Lack of financial barriers to pediatric cochlear implantation: impact of socioeconomic status on access and outcomes.
ABSTRACT (1) To analyze if socioeconomic status influences access to cochlear implantation in an environment with adequate Medicaid reimbursement. (2) To determine the impact of socioeconomic status on outcomes after unilateral cochlear implantation.
Retrospective cohort study.
University Hospitals Case Medical Center and Rainbow Babies and Children's Hospital (tertiary referral center), Cleveland, Ohio.
Pediatric patients (age range, newborn to 18 years) who received unilateral cochlear implantation during the period 1996 to 2008.
Access to cochlear implantation after referral to a cochlear implant center, postoperative complications, compliance with follow-up appointments, and access to sequential bilateral cochlear implantation.
A total of 133 pediatric patients were included in this study; 64 were Medicaid-insured patients and 69 were privately insured patients. There was no statistical difference in the odds of initial cochlear implantation, age at referral, or age at implantation between the 2 groups. The odds of prelingual Medicaid-insured patients receiving sequential bilateral cochlear implantation was less than half that of the privately insured group (odds ratio [OR], 0.43; P = .03). The odds of complications in Medicaid-insured children were almost 5-fold greater than the odds for privately insured children (OR, 4.6; P = .03). There were 10 complications in 51 Medicaid-insured patients (19.6%) as opposed to 3 in 61 privately insured patients (4.9%). Medicaid-insured patients missed substantially more follow-up appointments overall (35% vs 23%) and more consecutive visits (1.9 vs 1.1) compared with privately insured patients.
In an environment with adequate Medicaid reimbursement, eligible children have equal access to cochlear implantation, regardless of socioeconomic background. However, lower socioeconomic background is associated with higher rates of postoperative complications, worse follow-up compliance, and lower rates of sequential bilateral implantation, observed herein in Medicaid-insured patients. These findings present opportunities for cochlear implant centers to create programs to address such downstream disparities.
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ABSTRACT: Identify social and health care system factors that prevent congenitally deaf children from receiving cochlear implants (CIs) in a timely fashion. Retrospective chart review and parental interviews. University medical center hospital in a state with mandatory newborn hearing screening (NBHS). Fifty-nine congenitally deaf children who received CIs between January 1, 2002, and May 1, 2009. Demographic and health care details were collected from the 59 patients. Age at implantation. Thirty-four patients received implants at or before age 2 years (average age at implant surgery, 14 mo), and 25 patients received implants after age 2 years (average age, 65 mo). The presence of NBHS (p<0.001) and type of health insurance (p=0.05) the child had at the time of CI surgery were significant predictors of age at implantation. The following factors were associated with increased risk of delayed implantation: no NBHS (risk ratio [RR]=2.63), NBHS not identifying hearing loss (RR=1.63), Medicaid insurance alone (RR=1.21) or in combination with private insurance (RR=1.79), family physician as primary care provider (RR=1.50), and audiologist (RR = 1.30) or otolaryngologist (RR=1.31) as secondary care providers (versus implant center, RR=0.23). The main reasons for delay in CI surgery after age 2 years also were identified and include slow referrals for care (n=8) and parental delays (n=5). The data suggest placing special focus on children with associated risk factors, ensuring NBHS, and parent and primary care provider education on the importance of early intervention and referral to an implant center would likely limit delays in children receiving CIs.Otology & neurotology: official publication of the American Otological Society, American Neurotology Society [and] European Academy of Otology and Neurotology 04/2011; 32(3):406-12. DOI:10.1097/MAO.0b013e3182040c22 · 1.60 Impact Factor
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ABSTRACT: To analyze educational placement settings of Israeli children with cochlear implants (CIs) and evaluate the prognostic influence of the following demographic variables on mainstreaming: age at implantation, experience with CI, socioeconomic status, ethnicity, and parents' educational level. Retrospective review. Tertiary referral center. The study population comprised 245 children with severe-to-profound hearing impairment and at least 1 year of experience with a unilateral CI. Mean age at implantation was 4.5 ± 3.9 years, and mean duration of CI use was 5.4 ± 2.8 years. Follow-up review and statistical analysis of available data on educational placement after cochlear implantation. Placement in mainstream education. Regular schools were attended by 89 children (36.3%) and special education schools by 156 (63.7%). Variables found to be significantly associated with mainstream educational placement were younger age at implantation, higher level of parental education, higher socioeconomic status, and ethnicity. Multivariate analysis using a logistic regression model revealed that the factor with the highest positive correlation with mainstreaming was parental education level. Our results show that parental education, a variable that the health system cannot control, significantly influences postimplantation results in term of educational placement and can thus limit the chances of implanted children to achieve mainstream placement even when identified and implanted at an early age.Otology & neurotology: official publication of the American Otological Society, American Neurotology Society [and] European Academy of Otology and Neurotology 04/2011; 32(6):943-7. DOI:10.1097/MAO.0b013e31821a8407 · 1.60 Impact Factor
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ABSTRACT: This article highlights variables that affect cochlear implant performance, emerging factors warranting consideration, and variables shown not to affect performance. Research on the outcomes following cochlear implantation has identified a wide spectrum of variables known to affect pos0timplantation performance. These variables relate to the device itself as well as individual patient characteristics. Factors believed to affect spiral ganglion cell survival and function have been shown to influence postoperative performance. Binaural hearing affects performance. Social and educational factors also affect postoperative performance. Novel variables capable of affecting performance continue to emerge with increased understanding of auditory pathway development and neural plasticity.Otolaryngologic Clinics of North America 02/2012; 45(1):155-71. DOI:10.1016/j.otc.2011.08.023 · 1.34 Impact Factor