Since the earliest recipients received their devices more than 40 years ago, cochlear
implantation has continued to evolve, benefitting more individuals with greater diversity
of hearing loss. Originally introduced for those with bilateral profound cochlear
hearing loss, cochlear implants (CIs) were considered to be the last resort when hearing
aids could no longer provide any benefit. Today this perspective is considered woefully
outdated. Successful recipients include those with single-sided deafness, asymmetric
hearing loss, residual hearing in the implanted ear up to and including normal thresholds
through 1,000 Hz, sudden loss, long duration progressive loss, congenital loss implanted
by 9 months of age, auditory neuropathy spectrum disorder (ANSD), and more. Candidacy
determination is shifting from use of sentences in quiet in the best-aided condition
to ear-specific word recognition scores. Electric-acoustic stimulation in the same
ear is possible. Notably, implantation as soon as possible once benefit is determined
to be likely is encouraged and has been shown to result in better outcomes.
Yet, despite the exciting advancements that should be improving access to cochlear
implantation and exponentially increasing utilization, numerous barriers persist.
Misconceptions of contemporary candidacy, lack of comfort recommending CI, inequities
of health-related socioeconomic resources, outdated device labeling, restrictive insurance
coverage policies, lack of clarity regarding the link to cognitive health, and lack
of awareness by the public and referring providers have combined to prevent more than
an estimated 1 million patients who could benefit from CI from receiving this care.[1]
Recognizing that knowledge is power, this issue of Seminars in Hearing explores these barriers to cochlear implantation and seeks to empower clinicians
to successfully move their candidate patients past those barriers to enjoy better
hearing and communication through cochlear implantation.
This edition brings together a diverse and accomplished group of audiologists, neurotologists,
and public health specialists to outline the inherent problems with existing barriers,
to explore the opportunities that will arise from recognizing and embracing best practices,
and to deliver a case for change to increase utilization of this proven, life-changing
technology.
The issue opens with an analysis and quantification of the current problem. Ashley
Nassiri, MD, MBA, and colleagues map the patient experience as a way to uncover obstacles
that CI candidates and recipients face at nearly every step of the process. Marissa
Schuh, MPH, and Matthew Bush, MD, PhD, MBA, explore the disparities in cochlear implantation
through the social determinants of health. Consideration is given to how these factors
can influence equity in CI and how to incorporate this information in the evaluation
and management of patients receiving CIs.
The focus then shifts more specifically to the adult population. Terry Zwolan, PhD,
and Greg Basura, MD, discuss how the rate of improvement in adult CI outcomes has
outpaced expansion of candidacy requirements of FDA labeling, Medicare, and private
insurers in the United States, preventing many qualified candidates from financial
coverage of CI technology. Eric Babajanian, MD; Neil Patel, MD; and Richard Gurgel,
MD examine the relationship between cochlear implantation and cognition and quality
of life in older adults, as well as how frailty affects outcomes for older patients
with CIs. Sarah Mowry, MD, and colleagues dispel common myths and misconceptions related
to the risks associated with CI surgery that may deter providers from recommending
and patients from pursuing cochlear implantation. Finally, my colleagues and I describe
the importance of hearing aid verification using aided speech recognition materials
during hearing aid fitting and follow-up to confirm optimal functional of hearing
aid benefit, both as routine practice and as an essential component of the CI candidacy
evaluation.
Last but not least, challenges unique to the youngest CI candidates are discussed
as Lisa Park, AuD, and colleagues highlight the limitations of FDA criteria and clinical
practice for pediatric patients compared with adults as a barrier to pediatric implantation.
Karen Gordon, PhD, and colleagues make the case for the importance of access to bilateral
hearing through CI in children.
We hope that by compiling in one location many of the key factors of under-utilization
of CIs in the United States today, we have created an essential resource for empowering
change for the industry, for our practices, and, most importantly, for the hundreds
of thousands of patients who are struggling to achieve their best possible hearing
and for whom cochlear implantation may be the answer.
