Cost-benefit Analysis of Cochlear Implants: A Societal Perspective.

OBJECTIVES: While the costs and outcomes of cochlear implantation (CI) have been widely assessed, most of these analyses were solely performed from the perspective of healthcare costs. This study assesses the costs and benefits of CI in the Netherlands from a broader societal perspective, including health outcomes, healthcare cost, educational cost, and productivity losses and gains. DESIGN: The cost and benefits of CI were analyzed in this cost-benefit analysis, in which a monetary value is put on both the resources needed and the outcomes of CI. The costs and benefits were analyzed by prototypical instances of three groups, representing the majority of cochlear implant patients: prelingually deaf children implanted at the age of 1, adults with progressive profound hearing loss implanted at the age of 40 and seniors implanted at the age of 70 with progressive profound hearing loss. Costs and benefits were estimated over the expected lifetimes of the members of each group, using a Markov state transition model. Model parameters and assumptions were based on published literature. Probabilistic and one-way sensitivity analyses were performed. RESULTS: In all three patient groups, the total benefits of CI exceeded the total cost, leading to a net benefit of CI. Prelingually deaf children with a bilateral CI had a lifetime positive outcome net benefit of €433,000. Adults and seniors with progressive profound hearing loss and a unilateral CI had a total net benefit of €275,000 and €76,000, respectively. These results ensue from health outcomes expressed in monetary terms, reduced educational cost, and increased productivity. CONCLUSIONS: Based on estimates from modeling, the increased healthcare costs due to CI were more than compensated by the value of the health benefits and by savings in educational and productivity costs. In particular, for children and working adults, the societal benefit was positive even without taking health benefits into account. Therefore, CI generates an advantage for both patients and society.

Psychophysical assessment of spatial spread of excitation in electrical hearing with single and dual electrode contact maskers.

OBJECTIVE: To evaluate psychophysically the spatial spread of excitation in electrical hearing with a new dual contact masker and to investigate under which conditions it is possible to stimulate fibers in the immediate neighborhood of an electrode contact, which were not excited by neighboring electrode contacts. DESIGN: In this study a psychophysical forward masking paradigm with a dual contact masker was used to avoid off-site listening, the electrical analogue of off-frequency listening. The masker stimulus (300 msec) is presented nonsimultaneously on two electrode contacts, one on the apical side and another on the basal side of the probe contact, followed by a probe stimulus of 20 msec.Unmasked probe thresholds were compared with masked ones at a number of masker-probe distances, whereas growth of masking curves were measured for a fixed masker contact pair. Standard selectivity measurements (single contact masking) and the recovery of forward masking with one masker contact were included for comparison with existing methods. All experiments were carried out with six participants who use the Clarion CII device with a HiFocus I electrode array. RESULTS: For dual contact masking the amount of masking was significantly greater than for single contact masking and the width of the masking patterns was on average 1.1 mm broader than for single contact masking, resulting in a broad region of excitation, with masker-probe overlap for distances greater than 3 mm. Masking widths for dual and single contact masking were highly correlated. Growth of masking curves were highly nonlinear. They showed a strong elevation of the slope that starts for most subjects around the middle of the dynamic range or above. For 4 out of 6 subjects, no probe threshold was found above a masker amplitude of about 400-500 microA. The ratio of the maximum measurable masked probe thresholds and unmasked probe threshold ranged from 1.7 to 2.6 (S4 excluded). Recovery of masking functions follow an exponential decay. Time constants tau for the recovery process ranged from 21.6 msec to 114.9 msec. CONCLUSIONS: With a dual contact masker (1) off-site listening can be avoided, leading to larger estimates of the width of excitation patterns than in single contact masking, (2) it can be estimated for which stimulation level there is complete overlap of excitation patterns of adjacent electrode contacts, (3) it can be shown that stimulation of nerve fibers in the immediate neighborhood of an electrode contact which were not excited by neighboring electrode contacts is only possible if the probe stimulation amplitude is sufficiently high in comparison with amplitudes on neighboring contacts.