) explore usage and accessibility of sign language interpreters, (2) appraise the levels of quality of life (QOL) of deaf adults residing in New Zealand, and (3) consider the impact of access to and usage of sign language interpreters on QOL.

METHOD

Sixty-eight deaf adults living in New Zealand participated in this study. Two questionnaires were employed: a 12-item instrument about access and use of New Zealand sign language interpreters and the abbreviated version of the World Health Organization Quality of Life questionnaire (WHOQOL-BREF).

RESULTS

The results showed that 39% of this sample felt that they were unable to adequately access interpreting services. Moreover, this group scored significantly lower than a comparable hearing sample on all four WHOQOL-BREF domains. Finally, the findings revealed that access to good quality interpreters were associated with access to health services, transport issues, engagement in leisure activities, gaining more information, mobility and living in a healthy environment.

CONCLUSIONS

These findings have consequences for policy makers and agencies interested in ensuring that there is an equitable distribution of essential services for all groups within New Zealand which inevitably has an impact on the health of the individual.

Younger- and older-age adults with unilateral and bilateral cochlear implants: speech and spatial hearing self-ratings and performance

OBJECTIVE

Compare results of cochlear implantation in younger and older adults in the domains of disability and handicap, as well as in tests of word recognition and localization, across unilateral implant (CI), bilateral (CI + CI), and CI with an acoustic hearing aid in the nonimplanted ear (CI + HA).

DESIGN

Three parts: retrospective (postimplant only) analysis; prospective (preimplant versus postimplant); correlation between age and benefit from CI versus CI + CI. Two age groups, older and younger than 60 years, for the first 2 analyses; age is a continuous variable for the third analysis.

SETTING

Tertiary referral hospital clinic.

PATIENTS

Postlingually severely-to-profoundly hearing-impaired adults: Totals of 68 CI, 36 CI + CI, and 38 CI + HA in the retrospective part of the study; totals of 30 CI, 18 CI + CI, and 16 CI + HA in the prospective parts. Numbers vary from these totals on individual measures.

INTERVENTIONS

Patients receive either 1 or 2 cochlear implants; some with 1 CI opt to retain a hearing aid in the nonimplanted ear.

OUTCOME MEASURES

Principal measures: Hearing Handicap Inventory for the Elderly, Hearing Handicap Questionnaire, Speech, Spatial and Qualities of Hearing Scale, word recognition test, and soundfield localization test. The study is exploratory, but proceeding from a null hypothesis of no expected contrast as a function of patient age.

RESULTS

All patient groups show significant benefit after implantation. No significant age-related differences are observed in patients with unilateral implant, nor in CI + HA group. In the CI + CI group, the younger cohort showed very substantial increases in both performance and self-rated abilities; the older cohort provides more mixed outcomes.

CONCLUSION

Results for the CI group confirm and extend earlier research. The result for the younger group of CI + CI patients demonstrates the consistent incremental benefit obtained from a bilateral procedure. The mixed outcome observed in the older CI + CI group might be due to individual differences in interaction between effects of aging and the ability to integrate binaural cues.

Population norms and meaningful differences for the Assessment of Quality of Life (AQoL) measure

OBJECTIVE

The Assessment of Quality of Life (AQoL) instrument is widely used in Australian health research. To assist researchers interpret and report their work, this paper reports population and health status norms, general minimal important differences (MIDs) and effect sizes.

METHOD

Data from the 1998 South Australian Health Omnibus Survey (n=3,010 population-based respondents) were analysed by gender, age group and health status. Data from four other longitudinal studies were analysed to obtain estimated MIDs.

RESULTS

The mean (SD) AQoL utility score was 0.83 (0.20). Gender and age subgroup differences were apparent; the mean scores for women were consistent until their 50s, when scores declined. Greater variability was observed for males whose scores declined more slowly but consistently between 40-80 years. For both genders, those aged 80+ years had the lowest scores. When assessed by health status, those reporting excellent health obtained the highest utility scores; progressive declines were observed with decreasing health status. Effect sizes of 0.13 or greater may reflect important differences between groups. A difference in AQoL scores of 0.06 utility points over time suggests a general MID.

CONCLUSIONS

AQoL population norms, MIDs and effect sizes can be used as reference points for the interpretation of AQoL data. These findings add to the growing evidence that the AQoL is a robust and sensitive measure that has wide applicability.

IMPLICATIONS

The availability of population norms will assist researchers using the AQoL to more easily interpret and report their work.

Mental distress and quality of life in the hard of hearing

OBJECTIVE

This study aims to compare levels of psychological distress and the quality of life in the hard of hearing with levels reported by the signing deaf, and the hearing population.

METHOD

A total of 373 members of the Hard of Hearing Association completed the brief WHO's Quality of Life, 12-item General Health Questionnaire and Brief Symptom Inventory, and provided details about their initial and current deafness.

RESULTS

The hard of hearing have worse social relationships than the signing deaf, and are disadvantaged relative to the hearing in all areas measured. Quality of life is related to the level of satisfaction with the hearing achieved by hearing aids.

CONCLUSION

General psychiatrists need to be aware that patients who are hard of hearing may be even more isolated than deaf people in a signing community. Hard of hearing patients with unsatisfactory hearing aids can be greatly assisted by cochlear implants.

Connexin 26 variants and auditory neuropathy/dys-synchrony among children in schools for the deaf

Genetic and auditory studies of 731 children with severe-to-profound hearing loss in US schools for the deaf and 46 additional children receiving clinical services for hearing loss ranging from moderate to profound demonstrated that mutations in the connexin 26 (GJB2) and connexin 30 (GJB6) genes explain at least 12% of those with nonsyndromic sensorineural deafness. Otoacoustic emissions (OAEs) testing to detect functional outer hair cells indicated that 76 of the children had emissions and therefore may have (as yet unconfirmed) auditory neuropathy/dys-synchrony (AN/AD). Five of these children with OAEs were GJB2 homozygotes or compound heterozygotes with the genotypes 35delG/35delG, W77X/W77X, 35delG/360delGAG, 35delG/V95M, and V84M/M34T. In particular, unilateral AN/AD was confirmed in a child with moderate hearing loss and the 35delG/V95M genotype. Detecting OAEs in individuals with GJB2 mutations suggests that lack of functional gap junctions as a result of GJB2 mutations does not necessarily destroy all outer hair cell function.