Fear of cost and lack of insurance coverage were identified as major concerns for patients considering cochlear implant surgery.

“The safety and effectiveness of cochlear implants (CIs) has dramatically improved over the past 30 years, but the rate of eligible adults who receive a cochlear implant has continued to be under 10%, according to most studies,” Francis Creighton, MD, notes. “Furthermore, growing data show that failure to treat hearing loss in patients results in higher rates of cognitive decline and other comorbidities. Given this, there is significant public health interest to understand and improve the low penetrance rate of CIs in eligible adults.”

Research in this area has primarily examined intrinsic patient factors that make individuals more or less likely to get an implant, such as socioeconomic status, geographical proximity to surgical specialists, or a patient’s education level, according to Dr. Creighton. “While these works are important, we felt that a better understanding what preconceived opinions and knowledge the general public has about cochlear implantation, its low penetrance rate, and their associated risks and benefits is needed to better understand the current low rates of cochlear implantation in eligible adults.”

For a study published in Otology & Neurotology, Dr. Creighton and colleagues surveyed participants about their perceptions of cochlear implantation. Respondents were asked rank CI QOL-10 Global priorities and related tolerance for minor and major complications.

Low Uptake Driven by Perceptions of Costs & Surgical Risk

The study included 615 respondents (55% female; mean age, 39). Issues related to insurance (46%) and concerns about having surgery (21%) were cited as barriers that prevented eligible adults from receiving a CI.

“Fear of cost and lack of insurance coverage were identified as major concerns for patients and thought to be possible reasons for the low penetrance rate,” says Dr. Creighton. “In reality, every major insurance carrier in the United States, as well as Medicare and Medicaid, cover cochlear implants in patients meeting audiological criteria.”

In terms of surgical risk, respondents significantly underestimated rates of minor complications (P<0.0001) and almost all major complications (all P<0.0001), and overestimated rates of serious infections and the need for reimplantation (both P<0.005). The ability to hear strangers in loud situations was found to be the highest priority for a CI (26%). Respondents who knew someone with a CI were willing to accept greater rates of all minor and major complications (all P<0.05).

“Individuals had a very low risk tolerance for either minor or major complications, which I think for the otolaryngologic community helps to underscore the fact that, while these surgeries are generally very well tolerated, further improvement in surgical safety are needed to help allay fears,” Dr. Creighton says. “Interestingly, individuals who either were in healthcare or knew individuals who had CIs were much more likely to tolerate risk, helping to further support the idea of how much improved hearing can improve QOL.”

Specific complications examined by the researchers included changes in taste and vertigo, as well as meningitis, facial paralysis, and cerebrospinal fluid leak (Table). “The US population has very high standards for surgical procedures, and cochlear implantation is not exempt from that,” Dr. Creighton notes. “As a society, we expect excellence from our surgeons, and while most surgeons, myself included, think of cochlear implantation as extremely safe, we need to continue to push the boundaries to decrease even minor complications wherever and however we can. We have made significant strides over the past several decades, and I hope this can provide motivation to continue that trend.”

Additional Research Needed to Increase CI Uptake

A key takeaway of this study, according to Dr. Creighton, is that uptake of CIs remains very low. He also notes that individuals interested in CIs do not have to be “profoundly deaf” to be a good candidate for them. “It can significantly help with speech in noise as well as sound localization, which this study showed are important priorities for the public in hearing QOL.”

Dr. Creighton notes that future research should focus on strategies for continuing to improve the safety of cochlear implantation surgery through technological advances that incorporate robotics, image navigation, and artificial intelligence, and examine which patient and surgeon factors, such as volume, experience, and geographical location, can portend better or worse outcomes. “I also would like to see further work done in better delineating decision tree analyses and patient guides for those with hearing loss who are considering cochlear implantation,” he says.