ECONOMICS OF COCHLEAR IMPLANTATION 

COST-EFFECTIVENESS OF CI RELATIVE TO OTHER MEDICAL DEVICES

Cochlear Implantation (CI) is more cost-effective when compared with hearing aids (HAs) and other non-implantable treatments for hearing loss (Bond et al, 2009). From the health care perspective, CI is also more cost-effective when compared with other high cost implantable medical devices, such as pacemakers and implantable cardiac defibrillators. The cost-effectiveness ratios defined as ‘Cost per Quality Adjusted Life Year (QALY) gained’ for these interventions are shown

in Figure 1 - devices are listed from top to bottom in the order of most cost-effective to least cost-effective. Recent reports also suggest that earlier implantation leads to an improvement in the cost-effectiveness of CI, and unilateral or bilateral implantation is more cost-effective compared with no intervention in children and adults.

Cochlear implantation is cost-effective when compared with other treatments. 


COST-EFFECTIVENESS OF IMPLANTATION IS RELATED TO AGE AT IMPLANTATION

CI was more cost-effective in children implanted at age <18 months compared with children implanted at age 18-36 months, and age >36 months respectively (Semenov et al, 2013). Earlier implantation minimises language delays, allowing age- equivalent language development. This translates into related benefits such as higher educational placement, enhanced employment opportunities and productivity (Summerfield and Marshall 1999). CI was cost-saving in children when net savings from education expenses were considered (Schuleze-Gattermann et al, 2002; and Semenov et al, 2013). The total lifetime education cost savings from CI in children ranged from USD $167,000 to $191,000 (Semenov et al 2013).

The cost -effectiveness of CI improved with an earlier age at implantation, and was shown to be cost saving when education costs were included. 

COST-EFFECTIVENESS OF UNILATERAL CI VERSUS NO INTERVENTION

The cost-effectiveness of unilateral CI is illustrated in Figure 2. A comprehensive National Institute of Health and Care Excellence (NICE) health technology assessment (HTA) showed that unilateral CI compared with no intervention was cost- effective in both children and adults (Bond et al, 2009). Chen et al (2014) showed that unilateral CI was cost-effective in adults when compared with HAs or no intervention in the Canadian context. Francis et al (2002) showed unilateral CI in adults aged >50 years to be cost-effective in the US healthcare system. Lee et al (2006) demonstrated the cost-effectiveness of unilateral CI in adults in Korea. These studies used the Health Utility Index (HUI) for measuring health-related QALY.

By contrast, Summerfield et al 2010 used the time-trade off (TTO) method and Visual Analogue Scale (VAS).

Cochlear Implantation was cost-effective when compared with HAs or no intervention. 


COST-EFFECTIVENESS OF BILATERAL CI AND UNILATERAL CI COMPARED WITH HAs

Bond and colleagues (2009) identified shortcomings in the body of knowledge in relation to the clinical effectiveness and cost-effectiveness of bilateral CI and unilateral CI at the time of their review. The NICE review found sequential bilateral implants for children were cost effective compared with unilateral CI when the second implant was discounted at 40%.
They did not present a treatment pathway to identify what treatment options were available, or evaluate the number of assessment visits attended by patients for speech (re)habilitation. The paucity of high-level evidence at the time may account for this. Simultaneous bilateral CI was emerging as a treatment alternative.
 
 
Since this time new and higher levels of evidence show the clinical effectiveness and cost-effectiveness of bilateral and unilateral CI. Children receiving bilateral CI demonstrated better language development when compared with children implanted with unilateral CI. Reducing time by one year between the first and second implant also significantly improved predicted outcomes in language acquisition and speech development as measured by the Peabody Picture Vocabulary Test (p=0.004, Sarant et al. 2014).
 
The cost-effectiveness of bilateral CI is illustrated in Figure 3. Summerfield and colleagues (2010) reported higher stated preference utility measures for simultaneous and sequential bilateral CI when compared with unilateral CI. In 2013, Semenov and colleagues reported on an economic evaluation using a decision analytic model comparing unilateral CI with HAs. They demonstrated the clinical and cost-effectiveness of CI in the US context. Chen and colleagues (2014) reported on an economic evaluation of adults comparing bilateral CI with HAs. Their study demonstrated the cost-effectiveness of simultaneous bilateral CI in adults.
 
In 2013, the Medicaid Scheme (Washington State, U.S.A) approved the coverage of bilateral CI for children and adults based on an evaluation of the clinical and economic evidence by the Washington State Health Care Authority Review (2013).
Bilateral CI and unilateral CI were clinically effective and cost-effective when compared with HAs.
 

CONCLUSION

The cost effectiveness of unilateral CI compared with no intervention or HAs is well-established. To date, a large number of small studies, generally using patients as their own controls, demonstrated that bilateral CI significantly improved speech perception in noise and sound localisation, in children and adults (Bond et al, 2009). The NICE review in 2009 recommended the provision of simultaneous bilateral CI to children born deaf, adventitiously deaf or those newly diagnosed with severe-to-profound bilateral hearing impairment (Bond et al, 2009). Similar recommendations have been made by the Medicaid Scheme of Washington State of the United States more recently (Washington State Health Care Authority Review, 2013).

References:

  1. Bichey, Bradford G., and Richard T. Miyamoto. Outcomes in bilateral cochlear implantation. Otolaryngology-Head and Neck Surgery 2008; 138(5): 655-661. 

  2. Bond M, Mealing S, Anderson R, Elston J, Weiner G, Taylor RS, Hoyle M, Liu Z, Price A, Stein K. The effectiveness and cost-effectiveness of
cochlear implants for severe to profound deafness in children and adults: a systematic review and economic model. Health technology assessment 2009; 13(44):1-330. 

  3. Chen, J. M., Amoodi, H., & Mittmann, N. (2014). Cost-utility analysis of bilateral cochlear implantation in adults: A health economic assessment from the perspective of a publicly funded program. The Laryngoscope, 124(6), 1452-1458. 

  4. Francis HW, Chee N, Yeagle J, Cheng A, Niparko JK. Impact of
cochlear implants on the functional health status of older adults. The Laryngoscope 2002; 112(8):1482-8. 

  5. Heintzbergen, S., Kulin, N. A., IJzerman, M. J., Steuten, L. M., Werle, J., Khong, H., & Marshall, D. A. Cost-Utility of Metal-on-Metal Hip Resurfacing Compared to Conventional Total Hip Replacement in Young Active Patients with Osteoarthritis. Value in health 2013; 16(6), 942-952. 

  6. Lee HY, Park EC, Joong Kim H, Choi JY, Kim HN. Cost-utility analysis of cochlear implants in Korea using different measures of utility. Acta oto-laryngologica 2006; 126(8):817-23. 

  7. Oddershede, L., Riahi, S., Nielsen, J. C., Hjortshøj, S., Andersen, H. R., & Ehlers, L. Health economic evaluation of single-lead atrial pacing vs. dual-chamber pacing in sick sinus syndrome. Europace 2014; 16(6), 866-872. 

  8. Roze, S., Valentine, W. J., Zakrzewska, K. E., & Palmer, A. J. Health economic comparison of continuous subcutaneous insulin infusion with multiple daily injection for the treatment of Type 1 diabetes in the UK. Diabetic Medicine 2005; 22(9), 1239-1245. 

  9. Schulze-Gattermann, H., Illg, A., Lesinski-Schiedat, A., Schoenermark, M., Bertram, B., & Lenarz, T. Pediatric cost-benefit analysis. Laryngo- Rhino- Otologie 2013; 82, (5) 322-329. 

  10. Semenov YR, Yeh ST, Seshamani M, Wang NY, Tobey EA, Eisenberg LS, Quittner AL, Frick KD, Niparko JK, CDaCI Investigative Team. Age-dependent cost-utility of paediatric cochlear implantation. Ear and hearing 2013; 34(4):402-12. 

  11. Summerfield, A. Quentin, and David H. Marshall. “Paediatric cochlear implantation and health-technology assessment.” International Journal of Pediatric Otorhinolaryngology 1999; 47(2) 141-151. 

  12. Summerfield AQ, Marshall DH, Barton GR, Bloor KE. A cost-utility scenario analysis of bilateral cochlear implantation. Archives of Otolaryngology Head & Neck Surgery 2002; 128(11):1255-62. 

  13. Summerfield QA, Barton GR, Toner J, McAnallen C, Proops D, Harries C, Pringle M. Self-reported benefits from successive bilateral cochlear implantation in post-lingually deafened adults: randomised controlled trial. International Journal of Audiology 2006; 45(S1): 99-107. 

  14. Washington State Health Care Authority, 2013. Cochlear Implants: Bilateral versus Unilateral Final. Evidence Report . Health Care Clinical Committee Minutes


 

SOURCE:

Cochlear Ltd, Economics of Cochlear Implantation, February 2015