Effect of a Global Pandemic on Adult and Pediatric Cochlear Implantation across the United States

Barriers to Cochlear Implant Uptake in Adults: A Scoping Review

INTRODUCTION

Cochlear implants (CIs) provide access to sound and help mitigate the negative effects of hearing loss. As a field, we are successfully implanting more adults with greater amounts of residual hearing than ever before. Despite this, utilization remains low, which is thought to arise from barriers that are both intrinsic and extrinsic. A considerable body of literature has been published in the last 5 years on barriers to adult CI uptake, and understanding these barriers is critical to improving access and utilization. This scoping review aims to summarize the existing literature and provide a guide to understanding barriers to adult CI uptake.

METHODS

Inclusion criteria were limited to peer-reviewed articles involving adults, written in English, and accessible with a university library subscription. A cutoff of 20 years was used to limit the search. Barriers uncovered in this review were categorized into an ecological framework.

RESULTS

The initial search revealed 2,315 items after duplicates were removed. One hundred thirty-one articles were reviewed under full-text, and 68 articles met the inclusion criteria.

DISCUSSION

Race, ethnicity, and reimbursement are policy and structural barriers. Public awareness and education are societal barriers. Referral and geographical challenges are forms of organizational barriers. Living context and professional support are interpersonal barriers. At the individual level, sound quality, uncertainty of outcome, surgery, loss of residual hearing, and irreversibility are all barriers to CI uptake. By organizing barriers into an ecological framework, targeted interventions can be used to overcome such barriers.

Ten-Year Trends in Otolaryngological Surgery Volumes and the Impact of Infection Prevention During the COVID-19 Pandemic-A National Study

Background/Objectives: This register study elucidates the national trends in the otolaryngologic surgery volume in Finland over a ten-year period. In particular, we investigated whether the pandemic, which had a marked effect on communicable diseases, had an impact on infection-related ear, nose, and throat (ENT) procedures. For reference, we used noninfectious ENT procedures. Methods: The data of this study consisted of the volumes of different otolaryngological surgical procedures in Finland from 2012 to 2022. A linear regression model was applied to calculate long-term trends in surgery volumes. The annual predicted and observed surgical volumes of each procedure were compared. In addition, different procedures were compared based on whether they were mostly infection-related, non-infection-related, or both. Results: The results revealed that the pandemic altered the trends of many ENT procedures, and during the pandemic, infection-related surgeries declined more than non-infection-related surgeries did. The decline in infection-related surgery volumes seems to have lasted longer than the coronavirus disease 2019 (COVID-19) pandemic itself, as only tympanostomies and mastoidectomies of all the infection-related procedures included in this study have returned to the pre-pandemic trend. Some non-infection-related procedures and procedures with mixed indications also declined during the pandemic and sustained their reduction even in 2022. Conclusions: This study provides a nationwide insight into ENT surgery volumes in Finland over a ten-year period. Although causative reasoning cannot be conducted based on this study, it still provides a good indication of how the absence of respiratory viruses and multifactorial societal restriction measures could have a long-lasting effect on the epidemiology and management of many ENT diseases.

Economic Analysis of Cochlear Implants in Adults With Bilateral Severe-to-Profound Hearing Loss. A Systematic Review of the Literature

OBJECTIVE

To determine the cost-effectiveness or cost-utility of cochlear implants (CI) in adults with severe to profound bilateral hearing loss.

DATABASES REVIEWED

PubMed (Medline), The Cochrane Library, Embase via Elsevier, EBSCOhost CINAHL, and Scopus.

METHODS

The study included adult participants with severe to profound bilateral neurosensory hearing loss. The analysis encompassed quality of life improvements, costs, cost-effectiveness, cost-utility, cost-benefit, quality-adjusted life year (QALY), incremental cost-effectiveness ratio (ICER), and incremental cost-utility ratio (ICUR). Systematic reviews, meta-analyses, case series, and prospective or retrospective cohort studies published in English between 2010 and 2023 were retrieved. Exclusion criteria included incomplete studies, abstracts, clinical cases, editorials, letters, studies involving pediatric populations, single-side deafness, methodology research, noneconomic aspects of CI, mixed child and adult data, and studies published before 2010. The risk of bias was assessed following the criteria outlined in Appendix I of the economic evaluation's quality assessment as per the NICE Guideline Development Method.

RESULTS

Ten articles met the criteria and were included in the qualitative synthesis. One study conducted a prospective cost-utility analyses, one carried out a cost-benefit analyses, one was a randomized controlled clinical trial focusing on cost-utility, and another was a clinical trial addressing cost-effectiveness. Six studies employed Markov models, and one study utilized uniquely the Monte Carlo method. None quantified the economic impact of improved hearing on cognitive function.

CONCLUSIONS

The heterogeneity of sources impacted data quality. Unilateral and sequential bilateral CI appeared to be cost-effective when compared with bilateral hearing aids or nontechnological support. When properly indicated, simultaneous bilateral CIs are cost-effective compared to no interventions and to unilateral cochlear implantation through differential discounting or variations from the base cases, especially with a life expectancy of 5-10 years or longer.

AI model for predicting adult cochlear implant candidacy using routine behavioral audiometry

OBJECTIVE

To describe an AI model to facilitate adult cochlear implant candidacy prediction based on basic demographical data and standard behavioral audiometry.

METHODS

A machine-learning approach using retrospective demographic and audiometric data to predict candidacy CNC word scores and AzBio sentence in quiet scores was performed at a tertiary academic center. Data for the model were derived from adults completing cochlear implant candidacy testing between January 2011 and March 2023. Comparison of the prediction model to other published prediction tools and benchmarks was performed.

RESULTS

The final dataset included 770 adults, encompassing 1045 AzBio entries, and 1373 CNC entries. Isophoneme scores and word recognition scores exhibited strongest importance to both the CNC and AzBio prediction models, followed by standard pure tone average and low-frequency pure tone average. The mean absolute difference between the predicted and actual score was 15 percentage points for AzBio sentences in quiet and 13 percentage points for CNC word scores, approximating anticipated test-retest constraints inherent to the variables incorporated into the model. Our final combined model achieved an accuracy of 87 % (sensitivity: 90 %; precision: 80 %).

CONCLUSION

We present an adaptive AI model that predicts adult cochlear implant candidacy based on routine behavioral audiometric and basic demographical data. Implementation efforts include a public-facing online prediction tool and accompanying smartphone program, an embedded notification flag in the electronic medical record to alert providers of potential candidates, and a program to retrospectively engage past patients who may be eligible for cochlear implantation based on audiogram results.

Seven-Year Revision Rates for Cochlear Implants in Pediatric and Adult Populations of an Integrated Healthcare System

OBJECTIVE

We assessed three cochlear implant (CI) suppliers: Advanced Bionics, Cochlear Limited, and MED-EL, for implant revision requiring reoperation after CI placement.

STUDY DESIGN

Retrospective cohort study of integrated-health-system database between 2010 and 2021. Separate models were created for pediatric (age <18) and adult (age ≥18) cohorts.

PATIENTS

Pediatric (age <18) and adult (age ≥18) patients undergoing cochlear implantation within our integrated healthcare system.

MAIN OUTCOME MEASURE

Revision after CI placement. Cox proportional hazard regression was used to evaluate revision risk and adjust for confounding factors. Hazard ratios (HRs) and 95% confidence intervals (CIs) are presented.

RESULTS

A total of 2,347 patients underwent a primary CI placement, and Cochlear Limited was most implanted (51.5%), followed by Advanced Bionics (35.2%) and MED-EL (13.3%). In the pediatric cohort, the 7-year crude revision rate was 10.9% for Advanced Bionics and 4.8% for Cochlear Limited, whereas MED-EL had insufficient cases. In adults, the rates were 9.1%, 4.5%, and 3.3% for Advanced Bionics, MED-EL, and Cochlear Limited, respectively. After 2 years of postoperative follow-up, Advanced Bionics had a significantly higher revision risk (HR = 8.25, 95% CI = 2.91-23.46); MED-EL had no difference (HR = 2.07, 95% CI = 0.46-9.25).

CONCLUSION

We found an increased revision risk after 2 years of follow-up for adults with Advanced Bionics CI devices. Although we found no statistical difference between manufacturers in the pediatric cohort, after 2 years of follow-up, there were increasing trends in the revision probability for Advanced Bionics. Further research may determine whether patients are better suited for some CI devices.

Altered Trajectories: Considering the Long-Term Impact of Educational Disruption during the COVID-19 Pandemic on Neurodevelopment and a Call to Action for Neuropsychology

OBJECTIVE

The COVID-19 pandemic resulted in educational disruption of historic breadth and duration. The impact of school closures and remote learning have been evaluated in recent studies and reflect critical data for neuropsychologists who routinely assess brain development as it relates to diagnosis, recommendations, and informing public policy.

METHOD

Pre-pandemic and contemporaneous literature was summarized, including data on educational disruption and child and adolescent mental health challenges reported during the pandemic, and research on the impact of stress, social isolation, educational achievement, and other factors on brain development during critical developmental windows.

RESULTS

Studies indicate that prolonged educational disruption has resulted in attenuated learning gains, most remarkably for those already at risk for educational disparities. Studies have shown increased mental health challenges for youth during the pandemic, with higher rates of mood and eating disorders, and suicidal ideation. Given that some skills develop optimally within specific time periods, pandemic-related disruption has likely contributed to altered developmental trajectories.

CONCLUSION

Trajectory of neuropsychological development of children and adolescents, especially marginalized students, may be affected by effects on learning and mental health due to prolonged educational disruption and psychological stressors. Evaluation and treatment may be delayed due to backlog and increased demand. Clinical neuropsychological practice recommendations are presented with a call to action for the field in moving forward flexibly to increase access to evaluation services.

An Investigation of the Impact of Expanding High-Deductible Health Plans on Patient Decision for Cochlear Implant Surgery and Postoperative Outcomes

HYPOTHESIS

After the expansion of high deductibles, patients will delay cochlear implant (CI) surgery to the end of the year, and the risk of postoperative known risks will increase.

BACKGROUND

The Affordable Care Act was associated with increased enrollment in high-deductible health plans (HDHPs), which resulted in rising health insurance deductibles. Health insurance plans can cover a patient's cost of healthcare once the deductible is met. Patients have been shown to be economic rational decision makers and make decisions based on cost rather than health. They wait for their deductible to be met, typically at the end of the year, then proceed to have costly care. The goal of this study was to evaluate the impact of rising health insurance deductibles on the rate and postoperative outcomes of cochlear implantation and to assess changes by the Tax Cuts and Jobs Act.

METHODS

TriNetX was used to accumulate summary data on patients who obtained a CI between 2005 and 2022 at the beginning (quarter 1) and the end of the year (quarter 4) from the electronic medical records of 75 healthcare organizations. The trends in average rate of cochlear implantation and resultant postoperative known risks or complications were statistically evaluated.

RESULTS

After expansion of HDHPs, the rate of cochlear implantation between quarter 4 (19 cases per year) and quarter 1 (17 cases/year) was similar (p = 0.18). For all patient groups, the case volume significantly increased. Between quarter 4 and quarter 1, postoperative tinnitus was more common in the beginning of the year (risk ratio, 0.68; 95% confidence interval, 0.46-0.99).

CONCLUSIONS

The number of patients receiving CIs significantly increased despite the expansion of HDHPs. Tinnitus was a rare postoperative known risk in the beginning of the year. Patients are less likely concerned about cost of CI surgery because of the impact of hearing loss on quality of life.

National Trends in Cochlear Implantation Across the Department of the Defense: A Case for Inclusion as a General Otolaryngology Core Competency

OBJECTIVE

With ongoing national expansions in cochlear implantation (CI) candidacy criteria, more patients qualify for CI today than ever before. Among US veterans and military service members, the prevalence of qualifying degrees of hearing loss secondary to occupational noise exposure exceeds the general population. The primary aim of the current work was to evaluate CI trends across the military health system.

STUDY DESIGN

Database review.

SETTING

Military and civilian practices.

PATIENTS

Department of Defense (DoD) beneficiaries who underwent CI.

MAIN OUTCOME MEASURES

CI rates between 2010 and 2019.

RESULTS

A total of 3,573 cochlear implant operations were performed among DoD beneficiaries from 2010 to 2019. A majority of patients (55%) were older than 64 years, with the next most commonly implanted age group being 0 to 4 years of age (14%). From 2010 to 2019, annual CI increased at a rate of 7.9% per year for all implantation over the study period ( r = 0.97, p < 0.0001); there was a statistically significant difference of this rate compared with tympanoplasty, which was used as a reference procedure (rate, -1.9%; p = 0.03). This trend was similar for beneficiaries implanted both in military (11.9% per year, r = 0.77, p = 0.009) and civilian facilities (7.7% per year, r = 0.96, p < 0.0001); there was no statistically significant difference between the annual growth rates of these groups ( p = 0.68).

CONCLUSIONS

Although the number of devices implanted is rapidly increasing among DoD beneficiaries, reported national utilization rates remain low. This disparity likely exists in the general public, considering the aging demographic in the West and continual expansions in US Federal Drug Administration labeling. These data suggest that widespread expansion of the procedure to general otolaryngology practices will be required to meet current and future demands for CI. For this reason, CI should be considered for "key indicator" designation among residency training programs.

Incidence of Cochlear Implantation Among Adult Candidates in the United States

OBJECTIVES

To investigate the associations of age and year of cochlear implantation (CI) with CI incidence among adults 20 years and older residing in the US.

STUDY DESIGN

Deidentified cochlear implant data were acquired from prospective patient registries from two cochlear implant manufacturers (Cochlear Americas and Advanced Bionics), which supply an estimated 85% of cochlear implants in the US. Population estimates for severe-to-profound sensorineural hearing loss by age group were extracted from Census and National Health and Nutrition Examination Survey data.

SETTING

US CI centers.

PATIENTS

Adults 20 years and older who underwent CI.

INTERVENTIONS

CI.

MAIN OUTCOME MEASURES

CI incidence.

RESULTS

The study cohort included 30,066 adults 20 years and older who underwent CI from 2015 to 2019. When combining actual and estimated data from all three manufacturers, the annual number of cochlear implants increased 5,406 in 2015 to 8,509 in 2019. Overall, the incidence of CI among adult traditional (bilateral severe-to-profound hearing loss) CI candidates increased from 244 per 100,000 person-years in 2015 to 350 in 2019 ( p < 0.001). Although the elderly (80 years and older) population had the lowest incidence of CI, this cohort experienced the largest growth from an incidence of 105 per 100,000 person-years to 202 during the study period.

CONCLUSIONS

Despite growing incidence among those with qualifying hearing loss, cochlear implants remain widely underutilized. Elderly adults continue to exhibit the lowest relative cochlear implant utilization rates; however, trends over the last half-decade suggest a shift has occurred, resulting in improved access among this underserved subset.