Late last year the Ear Foundation in the UK released a report entitled “Adult Cochlear Implantation: Evidence and experience – The Case for a Review of Provision”. The report was written by Brian Lamb, OBE and Sue Archbold, PhD and can be found here.
To put this report in context… the UK has led the world in making informed and well grounded decisions about cochlear implantation. In 2009, after extensive research, they published the NICE guidelines for cochlear implantation. These guidelines moved the UK health system to bilateral implantation of children.
These guidelines were well reasoned and soundly based. They were reviewed in 2011 and endorsed unchanged because all further research confirmed the guidelines set in 2009 as correct. In 2013 an internal audit of outcomes of these guidelines was presented and again affirmed the guidelines.
These guidelines have seen a bilateral implantation rate in the UK of around 82% for children. Most of these are now simultaneous implantations – which provide better outcomes and cost less.
Back to this paper… Lamb and Archbold’s paper can be seen as the start of reassessing the UK’s guidelines for adult cochlear implants. They bring together the most recent research which is pointing towards:
- Bilateral cochlear implants for adults
- Lowering the thresholds for implantation
- Changing the way in which these thresholds are assessed
- Increasing the awareness and volume of implants for adults
While the document is written about adult implantation, it has some interesting information pertinent for New Zealand as we wrestle with moving to bilateral implantation for children.
Here is a short summary of the paper as it relates to the New Zealand Government’s need to address the lack of funding of bilateral cochlear implants for children.
Since the NICE review there has been a very substantial change in the overall level of knowledge about the effectiveness of cochlear implantation following a number of additional studies and meta-analyses. There has also been a reduction to the cost of implants while the technology has dramatically improved. These changes are reviewed below and strongly argue for the urgent need to review the NICE guidance on cochlear implantation.
Lamb and Archbold argue that our understanding of the benefits of cochlear implants has substantially improved as has the cost effectiveness of them.
The NICE review and the TAG/NICE report did find the evidence to support the effectiveness of bilateral cochlear implants but due to the limited evidence of additional patient benefit and the assessment of cost effectiveness of the second implant concluded that they could not recommend bilateral implants at that time.Since then there have been a number of studies and technology assessments which have been positive.
The strength of research supporting bilateral implantation has been added to. They go on to conclude…
that bilateral cochlear implantation produces clinically relevant improvements in speech perception in noise.
Studies which also look at self-reported benefits from patients also show that patient perception is that bilateral implants make a significant difference.
Adult cochlear implant users describe the benefits of getting a second cochlear implant as:
Reduced sense of isolation
Improvement at work
Improved social life
Better family relationships
Have 2nd CI in case 1 fails
In a real life sense these benefits are substantial for an adult. For a child, they are critical.
The paper then moves on to some economic changes and arguments. It notes that the cost of devices has reduced by 10-15% since the 2009 guidelines were developed. But more importantly it captures some interesting research on job prospects for those with hearing loss.
Hearing aids have been found to mitigate the effect for those with moderate to severe hearing loss by 65–77% and that those with severe hearing loss who did not use hearing aids had unemployment rates nearly double those who did use amplification (15.6% versus 8.3%).
This suggests, along with what we know about the problems that deaf people have in maintaining successful employment when they suffer profound deafness, that the use of cochlear implantation could have a profound impact on the ability of deaf people to maintain their employment status or gain employment and therefore stay more productive.
If the impact on employment was addressed there would be large economic benefits. A Canadian study 67 concluded that “Cochlear implantation not only improves quality of life but also translates into significant economic benefits for patients and the Canadian economy. These benefits appear to exceed the overall costs of cochlear implantation.” Those having implants saw a significant increase in median yearly income compared to pre implantation of $42,672 vs. $30,432.
These are remarkable figures. They suggest that those with cochlear implants would have half the unemployment rate of those who have profound hearing loss and didn’t have implants. It also suggests their income could be around 50% higher. These figures start to shed light on the massive quality of life and economic benefit that cochlear implants provide. They make the expenditure required to move to bilateral implantation look like a drop in the proverbial bucket.
The paper then goes on to discuss some social care issues…
…“The magnitude of the reduction in cognitive performance associated with hearing loss is clinically significant with the reduction associated with a 25 dB hearing loss being equivalent to an age difference of 7 years.” This is consistent with other studies that have looked at the relationship between declining social networks, which is a common consequence for older people with progressive hearing loss, and the onset of dementia or cognitive decline. It is also the case that when those in the older age group use hearing aids there has been a measured improvement in cognitive ability. Further we know that the risk of death within a year for a socially isolated older person is typically 26 % greater than the risk for a person of the same age who does not report being socially isolated.
While the Government is rightly concerned about the cost of adult social care the impact of hearing loss on this, including the growing association between hearing loss and dementia, is underplayed.
These are thorny issues… the growing body of research associating hearing loss with cognitive degeneration and other negative issues like depression. However they are important issues for both the officials and the Deaf/deaf community to face up to.
In the context of bilateral implantation for kiwi kids, we need to ask the question whether it is really worth doing half the job (unilateral implantation) and exposing our children to what appears to be increased rates of depression and later dementia?
The report concludes by celebrating the great success of the 2009 guidelines for children…
Cochlear implantation for children is now acknowledged as having a dramatic positive impact on children’s capacity to communicate, and consequently on their subsequent social and educational outcomes.
Cochlear implants are a modern miracle. They provide a massive quality of life gain. As the research and experience with them increases, as a nation, we need to ensure we are optimising their use for the benefit of our children and our adults who have hearing loss. This paper steps the debate around what is the optimal use well and truly forward. In New Zealand it puts us yet another step behind the international consensus of what is best practice.