Underinsurance in children is associated with worsened quality of life after cochlear implantation.

IMPORTANCE: Research has suggested that early cochlear implantation is associated with improved language outcomes. Select studies demonstrate that this translates into a higher quality of life following implantation. Previous work from our group has shown that underinsurance represents a risk factor for worsened auditory and language outcomes for implantees. However, to our knowledge, the effect of insurance status on quality of life outcomes following cochlear implantation has not been evaluated. OBJECTIVE: To assess quality of life outcomes for children receiving cochlear implants, accounting for age at implantation, insurance status, gender, surgeon, number of implants and duration of follow-up since implantation. DESIGN: A retrospective study using the Glasgow Children's Benefit Inventory (GCBI), a validated questionnaire measuring quality of life across four domains: learning, emotion, vitality and physical heath. Multivariate linear regression was used to examine the effects of age at implantation, insurance status, number of implants, sex, surgeon, and duration of follow-up on GCBI scores. Age at implantation was assessed as both a continuous and dichotomous variable, comparing children implanted by 12 months of age with those implanted after 12 months. SETTING: Children's National Health System in Washington, DC, a tertiary academic referral center. PARTICIPANTS: The GCBI was administered telephonically to parents/guardians of prelingually deaf children aged 2-16 years who received cochlear implants at the center between January 1, 2008 and December 31, 2018. RESULTS: Of 169 prelingually deafened implantee children who met inclusion criteria, parents/guardians of 64 (37.9%) responded to the questionnaire. After excluding children with late implantation (≥7 years age at CI) and missing GCBI responses, the final analytic sample consisted of 57 children. The mean age (SD) of the children at the time of the study was 3.3 (1.9) years, 63.2% were publicly insured, and 73.7% were implanted after 12 months of age. Average duration of follow-up was 3.9 (2.8) years. On a scale of -100 to +100, GCBI scores ranged from 41.7 to 95.8 (mean (SD), 64.0 (10.3)). Public health insurance (ß, -5.8 [95% CI, -10.6 to -0.01]), and older age at the time of implantation (ß, -0.1 [95% CI, -0.3 to 0.0]), particularly implantation following 12 months of age (p < 0.05), were significantly associated with lower GCBI scores after implantation. CONCLUSION: Publicly insured recipients of cochlear implants and children implanted at an older age, particularly after 12 months of age, experienced significantly lower quality of life measures.

Delays in Sound Recognition and Imitation in Underinsured Children Receiving Cochlear Implantation.

Importance: Barriers to early pediatric cochlear implantation in underinsured populations have been previously reported. However, to our knowledge, the effect of this delay on the development of auditory and speech-language objectives has not been evaluated. Objective: To determine if health care insurance status affects the achievement of proficiency in basic sound access and imitation tasks in children with cochlear implants. Design, Setting, and Participants: A retrospective review of 123 children aged 1 to 12 years receiving cochlear implants at the single tertiary referral academic free-standing Children's National Health System in Washington, DC, between January 1, 2008, and December 31, 2015. Main Outcomes and Measures: Auditory function after cochlear implantation, time to proficiency in Ling-6 scores, and number of speech therapy and audiological appointments, as well as current educational setting, were compared with patient age at diagnosis of hearing loss, age at cochlear implantation, cochlear implantation insertion technique, and health care insurance status for recipients of cochlear implants. Results: A total of 123 children aged 1 to 12 years (mean [SD] age, 64.0 [57.4] years) with cochlear implants were included in the study. Of 37 patients with complete and accurate Ling-6 test scores, 23 (62.1%) were able to have proficiency a mean of 5.1 months at follow-up. Despite equal auditory performance on pure-tone audiometry after cochlear implantation, publicly insured recipients had Ling-6 proficiency a mean of 6.0 months (95% CI, 5.5-6.5 months) later than privately insured recipients (11.0 vs 5.0 months). When controlling for patient age, time to cochlear implantation, number of therapy sessions, and cochlear implantation insertion technique, multivariable logistic regression analysis revealed health care insurance status to be the independent variable associated with inadequate Ling-6 discrimination scores (odds ratio, 46.2; 95% CI, 2.9-729.4). Conclusions and Relevance: Despite equal speech detection scores, publicly insured recipients of cochlear implantation had a significant and critical delay in attaining proficiency in a fundamental measure of sound recognition and imitation.

Does pediatric cochlear implant insertion technique affect intraoperative neural response telemetry thresholds?

OBJECTIVE: Recent reports of mostly adult patients suggest round window insertion is less traumatic than cochleostomy for cochlear implantation (CI), while other reports have indicated that curved electrode arrays lower the neural response telemetry (NRT) threshold and consume less power. We aimed to compare the intraoperative neural response telemetry (NRT) thresholds in children receiving cochlear implants through a cochleostomy (COCH) vs. a round window (RW) approach, as well as patients receiving a curved array vs. a straight one. DESIGN: A direct case-cohort comparison of NRT in pediatric CI recipients at two large tertiary pediatric hospitals from 2008 through 2014 was done. Univariate Mann-Whitney analyses and one-wayANOVA were performed to compare average NRT in RW vs. COCH insertion, and curved vs. straight electrodes. Multivariate regression was performed to control for age and pre- vs. postlingual patient status. RESULTS: Overall, 236 children were included, between January 2008 and October 2014 at two large tertiary referral medical centers. A total of 52 patients received a RW insertion and 184 received a cochleostomy. There was no statistically significant difference between RW insertion (187.9±18.7) and COCH (183.4±17.1) (p=0.125). The patients were divided into four categories: RW insertion with curved electrode (175.0±11.2), RW with straight electrode (192.1±18.8), COCH with curved electrode (182.2±16.7), and COCH with straight electrode (193.0±20.8). The lowest NRT current thresholds were achieved with curved electrode array insertions through the RW (p=0.001). Multivariate regression analysis revealed the following parameters were not independently associated with differences in NRT responses: RWI vs. COCH (p=0.12) and pre- vs. postlingual (p=0.18). The difference in NRT levels between curved electrode arrays and straight was shown to be statistically significant (p=0.00075). CONCLUSIONS: When controlling for insertion technique or pre- vs. postlingual hearing loss, the curved electrode array correlates with lower NRT thresholds. Although studies to examine functional language performance of these recipients are pending, initial results of this multi-institutional trial suggest that curved electrodes indeed result in lower NRT levels, particularly when inserted through the RW.

Barriers to early pediatric cochlear implantation.

OBJECTIVES: Universal newborn hearing screening has significantly improved the ability to identify patients with congenital sensorineural hearing loss (SNHL), which results in earlier treatment and better hearing and development outcomes. It is recommended that patients born with SNHL who meet criteria receive cochlear implants (CIs) by a target age of 12 months, however many children are being implanted at an older age. This study aims to describe populations of pre-lingual patients with SNHL that are at risk for delayed implantation and to identify and analyze barriers that cause this delay. METHODS: Charts of patients receiving a CI between January 2008 and June 2012 at a tertiary care cochlear implant center were reviewed retrospectively. We looked at patient demographics, age at hearing loss diagnosis, age at implantation, and etiology of hearing loss. Barriers to implantation were identified through surveys completed by team members. RESULTS: Fifty-seven CI recipients were identified of which 42 were in patients with pre-lingual SNHL. SNHL etiology included: cochlear dysplasia (18%), GJB2/GJB6 (17%), acquired (10%) extreme prematurity (9%), and idiopathic (46%). The median age of SNHL diagnosis for pre-lingual patients was 15 months. Compared to private insurance, public insurance status was associated with SNHL diagnosis at a significantly later median age (20.0 vs. 4.0 months, p=0.024), and with a significantly longer median interval from diagnosis to implantation (25.5 vs. 11.0 months, p=0.029). While cochlear implant team members identified delayed insurance approval and medical comorbidities as reasons for delayed implantation, the most significant factor identified was parental, with delayed/missed appointments or reluctance for evaluations or surgery. CONCLUSION: 52% of patients with pre-lingual SNHL that met criteria for CI were implanted more than 12 months after diagnosis. Having public or no insurance was significantly associated with delayed implantation. Parental barriers were most common factors cited for delays in implantation. Overcoming these delays necessitates appropriate identification of at risk patients and creating a system to educate families and chaperone them through the process.