Provincial Variation of Cochlear Implantation Surgical Volumes and Cost in Canada

Cochlear Implant Decision Making for Children With Residual Hearing: Perspectives of Practitioners

PURPOSE

Cochlear implants (CIs) are increasingly considered for children with residual hearing who benefit from hearing aids (HAs). However, the decision-making process for families of these children and for practitioners is particularly challenging because there is no clear audiological cut point for CI candidacy. This study aimed to understand Canadian practitioners' perspectives of the CI decision-making process and how they guide families of children with residual hearing.

METHOD

Semistructured interviews were conducted with a total of 17 practitioners through four focus groups and one individual interview. Interviews were transcribed verbatim, and a thematic analysis was carried out.

RESULTS

Data were organized into five broad domains: candidacy issues for children with residual hearing, practitioners' roles in decision support, additional considerations affecting decision making, factors facilitating decision making, and practitioners' needs.

CONCLUSIONS

This study found that practitioners' confidence in determining candidacy and supporting parents has increased due to their experiences with positive outcomes for these children. Practitioners indicated that there was a need for more research to guide the decision-making process.

Regional variation in cost of neonatal intensive care for extremely preterm infants

Background

Regional variation in cost of neonatal intensive care for extremely preterm infant is not documented. We sought to evaluate regional variation that may lead to benchmarking and cost saving.

Methods

An analysis of a Canadian national costing data from the payor perspective. We included all liveborn 23–28-week preterm infants in 2011–2015. We calculated variation in costs between provinces using non-parametric tests and a generalized linear model to evaluate cost variation after adjustment for gestational age, survival, and length of stay.

Results

We analysed 6932 infant records. The median total cost for all infants was $66,668 (Inter-Quartile Range (IQR): $4920–$125,551). Medians for the regions varied more than two-fold and ranged from $48,144 in Ontario to $122,526 in Saskatchewan. Median cost for infants who survived the first 3 days of life was $91,000 (IQR: $56,500–$188,757). Median daily cost for all infants was $1940 (IQR: $1518–$2619). Regional variation was significant after adjusting for survival more than 3 days, length of stay, gestational age, and year (pseudo-R² = 0.9, p < 0.01). Applying the model on the second lowest-cost region to the rest of the regions resulted in a total savings of $71,768,361(95%CI: $65,527,634–$81,129,451) over the 5-year period ($14,353,672 annually), or over 11% savings for the total program cost of $643,837,303 over the study period.

Conclusion

Costs of neonatal intensive care are high. There is large regional variation that persists after adjustment for length of stay and survival. Our results can be used for benchmarking and as a target for focused cost optimization, savings, and investment in healthcare.

Cochlear implants in Japan: Results of cochlear implant reporting system over more than 30 years

OBJECTIVE

To conduct a longitudinal national survey of cochlear implantation (CI) in Japan from 1985 through 2017.

METHODS

A retrospective analysis of adult and pediatric CI cases from 1985 to 2017 using the Oto-Rhino-Laryngological Society of Japan CI registration database was conducted. Surgical statistics were obtained, including number of surgeries, age, implanted side, facilities, and preoperative threshold levels for CI.

RESULTS

Since 1985, more than 11,100 CI surgeries have been conducted in Japan. The number exceeded 500 in 2005 and 1,000 in 2015. Since 2007, pediatric cases consistently surpassed adult cases until 2016. More facilities meet criteria for conducting CI as determined by Ministry of Health, Labor and Welfare and have now reached more than 100. Adult patients over 70 years old have become proportionally higher. Age at implantation steadily reduced in accordance with modifications of Japanese CI guidelines for children but is still not comparable to that in other developed countries. Although the number of CI surgeries for patients with moderate to severe hearing loss increased in the past ten years, the proportion was small.

CONCLUSIONS

The CI database in Japan is quite unique in that it documents almost all the CI surgeries in Japan, allowing us to summarize the present situation as follows: fewer CI surgeries occur than are necessary, and children receiving implants are older than those in other developed countries. Continuous improvement of CI awareness is needed in Japan.

Geographic Disparities in US Veterans' Access to Cochlear Implant Care Within the Veterans Health Administration System

Importance

Veterans are at high risk for developing sensorineural hearing loss leading to cochlear implant (CI) candidacy; however, the ability to care for these patients is limited by the number and location of Veterans Health Administration (VHA) facilities that provide specialized CI services.

Objective

To investigate geographic disparities in access to CI care within the VHA system for US veterans.

Design, Setting, and Participants

An analysis of census tract-level data including US veterans was conducted using the nationwide American Community Survey data collected by the US Census Bureau from January to December 2016, which were accessed in 2017.

Main Outcomes and Measures

Maps showing the geographic variability in need for specialized CI services, estimated as a function of the number of veterans and the distance to the nearest established VHA-based CI surgical or audiologic facilities.

Results

A total of 19.9 million veterans within the continental United States resided at a median distance of 80 miles (interquartile range [IQR], 30.1-140.9 miles; mean [SD], 1002 [465.8] miles) from the nearest VHA facility offering CI care; of these, 3.98 million (20.0%) resided more than 160.7 miles from the nearest VHA facility. When considering only comprehensive facilities offering both surgical and audiologic care, the median distance was 101.3 miles (IQR, 39.4-178.7 miles; mean [SD], 126.0 [448.4] miles), but 20.0% of veterans had to travel more than 201.0 miles to a VHA facility. Veterans residing in urban areas (74.0%) lived a median distance of 61.2 miles (IQR, 23.7-121.3 miles; mean [SD], 83.8 [477.1] miles) from the nearest VHA facility, with 2.9 million (20.0%) living the farthest at 140.7 miles. Veterans residing in rural areas (26.0%) lived a median distance of 119.8 miles (IQR, 79.0-182.4 miles; mean [SD], 146.9 [431.0] miles) from their nearest VHA facility, with 1.04 million (20.0%) living more than 206.2 miles from the nearest VHA facility.

Conclusions and Relevance

This study's findings suggest that large disparities exist in the distance to the nearest VHA-based CI facilities. Veterans face considerable geographic barriers to obtaining VHA-based CI care in many parts of the country, including some large metropolitan areas. Those requiring only audiologic services face similar geographic barriers as those requiring surgery. Thoughtful placement of new facilities, along with upcoming advances in remote programming of implants, may help ensure appropriate care for this high-risk population.