Measuring disability-specific patient benefit in cochlear implant programs: developing a short form of the Glasgow Health Status Inventory, the Hearing Participation Scale

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.

[Validity and reliability of the Nijmegen Cochlear Implant Questionnaire in German]

Hintergrund

Der Nijmegen Cochlear Implant Questionnaire (NCIQ) ist ein krankheitsspezifischer Fragebogen zur Erhebung der gesundheitsbezogenen Lebensqualität von Patienten vor und nach Cochleaimplantation.

Ziel der Arbeit

Validierung und Reliabilitätsprüfung der deutschen Übersetzung des NCIQ.

Material und Methoden

Es wurde eine prospektive Studie an 100 postlingual ertaubten oder hochgradig schwerhörigen Patienten durchgeführt, welche präoperativ sowie 3 und 6 Monate nach einer Cochleaimplantation mittels NCIQ, Abbreviated Profile of Hearing Aid Benefit (APHAB) und Hearing Participation Scale (HPS) untersucht wurden. Als Kontrolle fungierte ein postlingual ertaubtes oder hochgradig schwerhöriges, unbehandeltes Patientenkollektiv (n = 54). Cronbach‑α und Test-Retest-Reliabilität dienten der Reliabilitätsüberprüfung. Es wurde auf Inhalts‑, Übereinstimmungs- und auf diskriminative Validität getestet. Die Konstruktvaliditätsprüfung basiert auf kürzlich veröffentlichen Daten. Als Gütekriterien wurden die Sensitivität und eine ROC(„Receiver Operating Characteristic“)-Analyse, inklusive AUC(„Area Under the ROC Curve“)-Betrachtung, eingesetzt.

Ergebnisse

Das Test-Retesting ergab nach 3 und 6 Monaten postoperativ stabile NCIQ-Werte. Die Cronbach-α-Werte wiesen auf eine gute interne Konsistenz hin. Der NCIQ diskriminierte valide zwischen behandelten und unbehandelten Patientengruppen. Es ergaben sich statistisch signifikante, wenn auch schwache, Korrelationen zwischen dem NCIQ und dem APHAB (r = −0,22; p = 0,04) und dem HPS (r = 0,30; p = 0,01). Sensitivitäts- und ROC-Analysen zeigten eine gute Messqualität des deutschsprachigen NCIQ.

Schlussfolgerung

Die deutsche Übersetzung des NCIQ misst zuverlässig und valide die Lebensqualität vor und nach Cochleaimplantation und kann zur klinischen Erfolgskontrolle nach Cochleaimplantationen verwendet werden.

Cross-cultural adaptation and Italian validation of chronic otitis media outcome test 15 (COMOT-15)

Objective

Chronic suppurative otitis media (CSOM) may result in a serious impairment of the quality of life (QoL). The most relevant characteristics of CSOM are well represented in the “Chronic Otitis Media Outcome Test 15” questionnaire (COMOT-15). The aim of the study was to translate and adapt the COMOT-15 questionnaire into Italian.

Methods

This is a prospective study conducted on 52 Caucasian Italian-speaking patients with CSOM and 52 controls. The linguistic adaptation of the COMOT-15 consisted of the translation of the English version into Italian and reliability assessment of the translation. Psychometric measurements included internal consistency and test–retest reliability.

Results

Cronbach’s α was 0.95. The test-retest reliability showed a strong positive correlation for total score and all subscales. Age and gender had no influence on the scores. The correlation between the COMOT-15 and the pure tone average showed a significant association for the scale “Hearing Function”.

Conclusions

The Italian COMOT-15 questionnaire provides good internal consistency and is suitable for QoL evaluation in Italian-speaking patients suffering from CSOM. In addition, it is able to evaluate the subjective symptoms perceived by patients.

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.

Quality of life assessment in paediatric cochlear implant recipients in South India: Parental assessment and correlation with rehabilitation scores using a bilingual quality of life assessment questionnaire

Objectives: To assess the quality of life (QoL) of prelingually deaf paediatric population after Cochlear implantation (CI), using a bilingual questionnaire and to correlate with rehabilitation scores; to validate the questionnaire and recommend its use in future studies.Methods: This was a questionnaire based cross-sectional study. Parents of 151 paediatric prelingual CI recipients filled the questionnaire using a 5-point rating scale, with a score of 1-5. These scores were correlated with the CAP and SIR scores.Results and discussion: There was a positive correlation of QoL score with rehabilitation outcomes (r = 0.4638 and P ≤ 0.00001 for CAP; r = 0.3563 and P ≤ 0.00001 for SIR scores). The maximum scores (≥4.0) were given by parents for integration into educational system (4.86), response to environmental sounds (4.12) and overall parental satisfaction about child's performance (4.09). Minimum scores were given for ability to speak in sentences (2.9) and response to verbal sounds at a distance (3.23).Conclusion: The QoL of these children as assessed by the institutional questionnaire have correlated with the rehabilitation outcomes. These QoL results have a positive impact in counselling for early CI as well as for rehabilitation.

Prospective Evaluation of Cognitive Functions After Rehabilitation With Cochlear Implant or Hearing Aids: Preliminary Results of a Multicentric Study on Elderly Patients

Objective Recent literature has shown a growing interest in the relationship between presbycusis and cognitive decline, but significant evidence about the long-term benefit of rehabilitation on cognitive functions has not been reported yet. The aim of the study was to analyze audiological and neuropsychological performances in patients with cochlear implant (CI) or hearing aids (HAs) over time. Materials and Method Forty-four bilaterally deaf patients aged more than 60 years (25 with CI candidacy and 19 with HA candidacy) were enrolled. Patients were subjected to audiological evaluation, to a battery of neuropsychological tests (Mini-Mental State Examination [MMSE], Rey Auditory Verbal Learning Task [RAVLT], Rey-Osterreith Complex Figure Test, Digit/Corsi Span Forward and Backward, Multiple Features Target Cancellation, Trail-Making Test, Stroop Test, and Phonological and Semantic Word Fluency), and to a quality of life assessment (Short Form 36, Glasgow Benefit Inventory, Glasgow Health Status Inventory) at the baseline and after a long-term follow-up (6-12 months). Results Speech recognition scores in quiet and in noise were significantly improved even 6 months after auditory rehabilitation. Significant differences between pre- and post-rehabilitation scores were reported in physical and emotional impacts in life, general global health, vitality, and social activities. MMSE and RAVLT scores were significantly improved in both groups after 6 months of follow-up, suggesting a global involvement of memory domain. Mnesic performances remained unchanged between the first and second follow-up, but a further significant improvement in executive functions (Stroop Test) was detected in patients with CI reevaluated 12 months after implantation. A significant correlation of the RAVLT with signal-to-noise ratio at +10 dB speech-in-noise scores and the MMSE with signal-to-noise ratio at 0 dB speech-in-noise scores suggests the pivotal role of executive functions in recognition in noisy environment. Conclusions Our preliminary data confirm that hearing deprivation in aged patients represents a truly modifiable risk factor for cognitive decline, which can be positively faced by acoustic rehabilitation. The improvement of short- and long-term memory performances and the amelioration of executive and attentive functions suggest that hearing restoration with both HAs and CI may provide a recovery of superior cognitive domains probably through a reallocation of cortical resources altered by hearing deprivation.

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.

The impact of personality on adult patients' adjustability to orthodontic appliances

OBJECTIVE

To evaluate the impact of psychological traits on patients' choice of orthodontic appliances and their adjustability to orthodontic treatment.

MATERIALS AND METHODS

The sample consisted of 68 adult patients divided into three groups (28 buccal, 19 lingual, and 21 clear aligners). Prior to treatment participants filled out the Brief Symptom Inventory to assess symptoms of mental distress and the Narcissistic Vulnerability Scale to assess narcissistic personality traits. During the first week after appliance delivery and on day 14, patients completed a Health-Related Quality of Life questionnaire to assess their perception of pain and four areas of dysfunction. The correlation between personality traits and patients' reaction to treatment was evaluated.

RESULTS

Somatization was the only trait that affected the choice of lingual and clear aligner appliance. Reduced self-esteem regulation was associated with increased pain in all patients, while exploitation was associated with pain in lingual patients. Narcissistic vulnerability slightly influenced patients' adaptability to orthodontic appliances. Although adjustability to lingual appliances was the most difficult, only two parameters were affected by personality features. In the buccal group, adjustability was affected by numerous parameters. Adaptation to the clear aligner appliance was relatively uneventful and least affected by psychological features.

CONCLUSION

Anxious individuals tend to prefer lingual and clear aligner appliances. The selection of lingual and clear aligner appliances governs the patient's response and recovery process, leaving little room for the effect of psychological features. On the other hand, the buccal appliance allows for greater impact of personality traits on adjustability.

Prevalence & characteristics of severe and profound hearing loss in adults in a UK National Health Service clinic

OBJECTIVE

To estimate the prevalence of severe and profound hearing loss in a clinical population and to report the audiological and hearing-aid characteristics for this group, as well as outcome measures from use of hearing aids.

DESIGN

A retrospective observational study initially, followed by a postal Glasgow health status inventory (GHSI) to establish the patients functional outcomes.

STUDY SAMPLE

A clinical database of 32 781 cases was interrogated from which 2199 cases of severe /profound hearing loss were identified. From these, an adult sample stratified in terms of age and gender of n = 302 was contacted.

RESULTS

An estimated 6.7% of the local clinical population and 0.7% of the general population were found to have hearing > 70 dB averaged over 0.5, 1, and 2 kHz. Most patients were fitted with bilateral hearing aids, using a non-linear prescription, and as a group they reported a high level of social support.

CONCLUSIONS

This study has estimated the prevalence of severe and profound hearing loss as 6.7% of the clinical population, and 0.7% of the general population. This is consistent with previous work, although it probably underestimates the prevalence. Further work is indicated to strengthen the estimate.

The health impact of a hearing disability on older people in Australia

OBJECTIVES

A series of studies has proposed that hearing loss has adverse effects for other aspects of health. This article examines the health effects associated with self-reported hearing disability on older people.

METHODS

The study utilized the 2003 Australian Survey of Disability, Ageing, and Carers (n = 43,233), a weighted population-based survey providing data on self-reported disability and quality of life, to examine hearing disability among older Australians (55 years plus).

RESULTS

Of the estimated 654,113 people reporting hearing disability, 71% experienced limited communication and 60% used hearing aids. Compared with population norms, hearing disability at all levels was associated with poorer physical and mental health scores on the SF-12 measure, especially for people with severe or profound hearing loss, thus suggesting a threshold effect at advanced levels of disability.

DISCUSSION

Data support emerging literature suggesting a causal relationship between hearing disability and quality of life. Prospective studies to further examine this relationship are indicated.

Health-related quality-of-life outcomes from adult cochlear implantation: a cross-sectional survey

PURPOSE

The purpose of this study was to examine the extent to which cochlear implants and related rehabilitation improve health-related quality-of-life (HRQoL) and social participation for deafened adults and their partners.

METHOD

A cross-sectional survey was used to examine HRQoL and social participation experiences of 202 deafened adults (148 with implants and 54 without) and 136 partners associated with cochlear implant clinics in Australia and New Zealand. Respondents completed a mailed survey consisting of the Assessment of Quality of Life instrument (a utility instrument), the Participation Scale and questions concerning their socioeconomic status. Both univariate and multivariate analyses were performed.

RESULTS

Controlling for socioeconomic factors, people with cochlear implants reported improved HRQoL and social participation when compared with non-implantees. Implantees reported a relative gain in health utility of 50%, and a relative improvement in social participation of 31%. Such differences were not reported by partners, although patient and partner HRQoL were weakly correlated.

CONCLUSION

The results of this cross-sectional study suggest that cochlear implantation contributes significantly to improvements for deafened adults in everyday communication settings and makes a major contribution to their HRQoL. Nonetheless, when compared with population-based studies, this population continues to report considerably reduced quality of life. Partners also report significantly reduced quality of life when compared to population norms.

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

This paper prospectively documents the health-related quality of life (HRQoL) and social participation benefits of adult patients receiving cochlear implants in Australia and New Zealand. Thirty-four consecutively implanted patients completed the Assessment of Quality of Life (AQoL) and Hearing Participation Scale (HPS) instruments before implantation, and at 3- and 6-month follow-ups. Implantation resulted in significant improvements in AQoL and HPS scores, The effect size was 1.09 for both measures. Those in the top socio-economic tertile obtained the greatest gains. The HRQoL and social participation benefits were slightly larger than those reported elsewhere. This may be because participants used more recent technology (Nucleus 24 rather than Nucleus 22) and received auditory and self-efficacy training as part of their rehabilitation. The results suggest that cochlear implants have a large beneficial effect. They show that social and HRQoL outcomes can be parsimoniously measured using the HPS and AQoL instruments.

Suggested response criteria for phase II antitumor drug studies for neurofibromatosis type 2 related vestibular schwannoma

Neurofibromatosis type 2 (NF2) is a tumor suppressor gene syndrome characterized by multiple schwannomas, especially vestibular schwannomas (VS), and meningiomas. Anticancer drug trials are now being explored, but there are no standardized endpoints in NF2. We review the challenges of NF2 clinical trials and suggest possible response criteria for use in initial phase II studies. We suggest two main response criteria in such trials. Objective radiographic response is defined as a durable 20% or greater reduction in VS volume based on post-contrast T1-weighted MRI images collected with 3 mm or finer cuts through the internal auditory canal. Hearing response is defined as a statistically significant improvement in word recognition scores using 50-word recorded lists in audiology. A possible composite endpoint incorporating both radiographic response and hearing response is outlined. We emphasize pitfalls in response assessment and suggest guidelines to minimize misinterpretations of response. We also identify research goals in NF2 to facilitate future trial conduct, such as identifying the expectations for time to tumor progression and time to measurable hearing loss in untreated NF2-related VS, and the relation of both endpoints to patient prognostic factors (such as age, baseline tumor volume, and measures of disease severity). These data would facilitate future use of endpoints based on stability of tumor size and hearing, which might be more appropriate for testing certain drugs. We encourage adoption of standardized endpoints early in the development of phase II trials for this population to facilitate comparison of results across trials of different agents.

Acquired profound hearing loss: mental health and other characteristics of a large sample

The study investigated the mental health and other characteristics of people with acquired profound hearing loss (APHL) and contrasted this group with acquired hearing loss (AHL) in general. A survey was completed over the internet by 95 adults and by 27 people who had attended a one-week course of rehabilitation. The latter group completed questionnaires of anxiety and depression, post-traumatic stress, and hearing handicap. The survey covered a wide range of factors associated with the history of hearing loss and evaluated previous contacts with professional services. The data from the two samples were very similar and were combined. The results indicated the existence of sudden and progressive onset groups, reliance on lip-reading, a severe effect of tinnitus, and some support for the conclusion that the psychosocial impact was greater in APHL than in AHL. A subgroup of APHL was severely distressed and handicapped. Respondents valued medical and audiological services but there was little evidence that previous counselling and support had been helpful. Recommendations for rehabilitation are briefly discussed.

Measuring communicative participation: a review of self-report instruments in speech-language pathology

PURPOSE

To assess the adequacy of self-report instruments in speech-language pathology for measuring a construct called communicative participation.

METHOD

Six instruments were evaluated relative to (a) the construct measured, (b) the relevance of individual items to communicative participation, and (c) their psychometric properties.

RESULTS

No instrument exclusively measured communicative participation. Twenty-six percent (n = 34) of all items (N = 132) across the reviewed instruments were consistent with communicative participation. The majority (76%) of the 34 items were associated with general communication, while the remaining 24% of the items were associated with communication at work, during leisure, or for establishing relationships. Instruments varied relative to psychometric properties.

CONCLUSIONS

No existing self-report instruments in speech-language pathology were found to be solely dedicated to measuring communicative participation. Developing an instrument for measuring communicative participation is essential for meeting the requirements of our scope of practice.

Health-related quality of life of Austrian children and adolescents with cochlear implants

BACKGROUND AND OBJECTIVE

As shown by many studies, deaf children benefit considerably by cochlear implants (CI), concerning oral language and integration in mainstream schools. This had lead to the general view of a good quality of life of these children. Unfortunately so far nearly no studies on quality of life, and specially no studies on health-related quality of life (HRQoL) of children with cochlear implants, have been published. The present study with the objective for first, initial information on health-related quality of life of Austrian pupils with cochlear implants is a first step to fill this gap.

METHODS

Forty-four Austrian pupils, out of 65 candidates, age 8-16, with a hearing experience of at least 3 years with implants, and their parents were surveyed in the CI Center, Salzburg (cross sectional study). Basic medical and audiological data were available for all pupils. Because of reading comprehension difficulties 15 pupils were excluded. Parents and children were surveyed with the KINDLr, a generic instrument for health-related quality of life of children and adolescents. Main outcome measures were the HRQoL-total scores (mean, transformed to 100, standard deviation). In addition, 95% confidence intervals, effect sizes, t scores (one- and two-sided t-tests), rank order correlations and coefficients of determination were calculated.

RESULTS

The HRQoL-total score of the children with CI (n=18), age 8-12 was below the standard for hearing children (P<0.001). It differed from the total score of the parent rating (P<0.0001). The difference between the parent ratings of non-excluded and of excluded children (n=12) was not significant. The total score of the adolescents (n=11), age 13-16 was within the norm, with no significant difference between adolescent and parents. The total scores correlate with parent-child agreement in the ratings, with outcomes of audiological speech tests, length of time of deafness, and age at implantation.

CONCLUSIONS

Children with CI experience a lower health-related quality of life, compared to hearing children, with a low parent-child agreement. The findings of this study point to a normal subjective health of adolescents with CI.