Outcome uncertainty suppresses patient adoption of cochlear implants

Neurotologists often recommend cochlear implants for people with severe to profound hearing loss who no longer benefit from hearing aids.  A person with severe hearing loss cannot hear a raised voice only three feet away; one with profound hearing loss, a shouted voice in the ear, according to the World Health Organization.  

Despite their difficulties hearing, only about 5% of the indicated U.S. adult population has received a cochlear implant.  In recent years, indications have broadened. The market size of 2 million patients includes adults who might retain some residual hearing after the surgery, which may be amplified with hearing aid technology. Yet from 2000 to 2019, only about 100,000 adults in the U.S. underwent surgery for a CI, according to the National Institute on Deafness and Other Communication Disorders.

Instead, many patients cobble together a solution of hearing aids (which provide limited amplification), lip-reading, captioning apps, and in some cases sign language. They struggle to communicate in professional and social settings. 

After examining this situation, we concur with recently published peer-reviewed literature that patient barriers to treatment play a significant role in low CI penetration of the market.  Our analysis takes the literature a step farther – we believe that uncertainty surrounding the outcomes of cochlear implantation is a primary factor suppressing adult adoption. 

A Cochlear Implant Uses a Surgically Placed Electrode Array

Neurotologists perform cochlear implantation with the patient under general anesthesia in a one to two hour procedure.  During the surgery, the neurotologist places the core of the CI device, an electrode array, into the inner ear, or cochlea.  

Once in place, the device’s external microphones capture sound from the environment, a processor converts the sound waves into electrical impulses, and the electrode array transfers the impulses to the brain’s auditory nerve, thus enabling hearing. After surgery, CI recipients need to undergo one to two years of rehabilitation to train their brains to recognize new sounds.

Yet despite this potential miracle of hearing for patients with severe hearing loss, only a fraction of eligible adults elect to proceed. 

Cochlear Implantation Has Wide Range of Outcomes

To probe the reasons behind low adoption, we curated, analyzed, and synthesized recent contributions to the peer-reviewed hearing health literature.  Among those studies was a paper on adult CI outcomes mined from a multi-institutional database. 

The paper revealed that the median patient’s word recognition increases from 15% pre-implant (wearing a hearing aid) to 56% 12 months after implantation.  The top 25% of patients, who register a postoperative word recognition score of 75% or greater, will likely experience a greatly improved quality of life from better hearing. 

Yet the study population as a whole experience a wide range of outcomes, from 0% to 100% postoperative speech recognition. In other words, some patients recognize no words at all 12 months after surgery, while others essentially have normal hearing.  Moreover, the bottom 25% of patients has a 12-month postoperative word recognition score of 40% or less, which is essentially Medicare’s cutoff to undergo surgery in the first place.

This wide range of speech perception outcomes, we conclude, translates into considerable uncertainty for patients.  Although clinicians may counsel that patients with higher preoperative speech recognition generally realize the best outcomes, patients may still struggle to make an informed decision.  For example, how does their hearing loss history and willingness and ability to undergo rehabilitation affect their predicted outcome? Patients lack a mechanism for predicting their outcome. 

Outcome Uncertainty Drives Patient Concerns

Our analysis demonstrates that outcome uncertainty facing patients helps explain their reported concerns with cochlear implantation. We examined a recent study that surveyed 52 patients – including both patients who elected cochlear implants and those who opted out – in a single center.  We discovered that three of the top five patient-reported concerns with CIs center around hearing outcomes:

• “A cochlear implant would not significantly improve my ability to communicate.”
• “I did not want to risk losing my appreciation for music.” (Due to CI’s technological limitations, some people lose music appreciation.)
• “My current hearing aids are satisfactory for my needs.”

Our perspective is that many patients are concerned that a CI would not not improve communication ability and music appreciation better than their current solution of hearing aids. We believe that outcome uncertainty is a top causative patient barrier to cochlear implantation.

CI Centers Could Develop Personalized Risk/Benefit Analysis

A gap currently exists in the industry’s dialog on how outcome uncertainty drives adult patient decisions for cochlear implantation. As a first step, cochlear implant manufacturers and surgical centers would benefit from assigning a higher priority to addressing outcome uncertainty. 

Specifically, we see three important opportunities for cochlear implant centers in the United States. These initiatives would support adult patients and help them make informed decisions:

• Develop center-level data to summarize patient outcomes and expected timelines for rehabilitation
• Chart a personalized risk/benefit analysis for patients
• Create a center-level advocacy team that includes patients

Cochlear implants have the potential to dramatically improve a patient’s quality of life in personal and professional spheres by restoring hearing. Addressing outcomes uncertainty will help CI centers better address adult patient concerns and deliver on the promise of hearing.

Photo: bernie_photo, Getty Images

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