Barriers to Cochlear Implantation

INTRODUCTION: Cochlear implantation (CI) is the most effective treatment for profound sensorineural hearing loss, despite the low utilization of CI in the United States. Only about 5-7% of CI-eligible adults pursue CI, for reasons which remain unclear. OBJECTIVE: Our research has two primary aims: 1) to identify sociodemographic disparities in CI in Texas and explore trends using an all-payer database from 2010-2017; and 2) to investigate patient-reported barriers to, and motivators for, pursuing CI. METHODS: Aim 1) The publicly available Texas Outpatient Surgical and Radiological Procedure Data was accessed to analyze outpatient CI cases in the entire state of Texas. Variables analyzed include patient age, sex, race/ethnicity, and insurance status. Population data from the American Community Survey were utilized to generate CI utilization rates by patient demographic characteristics. Insurance data was obtained from the Kaiser Family Foundation. Aim 2) A single-institutional review of CI candidates between December 2010 and December 2018 was performed to identify patients who did not pursue surgery, as well as those who pursued surgery after a delayed time period or at a different institution. A 21-question survey was developed internally, aimed at identifying and ranking patients' concerns regarding surgical risks, adaptation to the CI, time commitment to adapt, costs, loss of residual hearing, and lack of benefit. Current hearing aid usage and familiarity with other CI users were also analyzed. The survey was administered via email or telephone. RESULTS: Aim 1) 6,158 CI cases were identified during the study period. The number of CI per year nearly doubled from 497 in 2010 to 961 in 2017. The majority of CI recipients were white (59.5%), male (51.9%), and privately insured (47.9%). Patients over 75 demonstrated the greatest increase in the CI rate per 100,000 population, increasing from 4.60 in 2010 to 14.30 in 2017. All racial/ethnic groups noted an increase in the CI per 100,000 population, with white patients demonstrating the highest rate in 2017, at 4.36 CI per 100,000 population. Asian patients had a 502% increase in the CI rate (from 0.42 to 2.53), compared with 87.9%, 84.4%, and 69.2% increases for White, Black, and Hispanic populations, respectively. Medicaid recipients were the only insurance group that did not experience a statistically significant growth from 2010-2017 (3.27 to 3.49, p=0.26). Aim 2) Fifty-two survey responses were received, comprised of 27 patients who did not pursue CI and 25 patients who did. The most commonly reported barrier was a belief that CI would not significantly improve the ability to communicate, followed by concerns over the post-operative recovery process, risks of surgery, and risks of losing music appreciation. Anesthetic risk and cost were the least important reasons not to pursue CI. The most commonly reported facilitator was a belief that hearing loss was affecting job performance. CONCLUSIONS: CI became more widespread between 2010-2017; however, vast disparities exist in who benefitted most from this growth in CI. Black and Hispanic populations had lower CI per 100,000 population than their white peers, while patients >65 years of age accounted for the greatest increase in CI. Moreover, the decision not to pursue CI despite eligibility is multifactorial and includes concern for minimal hearing benefit and perioperative risks. These factors should be taken into consideration when counseling patients on CI surgery. Resources should be devoted to promote CI to disadvantaged groups as identified in our research.