Chang DT, Ko AB, Murray GS, et al. Lack of financial barriers to pediatric cochlear implantation: impact of socioeconomic status on access and outcomes
Department of Otolaryngology-Head and Neck Surgery, Case Western Reserve University School of Medicine, University Hospitals Case Medical Center, Cleveland, Ohio 44106, USA. Archives of otolaryngology--head & neck surgery
(Impact Factor: 2.33).
07/2010; 136(7):648-57. DOI: 10.1001/archoto.2010.90
(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.
Available from: Marlan R Hansen
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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.
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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.
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.
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ABSTRACT: The cochlear implant (CI) is increasingly used to treat deafness, despite arguments from the deaf community. Deaf children born to hearing parents are the fastest growing group of CI recipients, making parents the primary consumers. Instead of focusing on the controversy over implants, this article examines the clinical structures shaping parental decision-making and how parents integrate clinical practices into family and community. Observations and in-depth interviews were conducted in a CI clinic and at various community sites. The data reveal strong inter-institutional co-operations between the clinic, the state and local school districts. Working together, these institutions anticipate parental needs, foster a CI community and thus increase compliance. I conclude that implantation is an ongoing practice enculturating parents into a new community characterised by the adoption of long-term rehabilitative duties. However, the long-term nature of rehabilitation creates disparities in outcomes, which would be better understood through further research on the social relations in families and across parent networks in the CI community.
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