Same-Day Patient Consultation and Cochlear Implantation: Innovations in Patient-Centered Health Care Delivery

Patient and clinician experiences with the multidisciplinary single-day cochlear implant selection (MSCS) protocol

PURPOSE

This study assessed the MSCS (Multidisciplinary Single-day Cochlear Implant Selection) protocol with a primary focus on sustaining or enhancing patient satisfaction throughout the cochlear implant selection process.

MATERIALS AND METHODS

Following the implementation of the new selection protocol, where all selection appointments take place on the same day, we surveyed 37 individuals who underwent the process. Twenty adhered to the standard procedure, while 17 followed the MSCS protocol. We also gathered feedback from seven out of eight involved healthcare providers. This method enabled us to evaluate the protocol's effectiveness in maintaining patient satisfaction and ensuring staff contentment with care delivery within a condensed timeframe.

RESULTS

Patient responses showed slight variations in average scores without statistical significant differences, indicating comparable satisfaction between the MSCS pathway and the standard protocol. The majority of patients preferred the MSCS protocol, with none of the MSCS participants opting for appointments spread over multiple days. Healthcare practitioners of the CI center also displayed similar or increased satisfaction levels with the MSCS protocol.

CONCLUSION

The adoption of the MSCS in daily clinical care has led to a decrease in patient appointment times without sacrificing patient satisfaction. Additionally, the majority of individuals actively choose the MSCS protocol. Among those who have directly experienced it, there is unanimous preference for the consolidated appointments over spreading them across multiple days. Professionals within the CI team express equal satisfaction with both the new and old protocols, indicating that the reduction in patient time does not diminish overall satisfaction.

Improved Postoperative Speech Recognition and Processor Use With Early Cochlear Implant Activation

OBJECTIVE

To report speech recognition outcomes and processor use based on timing of cochlear implant (CI) activation.

STUDY DESIGN

Retrospective cohort.

SETTING

Tertiary referral center.

PATIENTS

A total of 604 adult CI recipients from October 2011 to March 2022, stratified by timing of CI activation (group 1: ≤10 d, n = 47; group 2: >10 d, n = 557).

MAIN OUTCOME MEASURES

Average daily processor use; Consonant-Nucleus-Consonant (CNC) and Arizona Biomedical (AzBio) in quiet at 1-, 3-, 6-, and 12-month visits; time to peak performance.

RESULTS

The groups did not differ in sex ( p = 0.887), age at CI ( p = 0.109), preoperative CNC ( p = 0.070), or preoperative AzBio in quiet ( p = 0.113). Group 1 had higher median daily processor use than group 2 at the 1-month visit (12.3 versus 10.7 h/d, p = 0.017), with no significant differences at 3, 6, and 12 months. The early activation group had superior median CNC performance at 3 months (56% versus 46%, p = 0.007) and 12 months (60% versus 52%, p = 0.044). Similarly, the early activation group had superior median AzBio in quiet performance at 3 months (72% versus 59%, p = 0.008) and 12 months (75% versus 68%, p = 0.049). Both groups were equivalent in time to peak performance for CNC and AzBio. Earlier CI activation was significantly correlated with higher average daily processor use at all follow-up intervals.

CONCLUSION

CI activation within 10 days of surgery is associated with increased early device usage and superior speech recognition at both early and late follow-up visits. Timing of activation and device usage are modifiable factors that can help optimize postoperative outcomes in the CI population.

Pilot study of a multidisciplinary single-day cochlear implant selection protocol

PURPOSE

This study aimed to explore and introduce the potential of a MSCS (Multidisciplinary Single-day Cochlear Implant Selection) protocol. The primary objectives of this pilot were to reduce the duration between referral and surgery, minimize hospital visits and decrease the time healthcare professionals dedicate to the cochlear implant (CI) selection process.

MATERIALS AND METHODS

We established a pilot program at the CI center of the Erasmus MC, a tertiary referral center in the Netherlands, with the goal of improving and shorten the selection process. We evaluated our pilot, including 15 CI candidates, and conducted a retrospective analysis for time and cost savings.

RESULTS

The results showed that the pilot of the MSCS protocol significantly reduced the length of the CI selection phase (84 days vs 1; standard intake vs MSCS protocol) and the number of hospital visits (6 vs 2 visits; standard vs MSCS protocol), resulting in less travel time and lower costs for the CI candidates. The total time of professionals spend on patients was also reduced with 27 %.

CONCLUSION

This study highlights the potential benefits of the MSCS protocol in terms of reducing the burden on patients and healthcare providers and improving the efficiency of the CI selection process.

Hearing health care access for adult cochlear implant candidates and recipients: Travel time and socioeconomic status

Objectives

Access to cochlear implantation may be negatively influenced by extended travel time to a cochlear implant (CI) center or lower socioeconomic status (SES) for the individual. There is a critical need to understand the influence of these variables on patient appointment attendance for candidacy evaluations, and CI recipients' adherence to post-activation follow-up recommendations that support optimal outcomes.

Methods

A retrospective chart review of adult patients referred to a CI center in North Carolina for initial cochlear implantation candidacy evaluation between April 2017 and July 2019 was conducted. Demographic and audiologic data were collected for each patient. Travel time was determined using geocoding. SES was proxied using ZCTA-level Social Deprivation Index (SDI) information. Independent samples t tests compared variables between those who did and did not attend the candidacy evaluation. Pearson correlations assessed the association of these variables and the duration of time between initial CI activation and return for first follow-up visit.

Results

Three hundred and ninety patients met the inclusion criteria. There was a statistically significant difference between SDI of those who attended their candidacy evaluation versus those who did not. Age at referral or travel time did not show statistical significance between these two groups. There was no significant correlation with age at referral, travel time, or SDI with the duration of time (days) between initial activation and the 1-month follow-up.

Conclusions

Our findings suggest that SES may influence a patient's ability to attend a cochlear implantation candidacy evaluation appointment and may further impact the decision to pursue cochlear implantation.Level of evidence: 4 - Case Series.

Experience with Telemedicine in a Tertiary Academic Otologic Clinic During the COVID-19 Pandemic

OBJECTIVE

To examine the utility of telemedicine in a tertiary otologic practice.

STUDY DESIGN

Retrospective case series.

SETTING

Tertiary neurotology clinic.

PATIENTS

Consecutive adult patients presenting via video visit between January 2020 and January 2021.

INTERVENTIONS

Televideo modality to conduct visits with patients seeking evaluation for new concerns, second opinions, or routine follow-up for established conditions.

MAIN OUTCOME MEASURES

Success of the televideo visit defined by the televideo visit being sufficient for determining a definitive plan and not requiring deferment of recommendations for a subsequent in-person visit.

RESULTS

A total of 102 televideo visits were performed among 100 unique patients. Of those, 92 (90.2%) visits were for second opinions or evaluation of new concerns, most commonly for vestibular schwannoma (n = 32, 31.4%), followed by sensorineural hearing loss (n = 20, 19.6%). Other visits were conducted for early postoperative follow-up and established general follow-up. In 91.2% of cases (n = 93), patients were successfully evaluated and provided recommendations from the initial video visit. All visits with patients having a diagnosis of meningioma (n = 7), and nearly all with vestibular Schwannoma (97%, n = 31) and sensorineural hearing loss (95%, n = 19) were successful. Of the 79 patients offered surgery as one potential treatment option, 31 patients underwent surgery at our institution by time of review. Patients with unsuccessful visits (n = 9, 8.8%) were advised to schedule additional in-person diagnostic imaging, vestibular testing, or cochlear implant candidacy evaluation to establish a more definitive care plan.

CONCLUSION

Virtual televideo visits were successful for a high percentage of selected patients seen at a tertiary neurotology practice, particularly those seeking evaluation of vestibular schwannoma or sensorineural hearing loss.

Very early activation of cochlear implants: A review of the literature

Cochlear implantation (CI) has become the standard treatment for patients with severe-to-profound hearing loss. To date, an estimated 750,000 individuals spanning the entire lifecycle have benefited from this life-changing technology. Traditionally, the device is not "activated" for 3 to 4 weeks after surgery. However, an increasing number of centers have recently begun to question the conventional wisdom that several weeks are necessary and are activating their patients' device sooner after CI. This review aimed to provide a comprehensive insight to better understand the feasibility, outcomes, benefits, and limitations of very early cochlear implant activation. Data sources from published medical literature were reviewed. A detailed examination and summary were provided. History and safety were also emphasized. It was observed that approximately 20 studies have reported their experience with very early cochlear implant activation, ranging from the day of surgery to 1 week. Outcome measures are disparate, although there is general agreement that early activation is not only feasible but also provides some real-life benefits to patients and caregivers. The surgical, electrophysiological, audiological, and other outcomes were also reviewed. Very early activation is safe and beneficial in patients with cochlear implants. Many CI centers believe that such a process can lead to improvements in both patient-centered and fiscally responsible care. Although not ideal for all patients, cochlear implant programs may consider this option for their patients.

Catchment Profile of Large Cochlear Implant Centers in the United States

OBJECTIVE

To characterize the catchment area and patient profile of large cochlear implant (CI) centers in the United States.

STUDY DESIGN

Multi-institutional retrospective case series.

SETTING

Tertiary referral CI centers.

METHODS

Patients who underwent CI surgery at 7 participating CI centers between 2015 and 2020 were identified. Patients' residential zip codes were used to approximate travel distances and urban vs rural residential areas.

RESULTS

Over the 6-year study period (2015-2020), 6313 unique CI surgical procedures occurred (4529 adult, 1784 pediatric). Between 2015 and 2019, CI procedures increased by 43%. Patients traveled a median 52 miles (interquartile range, 21-110) each way; patients treated at rural CI centers traveled greater distances vs those treated at urban centers (72 vs 46 miles, P < .001). Rural residents represented 61% of the patient population and traveled farther than urban residents (73 vs 24 miles, P < .001). Overall, 91% of patients lived within a 200-mile radius of the institution, while 71% lived within a 100-mile radius. In adults, multiple regression analysis redemonstrated an association between greater travel distances and (1) older age at the time of CI and (2) residential rural setting (both P < .001, r2 = 0.2).

CONCLUSIONS

While large CI centers serve geographically dispersed populations, most patients reside within a 200-mile radius. Strategies to expand CI utilization may leverage remote programming, telemedicine, and strategic placement of new centers and satellite clinics to ameliorate travel burden.

Implementation Strategy for Highly-Coordinated Cochlear Implant Care With Remote Programming: The Complete Cochlear Implant Care Model

OBJECTIVE

To introduce and discuss implementation strategy for the Complete Cochlear Implant Care (CCIC) model, a highly-coordinated cochlear implant (CI) care delivery model requiring a single on-site visit for preoperative workup, surgery, and postoperative programming.

STUDY DESIGN

Prospective, nonrandomized, two-arm clinical trial.

SETTING

Tertiary referral CI center.

PATIENTS

Adults who meet audiologic criteria for cochlear implantation.

INTERVENTIONS

Cochlear implantation, coordinated care delivery, including remote programming.

MAIN OUTCOME MEASURES

Care delivery model feasibility and process implementation.

RESULTS

Patients determined to be likely CI candidates based on routine audiometry are eligible for enrollment. The CCIC model uses telemedicine and electronic educational materials to prepare patients for same-day on-site consultation with CI surgery, same or next-day activation, and postoperative remote programming for 12 months. Implementation challenges include overcoming inertia related to the implementation of a new clinical workflow, whereas scalability of the CCIC model is limited by current hardware requirements for remote programming technology. A dedicated CCIC process coordinator is critical for overcoming obstacles in implementation and process improvement through feedback and iterative changes. Team and patient-facing materials are included and should be tailored to fit each unique CI program looking to implement CCIC.

CONCLUSION

The CCIC model has the potential to dramatically streamline hearing healthcare delivery. Implementation requires an adaptive approach, as obstacles may vary according to institutional infrastructure and policies.

Same-Day Patient Consultation and Cochlear Implantation: Patient Experiences and Barriers to Implementation

OBJECTIVE

This study aimed to assess the efficacy of same-day cochlear implant (SDCI) evaluation and surgery in improving patient experience.

PATIENTS

Adult CI candidates participated in this study.

INTERVENTIONS

Education materials and communication with providers were offered via telephone, e-mail, and/or telemedicine. Patients then arrived for in-person consultation, imaging studies, and outpatient CI surgery in one visit and received a 3-month postoperative survey.

MAIN OUTCOME MEASURES

Preoperative hearing, referral-to-surgery time, travel burden, and patient satisfaction were included as outcome measures.

RESULTS

Of 35 patients who qualified, 14 were successfully contacted regarding the same-day program: 9 underwent CI, 1 enrolled but did not ultimately meet candidacy criteria, and 4 declined because of coronavirus and/or active medical conditions and did not pursue a CI. For the nine patients who underwent SDCI, mean age was 78 years, and mean preoperative consonant-nucleus-consonant score was 16% in the implanted ear. Mean referral-to-surgery time was 103 days and, after accounting for cancellations because of coronavirus, was 52 days. Mean travel distance to institution was 234 miles. Of the seven patients who completed the follow-up survey, none felt rushed for surgery, and mean program experience was rated 8.6 out of 10. Net promoter score was positive (+72), supporting high experience favorability among patients. Barriers to program expansion included patient recruitment and education, surgery scheduling, and the coronavirus pandemic.

CONCLUSIONS

No patients declined the SDCI program to pursue traditional CI evaluation, and all patients were satisfied with their experience. The SDCI program is a feasible and successful model that overcomes barriers to implantation, including travel burden, and improves access to care.

Cochlear implant outcomes in the very elderly

PURPOSE

Managing hearing health in older adults has become a public health imperative, and cochlear implantation is now the standard of care for aural rehabilitation when hearing aids no longer provide sufficient benefit. The aim of our study was to compare speech performance in cochlear implant patients ≥80 years of age (Very Elderly) to a younger elderly cohort between ages 65-79 years (Less Elderly).

MATERIALS AND METHODS

Data were collected from 53 patients ≥80 years of age and 92 patients age 65-79 years who underwent cochlear implantation by the senior author between April 1, 2017 and May 12, 2020. The primary outcome measure compared preoperative AzBio Quiet scores to 6-month post-activation AzBio Quiet results for both cohorts.

RESULTS

Very Elderly patients progressed from an average AzBio Quiet score of 22% preoperatively to a score of 45% in the implanted ear at 6-months post-activation (p < 0.001) while the Less Elderly progressed from an average score of 27% preoperatively to 60% at 6-months (p < 0.001). Improvements in speech intelligibility were statistically significant within each of these cohorts (p < 0.001). Comparative statistics using independent samples t-test and evaluation of effect size using the Hedges' g statistic demonstrated a significant difference for average improvement of AzBio in quiet scores between groups with a medium effect size (p = 0.03, g = 0.35). However, when the very oldest patients (90+ years) were removed, the statistical difference between groups disappeared (p = 0.09).

CONCLUSIONS

When assessing CI performance, those over age 65 are typically compared to younger patients; however, this manuscript further stratifies audiometric outcomes for older CI recipients in a single-surgeon, high-volume practice. Our data indicates that for speech intelligibility, patients between age 65-79 perform similarly to CI recipients 80-90 years of age and should not be dismissed as potential cochlear implant candidates.

Exploring Factors Responsible for Delay in Pediatric Cochlear Implantation

OBJECTIVE

To identify and characterize demographic and socioeconomic factors associated with delays in cochlear implantation (CI) in children.

STUDY DESIGN

Retrospective.

SETTING

Tertiary pediatric CI referral center.

PATIENTS

All patients under 18 years of age receiving CI between March 2018 and February 2020.

INTERVENTIONS

CI.

MAIN OUTCOME MEASURES

Primary outcome measures included age at implantation and time from hearing loss diagnosis and candidacy evaluation to CI.

RESULTS

Seventy-two patients were identified (44% women, average age at implantation 4.9 yr). Age at implantation was older in patients with public, rather than private, insurance (6.0 ± 0.8 yr versus 3.1 ± 0.7 yr, p = 0.007) and those from low-income areas (8.6 ± 7.6 yr versus 2.4 ± 3.0 yr, p = 0.007). Time between hearing loss diagnosis and implantation was longer in publicly insured patients (4.1 ± 0.6 yr versus 2.2 ± 0.5 yr, p = 0.014). Time between identification as a CI candidate and implantation was longer in publicly insured patients (721 ± 107d versus 291 ± 64 d, p = 0.001). Among children with congenital profound hearing loss, publicly insured patients continued to be older at implantation (1.9 ± 0.2 versus 1.0 ± 0.2 yr, p = 0.008). Latinx children were more often publicly insured whereas white children were more often privately insured (p < 0.05). Publicly insured patients had delays in the pre-CI workup, including, in no particular order, vestibular evaluation (621 ± 132 d versus 197 ± 67 d, p = 0.007), developmental evaluation (517 ± 106 d versus 150 ± 56 d, p = 0.003), speech evaluation (482 ± 107 d versus 163 ± 65 d, p = 0.013), and children's implant profile (ChIP) assessment (572 ± 107d versus 184 ± 59d, p = 0,002). On ChIP evaluation, concerns regarding educational environment and support were higher in Spanish-speaking children (p = 0.024; p = 2.6 × 10-4) and children with public insurance (p = 0.016; p = 0.002).

CONCLUSIONS

Disparities in access to CI continue to affect timing of pediatric cochlear implantation.

Barriers to Adult Cochlear Implant Care in the United States: An Analysis of Health Care Delivery

Persistent underutilization of cochlear implants (CIs) in the United States is in part a reflection of a lack of hearing health knowledge and the complexities of care delivery in the treatment of sensorineural hearing loss. An evaluation of the patient experience through the CI health care delivery process systematically exposes barriers that must be overcome to undergo treatment for moderate-to-severe hearing loss. This review analyzes patient-facing obstacles including diagnosis of hearing loss, CI candidate identification and referral to surgeon, CI evaluation and candidacy criteria interpretation, and lastly CI surgery and rehabilitation. Pervasive throughout the process are several themes which demand attention in addressing inequities in hearing health disparities in the United States.

Perioperative Nursing Care of the Patient Undergoing a Cochlear Implant Procedure

A cochlear implant (CI) is used in the auditory rehabilitation of adult and pediatric patients with sensorineural hearing loss who do not benefit from conventional hearing aids. Perioperative nursing care of the patient with sensorineural hearing loss undergoing cochlear implantation is not extensively discussed in the literature. Preoperative care involves managing the patient and family's expectations for the procedure and determining the most effective communication techniques for each patient. Postoperative care involves monitoring patients closely and identifying the signs and symptoms of a number of possible postoperative complications, as well as knowing how to prevent these complications and respond to them. Thorough patient and family discharge instructions are vital to a successful cochlear implantation result. This article provides perioperative nurses caring for patients receiving a CI with detailed information to help ensure that they provide these patients with the most appropriate and effective care.

Improving access to care for children with cancer through implementation of an electronic referral system (IMPACT): A single-center experience from Saudi Arabia

BACKGROUND

Delayed access to cancer care has been associated with childhood cancer death. Improving timely access to cancer care is the first important step in the cancer treatment journey. We introduced an electronic referral system (e-RS) to improve timely access to cancer care. This study aimed to assess the impact of implementing an e-RS on timely access to cancer care.

METHODS

A retrospective cross-sectional study of pediatric oncology patients selected through a consecutive nonprobability sampling technique was performed to determine the turnaround time (TAT) of children with cancer diagnosed 12 months before and after implementation of the e-RS. TAT was defined as time in hours from referral to approval for admission.

RESULTS

Of the 326 pediatric oncology patients diagnosed between January 2014 and December 2015, 59.9% were male and 40.1% were female. Median age for both sexes was 5.0 years (interquartile range [IQR]: 2.5-9.0 years). Among these, 98.2% were Saudi nationals. Hematological malignancies accounted for 50.6% of referrals and 16.6% had lymphoma. The median TAT of the manual referral system (m-RS) and e-RS was 18 h (IQR: 2-25 h) and 2 h (IQR: 1-16 h; P = .0001), median length of hospital stay during first admission was 11 days versus 9 days (P = .14), and death events occurred in 11 patients versus zero patients referred using the m-RS versus e-RS (P = .003), respectively.

CONCLUSION

The introduction of an e-RS was associated with more rapid processing of pediatric patients for cancer treatment and fewer patient deaths during the initial evaluation and treatment during that time period.