Cochlear implantation: Are we meeting the standard of care in New Zealand?

 

Michel Neeff, ENT and Cochlear Implant Surgeon questions why only 1 in 20 adults in New Zealand are getting access to life-changing cochlear implant technology.

 


 

For over thirty years in New Zealand, cochlear implants have been transforming the lives of people affected by a severe to profound hearing loss, albeit in small numbers. This year, just 40 adults will receive government funding for a cochlear implant. This funding level has not changed in 7 years. Today, there are 230 people on the waiting list, and every year this number is expected to increase by 40 to 50 people.

According to data from the World Health Organisation in 2019, 432 million adults have a disabling hearing loss, of which, 53 million could benefit from a cochlear implant. Losing your hearing is frightening, which was aptly explained by one client, ”Deafness isolates you from your family, from your friends, from every avenue of previous communication. Likening it to a living death is not too much of an exaggeration.”

Due to the devastating impact of severe hearing loss on their lives, combined with lengthy and uncertain wait times, more and more deaf New Zealanders are putting themselves into debt or turning to their communities to self-fund a cochlear implant.

Auckland teacher, Mark Newman, met the clinical criteria as set out in a new international consensus document on the use of cochlear implants in adults, but due to the strict funding criteria in New Zealand, was unable to access a publically-funded implant. Mark was terrified that he would lose his job, so decided to fundraise for a cochlear implant through Facebook and Givealittle. He got his first implant in December 2017. Two years later, he took out a loan through GEM finance for his second one.

Mark says, “If I had not funded my implants I would have lost my career. I’d already lost my social life and enjoyment of music, I wasn’t prepared to lose anymore.”

As an ENT surgeon, I am seeing more and more patients like Mark, whom I should be able to help in the public health system but cannot due to the exceptionally limited funding available. The inequity of access to treatment for hearing loss in New Zealand is costing, not only the individual but also society.

It is widely accepted that early identification and treatment can prevent the devastating effects of hearing loss; the communication difficulties, the isolation and loneliness, social exclusion, mental health issues and cognitive decline. However, only 1 in 20 adults are getting access to this life-changing technology.

In order to address this shortfall an international, multidisciplinary working group recently reviewed the evidence for cochlear implantation and released the first-ever global consensus on the use of cochlear implants for the management of adults living with hearing loss which contained seven statements as follows.

Level of awareness: 
The level of awareness about the benefits of cochlear implantation remains poor. In NZ only 1:20 patients who would benefit from an implant are actually identified. Even ENT Surgeons and Audiologists are not always aware when a patient should be referred. Physicians, GPs and aged care workers are ideally placed to identify patients early. As a general rule, once a patient is unable to communicate on a mobile phone with an appropriate hearing aid in place a referral for a cochlear implant assessment is appropriate. The implant programme is aiming to simplify the referral process to make access for an assessment easier.

Best practise clinical pathway for diagnosis:
Once a significant hearing loss is suspected a referral to an audiologist should be arranged. A pure tone audiogram, a speech audiogram and an aided audiogram will be performed. The audiologist or referrer can discuss the results with the cochlear implant team and a review can be arranged if appropriate. Remember that age is no barrier to cochlear implantation. The oldest cochlear implant recipient in the Northern Programme in NZ was well over 80 years old!

Best Practise Guidelines for surgery:
Surgical techniques have been well defined and the electrodes refined over the years. Surgery aims to preserve the inner ear structure to preserve any residual hearing where present (soft surgery). This results in less scarring and better hearing outcomes. The residual hearing can be an additional boost for the cochlear implant hearing. Apart from improved hearing, cochlear implants can reduce tinnitus and improve balance.

Clinical effectiveness of cochlear implants:
Cochlear implants are the standard of care for severe to profoundly hearing impaired postlingually deaf patients and prelingually deaf children younger than 5. Cochlear implants significantly improve speech recognition in quiet and in noise. Cochlear implants are main stream devices and need to be considered when managing hearing impaired patients. The earlier a patient receives an implant, the better the outcome.

Factors associated with post-implant outcomes:
Even though early implantation is favoured, a prolonged period of severe hearing loss is no contraindication for cochlear implantation. Soft surgery leads to better hearing outcomes and residual hearing can be used to also stimulate the natural hearing pathway in conjunction with cochlear implant hearing. Using a cochlear implant in one ear and a hearing aid in the other (bimodal hearing) can also provide additional hearing benefit and is encouraged.

Improved cognitive health:
Improving hearing loss by cochlear implantation has significant positive effects on depression, loneliness, isolation, and memory loss and dementia. The Northern Cochlear Implant Programme recently demonstrated improved quality of life and social interaction for all cochlear implant recipients tested. A recent publication in the Lancet (2017) demonstrated that hearing loss is a modifiable risk factor in dementia. Early implantation is of utmost importance.

Cost implications of cochlear implantation:
Cochlear implantation is the 3rd most cost-effective intervention. Working-age cochlear implant recipients have a much higher chance to return to regular employment, for governments a life-long downstream saving in terms of benefits not having to be paid. There are also across sector savings as CI recipients have fewer falls/accidents, less depression, less memory loss which would otherwise require funding to manage these conditions.

Unfortunately, cochlear implants remain seriously underfunded in NZ and we are not meeting the standard of care. Since 2003, 17 adults have died while on the waiting list for a cochlear implant. For many others, they languish for more than two years, living with the uncertainty of when they might get their hearing restored, and their lives back. 

As physicians, we should not be playing God and making life-changing decisions about who should and should not get their hearing restored. There is nowhere else for patients to go. A cochlear implant is their last hope. We need to do better. 

The New Zealand government needs to step up and urgently address this growing crisis.

For more information on cochlear implants for adults, please visit: www.pindrop.org.nz

For a comprehensive overview of the consensus paper, please visit: www.adulthearing.com