Estimated Costs Associated With Management of Otosclerosis With Hearing Aids vs Surgery in Europe.

Importance: Surgery and hearing aids have similar outcomes in terms of hearing acuity but differ in terms of cost, aesthetics, and patient quality of life. The cost-effectiveness and budget impact of otosclerosis treatments have never been studied in Europe. Objectives: To compare the estimated mean costs per patient over 10 years of surgery vs hearing aids for the treatment of otosclerosis and to estimate the budget impact of an increase in the proportion of patients receiving surgical treatment. Design, Setting, and Participants: This economic evaluation analyzed French and European epidemiological data on the surgical management of symptomatic otosclerosis and compared them with data from the literature to build economic models. The analysis was conducted in January 2021. Exposures: Two care pathways were considered in the treatment of otosclerosis, either hearing aid or surgery. Main Outcomes and Measures: Costs were studied over 10 years using Markov models of the 2 care pathways (hearing aid vs surgery). The budget impact analysis was performed over 5 and 10 years, assuming a 1-percentage point yearly increase in the proportion of patients receiving surgical treatment. Results: Over 10 years, the estimated mean cost per patient was significantly lower in the surgery group compared with the hearing aid group (€3446.9 vs €6088.4; mean difference, -€2641.5; 95% CI -€4064.8 to -€1379.4 [US $3913.4 vs US $6912.4; mean difference, -US $2999.0; 95% CI, -US $4614.9 to -US $1566.1]). Increasing surgical treatment by 1 percentage point per year for 10 years would lead to overall savings of €1 762 304 (US $2 000 798) in France, with an increase of €1 322 920 (US $1 501 952) at 10 years for the public health insurance system and a decrease of €3 085 224 (US $3 502 750) at 10 years for patients and private health insurers. Sensitivity analyses showed that these results were robust. Conclusions and Relevance: These results suggest that in France, treating otosclerosis surgically is slightly less expensive over 10 years than using hearing aids, when considering all payers. The proposed models developed in this study could be adjusted to perform the same analysis in other countries.

Global return on investment and cost-effectiveness of WHO's HEAR interventions for hearing loss: a modelling study.

BACKGROUND: To address the growing prevalence of hearing loss, WHO has identified a compendium of key evidence-based ear and hearing care interventions to be included within countries' universal health coverage packages. To assess the cost-effectiveness of these interventions and their budgetary effect for countries, we aimed to analyse the investment required to scale up services from baseline to recommended levels, and the return to society for every US$1 invested in the compendium. METHODS: We did a modelling study using the proposed set of WHO interventions (summarised under the acronym HEAR: hearing screening and intervention for newborn babies and infants, pre-school and school-age children, older adults, and adults at higher risk of hearing loss; ear disease prevention and management; access to technologies such as hearing aids, cochlear implants, or hearing assistive technologies; and rehabilitation service provision), which span the life course and include screening and management of hearing loss and related ear diseases, costs and benefits for the national population cohorts of 172 countries. The return on investment was analysed for the period between 2020 and 2030 using three scenarios: a business-as-usual scenario, a progress scenario with a scale-up to 50% of recommended coverage, and an ambitious scenario with scale-up to 90% of recommended coverage. Using data for hearing loss burden from the Global Burden of Disease Study 2019, a transition model with three states (general population, diagnosed, and those who have died) was developed to model the national populations in countries. For the return-on-investment analysis, the monetary value of disability-adjusted life-years (DALYs) averted in addition to productivity gains were compared against the investment required in each scenario. FINDINGS: Scaling up ear and hearing care interventions to 90% requires an overall global investment of US$238·8 billion over 10 years. Over a 10-year period, this investment promises substantial health gains with more than 130 million DALYs averted. These gains translate to a monetary value of more than US$1·3 trillion. In addition, investment in hearing care will result in productivity benefits of more than US$2 trillion at the global level by 2030. Together, these benefits correspond to a return of nearly US$15 for every US$1 invested. INTERPRETATION: This is the first-ever global investment case for integrating ear and hearing care interventions in countries' universal health coverage services. The findings show the economic benefits of investing in this compendium and provide the basis for facilitating the increase of country's health budget for strengthening ear and hearing care services. FUNDING: None.

Longitudinal economic analysis of Bonebridge 601 versus percutaneous bone-anchored hearing devices over a 5-year follow-up period.

OBJECTIVES: Percutaneous bone-anchored hearing devices (pBAHDs) are the most commonly used bone conduction implants (BCI). Concerns surround the long-term complications, notably skin-related, in patients with percutaneous abutments. The active transcutaneous BCI Bonebridge system can help avoid some of these pitfalls but is often considered a second-line option due to various factors including perceived increased overall costs. DESIGN: Longitudinal economic analysis of Bonebridge BCI 601 versus pBAHD over a 5-year follow-up period. SETTING: A specialist hearing implant centre. PARTICIPANTS: Adult patients (≥16 years) with conductive hearing loss, mixed hearing loss or single-sided deafness, who received a Bonebridge or pBAHD implant between 1/7/2013 and 1/12/2018 with a minimum 12-month follow-up. MAIN OUTCOME MEASURES: We compared the mean costs per implanted patient for both implants at 1, 3 and 5 years postoperative time points. Clinical effectiveness was evaluated using objective and patient-reported outcome measures. RESULTS: The mean total cost per patient of Bonebridge was significantly higher than pBAHD at 1-year post-implantation (£8512 standard deviation [SD] £715 vs £5590 SD £1394, P < .001); however, by 5-years post-implantation this difference was no longer statistically significant (£12 453 SD £2159 vs £12 575 SD £3854, P > .05). The overall cost convergence was mainly accounted for by the increased long-term complications, revision surgery rates and higher cost of the pBAHD external processor compared to Bonebridge. CONCLUSIONS: Long-term costs of Bonebridge to healthcare providers are comparable to pBAHDs, whilst offering lower complication rates, comparable audiological benefit and patient satisfaction. Bonebridge should be considered as a first-line BCI option in appropriate cases.

Long-Term Incidence and Predictors of Significant Hearing Loss Requiring Hearing Assistive Devices Among Childhood Cancer Survivors: A Population-Based Study.

PURPOSE: Hearing loss is a significant late effect among childhood cancer survivors. Recent guidelines note insufficient evidence to quantify its natural history or risk associated with specific exposures. We examined the long-term incidence and predictors of hearing loss requiring hearing amplification devices (HADs) using population-based health care data. METHODS: In Ontario, Canada, HAD costs are subsidized by the Assistive Devices Program (ADP). Ontario children < 18 years of age at cancer diagnosis between 1987 and 2016 were identified and linked to ADP claims. Cumulative HAD incidence was compared between cases and matched controls. Patient, disease, and treatment predictors of HAD were examined. RESULTS: We identified 11,842 cases and 59,210 controls. Cases were at higher risk for HAD (hazard ratio [HR], 12.8; 95% CI, 9.8 to 16.7; P < .001). The cumulative incidence of HAD among survivors was 2.1% (95% CI, 1.7% to 2.5%) at 20 years and 6.4% (95% CI, 2.8% to 12.1%) at 30 years post-diagnosis. The 30-year incidence was highest in neuroblastoma (10.7%; 95% CI, 3.8% to 21.7%) and hepatoblastoma (16.2%; 95% CI, 8.6% to 26.0%) survivors. Predictors of HAD in multivariable analyses included age 0-4 years at diagnosis (v 5-9 years; HR, 2.2; 95% CI, 1.4-3.3; P < .001). Relative to no cisplatin exposure, patients receiving < 200 mg/m2 were not at greater risk, unlike those receiving higher cumulative doses. Relative to no cranial or facial radiation, those who had received ≤ 32.00 Gy were at no higher risk, unlike those who had received > 32.00 Gy. Carboplatin exposure was not associated with HAD. CONCLUSION: Childhood cancer survivors are at elevated risk for requiring HAD, which continues to increase between 20 and 30 years after diagnosis. Thresholds of cisplatin and radiation exposure exist, above which risk substantially increases. Prolonged monitoring and trials of otoprotective agents are warranted in high-risk populations.

Using a Bone-Conduction Headset to Improve Speech Discrimination in Children With Otitis Media With Effusion.

The recommended management for children with otitis media with effusion (OME) is 'watchful waiting' before considering grommet surgery. During this time speech and language, listening skills, quality of life, social skills, and outcomes of education can be jeopardized. Air-conduction (AC) hearing aids are problematic due to fluctuating AC hearing loss. Bone-conduction (BC) hearing is stable, but BC hearing aids can be uncomfortable. Both types of hearing aids are costly. Given the high prevalence of OME and the transitory nature of the accompanying hearing loss, cost-effective solutions are needed. The leisure industry has developed relatively inexpensive, comfortable, high-quality BC headsets for transmission of speech or music. This study assessed whether these headsets, paired with a remote microphone, improve speech discrimination for children with OME. Nineteen children aged 3 to 6 years receiving recommended management in the United Kingdom for children with OME participated. Word-discrimination thresholds were measured in a sound-treated room in quiet and with 65 dB(A) speech-shaped noise, with and without a headset. The median threshold in quiet (N = 17) was 39 dB(A) (range: 23-59) without a headset and 23 dB(A) (range: 9-35) with a headset (Z = -3.519, p < .001). The median threshold in noise (N = 19) was 59 dB(A) (range: 50-63) without a headset and 45 dB(A) (range: 32-50) with a headset (Z = -3.825, p < .001). Thus, the use of a BC headset paired with a remote microphone significantly improved speech discrimination in quiet and in noise for children with OME.

Direct cost comparison of minimally invasive punch technique versus traditional approaches for percutaneous bone anchored hearing devices.

BACKGROUND: Minimally Invasive Ponto Surgery (MIPS) was recently described as a new technique to facilitate the placement of percutaneous bone anchored hearing devices. The procedure has resulted in a simplification of the surgical steps and a dramatic reduction in surgical time while maintaining excellent patient outcomes. Given these developments, our group sought to move the procedure from the main operating suite where they have traditionally been performed. This study aims to test the null hypothesis that MIPS and open approaches have the same direct costs for the implantation of percutaneous bone anchored hearing devices in a Canadian public hospital setting. METHODS: A retrospective direct cost comparison of MIPS and open approaches for the implantation of bone conduction implants was conducted. Indirect and future costs were not included in the fiscal analysis. A simple cost comparison of the two approaches was made considering time, staff and equipment needs. All 12 operations were performed on adult patients from 2013 to 2016 by the same surgeon at a single hospital site. RESULTS: MIPS has a total mean reduction in cost of CAD$456.83 per operation from the hospital perspective when compared to open approaches. The average duration of the MIPS operation was 7 min, which is on average 61 min shorter compared with open approaches. CONCLUSION: The MIPS technique was more cost effective than traditional open approaches. This primarily reflects a direct consequence of a reduction in surgical time, with further contributions from reduced staffing and equipment costs. This simple, quick intervention proved to be feasible when performed outside the main operating room. A blister pack of required equipment could prove convenient and further reduce costs.

Comprehensive Hearing Aid Intervention at a Free Subspecialty Clinic.

Importance: Providing a model of a comprehensive free audiologic program may assist other health care professionals in developing their own similar program. Objective: To describe the structure, feasibility, and outcomes of a free subspecialty clinic providing hearing aids to develop a paradigm for other programs interested in implementing similar projects. Design, Setting, and Participants: A retrospective case series was conducted from September 1, 2013, through March 31, 2016. In a partnership between a free independent clinic for indigent patients and an academic medical center, 54 indigent patients were referred to the clinic for audiograms. A total of 50 of these patients had results of audiograms available for review and were therefore included in the study; 34 of these 50 patients were determined to be eligible for hearing aid fitting based on audiometric results. Exposures: Free audiometric testing, hearing aid fitting, and hearing aid donation. Main Outcomes and Measures: The number of hearing aids donated, number of eligible patients identified, number of patients fitted with hearing aids, and work effort (hours) and start-up costs associated with implementation of this program were quantified. Results: A total of 54 patients (31 women [57.4%] and 23 men [42.6%]; median age, 61 years; range, 33-85 years) had audiograms performed, and 84 hearing aids were donated to the program. The patients were provided with free audiograms, hearing aid molds, and hearing aid programming, as well as follow-up appointments to ensure continued proper functioning of their hearing aids. Since 2013, a total of 34 patients have been determined to be eligible for the free program and were offered hearing aid services. Of these, 20 patients (59%) have been fitted or are being fitted with free hearing aids. The value of services provided is estimated to be $2260 per patient. Conclusions and Relevance: It is feasible to provide free, comprehensive audiologic care, including hearing aids and fitting, in a well-established, free clinic model. The opportunity for indigent patients to use hearing aids at minimal personal cost is a major step forward in improving access to high-quality care.

Minimally Invasive Ponto Surgery compared to the linear incision technique without soft tissue reduction for bone conduction hearing implants: study protocol for a randomized controlled trial.

BACKGROUND: Over the last years, less invasive surgical techniques with soft tissue preservation for bone conduction hearing implants (BCHI) have been introduced such as the linear incision technique combined with a punch. Results using this technique seem favorable in terms of rate of peri-abutment dermatitis (PAD), esthetics, and preservation of skin sensibility. Recently, a new standardized surgical technique for BCHI placement, the Minimally Invasive Ponto Surgery (MIPS) technique has been developed by Oticon Medical AB (Askim, Sweden). This technique aims to standardize surgery by using a novel surgical instrumentation kit and minimize soft tissue trauma. METHODS: A multicenter randomized controlled trial is designed to compare the MIPS technique to the linear incision technique with soft tissue preservation. The primary investigation center is Maastricht University Medical Center. Sixty-two participants will be included with a 2-year follow-up period. Parameters are introduced to quantify factors such as loss of skin sensibility, dehiscence of the skin next to the abutment, skin overgrowth, and cosmetic results. A new type of sampling method is incorporated to aid in the estimation of complications. To gain further understanding of PAD, swabs and skin biopsies are collected during follow-up visits for evaluation of the bacterial profile and inflammatory cytokine expression. The primary objective of the study is to compare the incidence of PAD during the first 3 months after BCHI placement. Secondary objectives include the assessment of parameters related to surgery, wound healing, pain, loss of sensibility of the skin around the implant, implant extrusion rate, implant stability measurements, dehiscence of the skin next to the abutment, and esthetic appeal. Tertiary objectives include assessment of other factors related to PAD and a health economic evaluation. DISCUSSION: This is the first trial to compare the recently developed MIPS technique to the linear incision technique with soft tissue preservation for BCHI surgery. Newly introduced parameters and sampling method will aid in the prediction of results and complications after BCHI placement. TRIAL REGISTRATION: Registered at the CCMO register in the Netherlands on 24 November 2014: NL50072.068.14 . Retrospectively registered on 21 April 2015 at ClinicalTrials.gov: NCT02438618 . This trial is sponsored by Oticon Medical AB.

Hearing Loss Health Care for Older Adults.

Hearing deficits are highly prevalent among older adults and are associated with declines in cognitive, physical, and mental health. However, hearing loss in the geriatric population often goes untreated and generally receives little clinical emphasis in primary care practice. This article reviews hearing health care for older adults, focusing on what is most relevant for family physicians. The objective of hearing loss treatment is to ensure that a patient can communicate effectively in all settings. We present the 5 major obstacles to obtaining effective hearing and rehabilitative care: awareness, access, treatment options, cost, and device effectiveness. Hearing technologies are discussed, along with recommendations on when it is appropriate to screen, refer, or counsel a patient. The purpose of this article is to provide pragmatic recommendations for the clinical management of the older adult with hearing loss that can be conducted in family medicine practices.

[Hearing aid fitting: Effect of doubling the standard rate on compliance, quality of results, and excess payments]. / Hörgeräteversorgung: Folgen der Festbetragsverdoppelung auf Compliance, Ergebnisqualität und Zuzahlungen.

BACKGROUND: This study investigates the effect that doubling the standard rate for hearing aid fitting which is covered by statutory insurance has had on the size of excess payments and compliance, as well as on benefits for patients and their satisfaction. METHODS: In April 2014, 859 members of a statutory insurance scheme (hkk) who received hearing aids in the 6 months prior to the reform were questioned on the timing and financial details of their hearing aid fitting, as well as on treatment compliance and quality of the results using a standardized questionnaire. In October 2014, the same questionnaire was used to collect these data from a further 622 insurance holders who had received hearing aids in the 8 months following introduction of the new regulation. Most of the questions concerning hearing quality corresponded to those of the Abbreviated Profile of Hearing Aid Benefit (APHAB) questionnaire. RESULTS: The project revealed a statistically significant decrease of 6 percent points in the proportion of hearing aid users who had to pay any excess whatsoever; from 80.6% to 74.1%. However, 40% of the insured persons continued to pay an excess of 1000 euros and more. The subjective hearing quality remained practically unimproved by the reform and was statistically, almost without exception, independent of whether hearing aid users wore expensive devices associated with a large excess, or devices available at the standard rate. Finally, the study confirmed a previously recognized usage pattern characterized by noncompliance. For example, approximately 40% of hearing aid users did not wear their device in the everyday environment. This observation was independent of the size of the excess and the timing of the most recent visit to the hearing aid acoustician. CONCLUSION: Despite doubling of the standard rate, three quarters of patients pay an excess--sometimes a substantial one. The subjective hearing quality was not improved by doubling the standard rate; the majority of patients continue to complain of considerable problems with hearing in difficult situations (environments with background or reverberant noise). Satisfaction with hearing quality is neither dependent on the doubling of the standard rate, nor on whether or not an excess was paid. Compliance may possibly be improved by structured follow-up, which should involve the prescribing otorhinolaryngologists, as well as phoniatrists, pedaudiologists, and hearing aid acousticians.

Cost of placement and complications associated with osseointegrated bone-conducting hearing prostheses: a retrospective analysis of medicare billing data.

OBJECTIVE: To report the cost of placement and complications related to osseointegrated bone-conducting hearing prostheses (OBHPs) in a Medicare population. MATERIALS AND METHODS: We performed a retrospective analysis of nationwide Medicare claims data for operative and nonoperative complications associated with the placement of percutaneous OBHPs between the first quarter of 2007 and the second quarter of 2009 for which there were 6 subsequent quarters of follow-up. We used Medicare Standard Analytical Files (SAF), which contain a 5% random sample of Medicare fee-for-service beneficiaries, excluding those that also were enrolled in a managed-care organization. RESULTS: We identified 118 patients who had OBHPs placed in the requisite period. Their complication billing data were analyzed for the six-quarters after initial placement. Seventy patients (59%) had no billing codes for complications or repeat procedures after receiving the implant, whereas 48 patients (41%) had such codes. The total adjusted mean cost with repeat/revision operations or complications was $7,812 per patient compared with $6,733 for those without these issues, an increase of $1,079 or 16%. DISCUSSION: We estimate that complications associated with the implantation of percutaneous OBHPs led to $417,616 in additional costs in the entire Medicare fee-for-service population during the study period and that the total cost of placement of these devices together with the cost of their complications totaled $6,789,248. In conclusion, the Medicare SAF database suggests that complications associated with OBHP increased the overall cost of placement by 16%. Like all surgical procedures, these complications and their associated costs should be taken into account when considering treatment options for patients who experience hearing loss.

[The Königsteiner Empfehlung of 2012 - essential alterations and modifications]. / Die Königsteiner Empfehlung von 2012 - Wesentliche Neuerungen und Änderungen.

BACKGROUND: Since 1974, the recommendation for assessment of hearing impairment caused by noise - formerly known as "Königsteiner Merkblatt" (now: "Königsteiner Empfehlung") - has been representing the state of the art for the assessment of the occupational disease BK-No. 2301. It was updated several times, the last time in 2012. It provides a summary of the current medical knowledge. A new measurement for the entire working life - the Effective Noise Dose by Liedtke - was introduced. Otoacoustic emissions (OAE) are now the crucial tests in order to detect a hair cell dysfunction. As from now the tinnitus has to be put under a more comprehensive examination. On the strength of post experience the previous speech audiometry (Freiburger Test) is reliable, it was retrained. In future the indication for hearing aids will be oriented towards the aid guidelines of the legal health insurance. The questionnaire for the expert opinion was revised and the fee was adapted.

The effects and costs of a hearing screening and rehabilitation program in residential care homes for the elderly in the Netherlands1.

PURPOSE: This study describes the effects and costs of hearing screening and rehabilitation in residential care homes for the elderly. It was hypothesized that offering an in-house hearing screening and rehabilitation program would be an effective strategy to increase hearing aid ownership among the residents. METHOD: All 705 residents of 8 residential care homes in the Netherlands were invited to participate in a hearing screening (pure-tone audiometry) and rehabilitation (hearing aids) program. Resident participation was analyzed, and the costs were calculated. RESULTS: A total of 243 residents (34%) participated in the screening, 222 (91%) of whom had hearing loss. Ninety-one (41%) of the screening participants with hearing loss started rehabilitation, which was successful for 50 (55%) of them. Hearing aid ownership among the residents with hearing loss increased from 28% at the start of the program to 33% at the end. The costs were €1,896 (US $2,480) per successfully rehabilitated resident. Hearing aid trials and hearing aids together accounted for 83% of the total costs. CONCLUSION: The effectiveness of the program was limited, as hearing aid ownership increased only slightly. Cost reduction measures should focus on decreasing the number of unsuccessful hearing aid trials.