Changing the Course of Care at the Local Level in Adults with Severe Hearing Loss



Debunking 5 Cochlear Implant Myths
By Brian Taylor, Au.D.

Cochlear implants (CI) are the standard treatment for bilateral, severe to profound sensorineural hearing loss. It is estimated there are over 30,000 recipients implanted per year worldwide (Vaerenberg, et al 2014). Yet, cochlear implant audiologists remain a subspecialty within the audiology profession. In many medical centers in the United States, cochlear implant audiologists work primarily with children and adults with severe-to-profound hearing loss, participating in the identification, selection, and rehabilitation process of cochlear implantation. Survey data indicate that cochlear implants specialization is confined to a small number of audiologists, as only approximately 11% of audiologists self-identify as working with cochlear implants. This shortage of CI audiologists is likely to have an impact on access to care, but it provides an opportunity for audiologists to participate in the care of adults with severe-to-profound hearing loss, beyond fitting hearing aids.

This schism between cochlear implant audiology and other types of clinical audiology is not without merit. Historically, many of the skills required in the cochlear implant clinical realm, such as mapping of an implanted medical device, CI candidacy selection, counseling and surgical considerations are unique relative to other areas of clinical audiology. However, as cochlear implant candidacy requirements have become less restrictive, and as the programming and adjustment process (known as mapping) has become more automated, there are increasing opportunities for audiologists, who are not cochlear implant specialists, to more fully participate in the care of adults with severe hearing loss.

This article debunks five myths that, until now, have prevented more audiologists from getting involved in the care of CI users—and makes the case for why private practice audiologists should get involved in the process of providing care to these patients.
Myth 1: Cochlear Implants Are Suitable for Individuals with Profound Hearing Impairments Only
The opinion generally held by CI experts is that, for the motivated candidate, cochlear implants can be a life-changing experience. Figure 1 shows the hypothetical performance over time for many adult patients with a moderate, progressing-to-severe hearing loss. The Figure can be used to demonstrate how various interventions are intended to improve auditory performance for a hearing-impaired individual over time. At some point, many of these patients become hearing aid users. The hypothetical amount of improvement from bilateral hearing aid use for individuals with severe hearing loss is shown in the center of Figure 1. (Labelled as “2 HA’s”). Also depicted in Figure 1, is the presumed improvement from various interventions involving cochlear implantation and follow-up care. Notice the rather dramatic levels of improvement following intervention, compared to hearing aid use.
Figure 1. The Hypothetical Course of Auditory Performance Over Time for Adults with Gradual, Adventitious Severe Hearing Loss. Note: The average levels of improved performance that result from three different types of interventions (depicted by the red, blue, and green lines)


The three colored lines in Figure 1 illustrate three distinct types of interventions involving cochlear implants: 1.) one cochlear implant (unilateral arrangement), 2.) one cochlear implant + one hearing aid (bimodal arrangement), and 3.) either a unilateral or bimodal arrangement + auditory training. Even though each of these three lines in Figure 1 represents a hypothetical case, there is ample evidence the properly selected candidate will experience benefit in an equivalent manner (Blamey, et al 2013). In effect, Leigh et al (2013) indicated appropriate candidates can be advised that they have a greater than 75% chance of improving their speech perception with a cochlear implant over their best preoperative condition, and a 95% of chance of improvement in their implanted ear alone. Given the multiple intervention options that can optimize CI outcomes, audiologists who do not specialize in CI have an opportunity to participate in the management of CI users by providing some combination of care with a bimodal arrangement, auditory training, and mapping a cochlear implant.

What once was an intervention for the most profoundly hearing impaired, has expanded to include individuals with moderate-to-severe hearing loss. Driven primarily by improvements in CI technology and surgical procedures, the pool of patients considered to be viable candidates for CI has expanded. Today, an adult with unaided hearing thresholds worse than 60 dB at 500 Hz, 70 dB at 1000 Hz and 90 dB at 2000 Hz, unaided single word recognition performance worse than 45% in the better ear and documentation that hearing aid benefit is suboptimal would be within the candidacy requirements for CI (Gubbels, et al, 2017). Because the audiological candidacy requirements have expanded, it is believed a larger pool of patients, many of which might be experiencing poor hearing aid benefit, are now CI eligible. Thus, a larger number of audiologists, not directly affiliated with a cochlear implant center are needed to identify and manage these potential CI recipients.

Given the paucity of audiologists who specialize in CI, combined with the relatively poor benefit many individuals with severe-to-profound hearing loss receive from their hearing aids, it is an excellent opportunity for audiologists, who do not specialize in CI, to become directly involved in providing a full range of reimbursable CI services to adult patients. Moreover, because third party insurance and Medicare reimburse for many of the services related to CI, and because non-audiologists who dispense hearing aids are not eligible to receive third party reimbursement, providing CI services can be a differentiator in a competitive marketplace that is about to see the rise of over-the-counter hearing aids and the continued success of big-box retail.

A recent prospective study sheds light on factors that contribute to low CI uptake rates among adults with severe profound hearing loss. Over a two-year period, Holder, et al (2018) collected data on 287 adults who presented at their clinic for a CI evaluation. The primary goal of the study was to better understand the adult population seeking a CI evaluation. A secondary goal of the study, according to the researchers, was to define the percentages of adults presenting for the CI evaluation who were bimodal (CI plus hearing aid in contralateral ear) or bilateral CI candidates.

Results of the prospective study reveal several remarkable findings: All the adults (mean age = 62.3 years) who presented to the clinic for a CI evaluation had hearing aid experience, but a whopping 62% of these individuals presented to the CI evaluation without their hearing aids. Additionally, only 32 of the 110 (29%) individuals who wore their hearing aids to the CI evaluation were successfully fitted to a standard audibility target for average level sound inputs.

Perhaps even more surprising, despite the expanded CI candidacy requirements that have occurred over the past decade-plus, nearly two-thirds of individuals who presented for the CI evaluation at Vanderbilt University Clinic had a severe-to-profound hearing loss with a mean pure tone average of 82.5 dB and very low unaided sentence recognition-in-noise scores on the AzBio of 23.3% across all 287 adults. Even though CI candidacy requirements have expanded, individuals with moderate-to-profound hearing loss, with aided speech understanding near the upper range of candidacy, are not finding their way into the CI center for an evaluation.
Myth 2: There Are a Small Number of Adults with Severe-to-Profound Hearing Loss Who Could Benefit from a Cochlear Implant
The exact number of individuals with severe-to-profound hearing loss varies. Blanchfield, et al (2001) estimated that approximately 738,000 Americans had severe-to-profound hearing loss, with seniors aged 65 and older representing 54% of this population. Alice et al (2013) reported between 0.6 to 1.1% of the general population has a severe-to-profound loss, which cannot benefit from a hearing aid. Additionally, it is expected that the prevalence of severe-to-profound hearing loss will more than double in the next 30 to 40 years, mainly due to an aging population.

Another recently published study examining the prevalence, characteristics, and treatment patterns of hearing loss in the U.S., sheds light on the current plight of individuals with severe-to-profound hearing loss. Mahboubi et al (2017) examined the functional capability of individuals with a range of self-perceived hearing difficulties. Of considerable interest, their analysis suggests 2.8 million adults in the U.S. (1.1% of the population) are unable to hear shouting in a quiet room, which likely equates to a severe-to-profound degree of hearing impairment. According to the researchers, moreover, a mere 5.3% of the adults in this category received a recommendation for a cochlear implant. Perhaps even more troubling, of this small percentage of individuals referred for a cochlear implant, just 1 in 5 people, within that small cohort of adults with self-perceived severe-to-profound hearing loss, actually received a CI. Despite solid clinical evidence supporting the effectiveness of CI and insurance reimbursement for the procedure, the low rate of referral for a CI evaluation in this study is consistent with previous estimates of a 5% utilization rate in the eligible adult population with severe profound hearing loss. This low CI uptake rate is an opportunity for otolaryngologists and audiologists to raise awareness among primary care physicians and the general population about the benefits of cochlear implants.

Another consideration are the long-term ill-effects of untreated (or inadequately treated) hearing loss in adults with severe-to-profound hearing loss. Data suggest that individuals with severe-to-profound hearing loss are vulnerable to several negative consequences resulting from their condition. Adults with severe-to-profound hearing loss have lower family incomes, are less educated, and are more likely to be unemployed than the general population (Blanchfield, et al, 2001). Thus, improved access to cochlear implantation and related interventions is warranted.

Perhaps more germane to clinical practice, there is ample evidence suggesting most hearing aid dispensing centers are already serving a substantial number of adults with severe-to-profound hearing loss. Numerous studies report a range between 6.7% and 13.5% of an audiologist’s clinical caseload has a severe-profound hearing loss (see Turton & Smith, 2013 for a review of these studies). Based on the updated hearing threshold CI candidacy requirements, and lower-than-expected benefit from hearing aids, many of these individuals already seeking assistance from a non-CI audiologist would be considered candidates for cochlear implants. Unfortunately, many of these individuals, because they don’t have access to a clinic specializing in CI, fail to get properly evaluated for implantation. Table 1 provides a summary of these important data points that underscore the need for mainstreaming cochlear implants into audiology practices.
Table 1: Numbers to Know—A Summary of Key Demographics
  • 11% of audiologists in the US specialize in CI.
  • About 1% of the entire American adult population has severe-profound hearing loss.
  • 5.3% of individuals with severe-profound hearing loss report they received a recommendation for a CI evaluation.
  • Just under 8% of adults with severe-to-profound hearing loss have received a cochlear implant.
  • 6.7% to 13.5% of an audiology clinic’s caseload is already comprised of patients with severe-profound hearing loss, with an indeterminant number of them receiving lower-than-expected benefit from hearing aids.
Myth 3: Working with Cochlear Implant Recipients Requires Specialization
When cochlear implants became clinically available more than 30 years ago, a high degree of specialization was required to become proficient at all aspects of the selection, mapping, and long-term management process. Even today, several electrical parameters of the CI need to be programmed and adjusted. These parameters, as a whole, are commonly called the cochlear implant MAP. Finding and programming the optimal values for a recipient is referred to as “mapping”. Cochlear implant mapping is achieved using proprietary software and a hardware interface connected to the processor, and depends on behavioral responses from the CI recipient. Since many patients with cochlear implants, especially in the early years, relied on sign or written language to communicate, combined with rather primitive computing capability, the mapping process was often time consuming, inefficient and also prone to specialization.

Given the historically strict candidacy requirements for receiving a cochlear implant, the need to become specialized in CI is borne out of the distinct needs of profoundly impaired adults and children. It is common that many individuals with this magnitude of hearing loss rely primarily on sign language to communicate. Further, they often struggle with, or reject hearing aids, and have other unique needs. The characteristics of individuals with profound hearing loss, combined with their relatively sparse numbers relative to other patients with milder degrees of impairment, make it difficult for the non-CI audiologist to provide the effective care to this group. For all these reasons, cochlear implant audiology evolved into a sub-specialty with roughly 10% of clinical audiologists involved in it.

Over time, however, we have experienced a convergence in cochlear implant technology and hearing aid technology that make these interventions more alike than different. Today, unlike prior decades, cochlear implants are programmed and fine-tuned like hearing aids, often with automated computer-based algorithms designed to streamline the fitting process. For example, a software application using deterministic and probabilistic logic, called Fitting to Outcomes eXpert (FOX), has been developed to optimize and automate cochlear implant programming, and will soon become available commercially (Battner et al 2015). Additionally, because the candidacy requirements for cochlear implantation have broadened, a growing number of patients within a typical hearing aid dispensing practice would be considered CI eligible. For all these reasons, less specialization is needed to fit and fine-tune (map) cochlear implants in a local providers office. The rationale for providing CI services are listed in Table 2.
Table 2: A Summary of the Advantages of Providing CI Care In a Local Practice.—Reasons for Teaming with an Existing CI Surgery Center
  • Offer a clinically proven alternative to hearing aids for adults with severe to profound hearing loss.
  • Generate alternative sources of revenue.
  • Differentiate your practice from hearing instrument specialists and retail audiologists who are not equipped to offer CI services or cannot get reimbursed from third party payers for them.
  • Develop relationships with the medical community.
  • Strengthen your brand as a multispecialty center of excellence.
Myth 4: For Older Individuals with Longstanding Severe-to-Profound Hearing Loss, There Is No Difference in Benefit Between Hearing Aids and Cochlear Implants
Although younger adults tend to receive more favorable cochlear implant outcomes relative to older adults, a review of the literature provides convincing evidence that cochlear implants in older adults are safe, improve speech understanding, enhance participation in daily activities, and boost mental health (see Clark et al 2012 for a review). Older adults progress more slowly and experience smaller gains in speech perception and quality of life improvements (Friedlund, et al 2003). Additionally, other aspects of communication, such as psychological and physical status, cognitive ability and family and emotional support affect intervention status and need to be managed by the audiologist.

Another consideration is the expected benefit received from a CI relative to hearing aids. There is evidence suggesting that, on balance, cochlear implants outperform hearing aids for the appropriate CI candidate. Bittencourt et al (2012) demonstrated that a group of CI users had significantly higher word recognition ability, one year post implantation, when compared to a group of similarly matched hearing aid users. Studies that have compared hearing aid to CI use, along other dimensions of benefit, are summarized in Figure 2. In addition, although still a challenge, most study participants reported improvements with telephone use and group conversations (Clark, et al 2012). Although older adults with longstanding hearing loss probably will not experience the same degree of improvement from a CI as younger adults with deafness of shorter duration, studies indicate these individuals can still derive substantial benefit from cochlear implants.
Figure 2. A Summary of Studies Showing the Difference in Average Outcomes for Adults with Severe-to-Profound Hearing Loss for Cochlear Implant Versus Hearing Aid Use
New Hearing Aid Performance Dimension Relative to Existing Hearing Aid Use Cochlear Implant
+19% Word Recognition Scores (1-year post-intervention+43%a
0%Residual Improvement on Word Recognition Scores (2-years post-intervention) +16%a
No change Speech Understanding Ability in Noise (Subjective: 1-year post-intervention) Improvedb,c
No change Anxiety and Depression Improvedc
No change Confidence and Participation in Social Activities Improvedb,c
No change Overall Quality of Life Improvedb,c,d
a Bittencourt, A. et al (2012) Post-lingual deafness: benefits of cochlear implants vs. conventional hearing aids. Braz J Otorhinolarngol 78, 2, 124-127.
b Lenarz, T. et al (2017) Patient-related benefits for adults with cochlear implantation: a multicultural longitudinal observational study. Audiology & Neurotology. 22, 61-73.
c Clark, J. et al (2012). Cochlear implant rehabilitation in older adults: Literature review proposal of a conceptual framework. Journal of the American Geriatric Society 60, 10, 1936-1945.
d Damen, G. (2007) Cochlear implantation and quality of life in postlingually deaf adult: long-term follow-up. Otolaryngology Head Neck 36, 597-604.
Myth 5: Audiologists Cannot Generate Revenue from Cochlear Implants
One of the shortcomings of audiology, unlike similar allied professions such as dentistry and optometry, is an inability to generate consistent revenue pathways. Data from multiple industry surveys tend to indicate that the average practice generates 80% or more of its revenue from the sales of hearing aids. Although hearing aid revenue is likely to remain a staple source of revenue for many practices, the rise of over-the-counter, self-fitting hearing aids, as well as big-box retail and Medicare Advantage programs, are likely to create pressure on audiology practices to find consistent alternative revenue streams. The provision of cochlear implant services could be one of these reliable sources of revenue.

Viewed through the lens of the traditional hearing aid dispensing business model, in which services provided over several years are bundled with the price of hearing aids, it is not surprising that many audiologists view cochlear implants as a money-losing proposition. However, to see the revenue-generating potential of cochlear implants, it is helpful to evaluate the amount of service time spent with the typical cochlear implant user over a five-year period. Each of these scheduled appointments with the audiologist is, after all, a revenue-generating opportunity, if an unbundled service model is used. Beyond simply billing for your time, it is imperative that the correct CPT codes are used in the billing process (see The Source, page 46)

Based on observational data from several CI centers, the average adult patient requires approximately 5-to-6 hours of billable clinic time for the first year and about 2 hours of care per year over subsequent years. To gain a better understanding of the revenue-generating potential of CIs, audiologists must first calculate their revenue per hour (RPH) needed to cover all costs and provide a marginal profit. See Kim Cavitt's monthly column on page 46 of issue for details on CPT codes associated with the provision of cochlear implants.

In addition to billing for your clinical time for each appointment, there are other revenue-generating opportunities related to the provision of services for cochlear implant recipients. Many patients with bilateral severe-to-profound hearing loss choose to wear a hearing aid in the non-CI ear, and there is evidence to suggest a bimodal arrangement is beneficial to the patient (Blamey, et al, 2013).

One vestigial effect of CI remaining a subspecialty within audiology is the fact that hearing aids and cochlear implants are usually billed differently. Because hearing aids are less likely to receive reimbursement from third-party payers, patients have been conditioned over time by their audiologist to pay out-of-pocket for ancillary items and services, such as batteries, warranties and office visits for routine services. On the other hand, due perhaps to the medical nature of cochlear implants, ancillary CI products and services are billed to third-party payers, and CI recipients have been conditioned not to pay out of pocket for any of them.

This landscape — hearing aid patients pay out-of-pocket and CI recipients do not — is an opportunity for audiology to unbundle some of the value-added extras that result from an outstanding level of care for CI recipients. In the future, both hearing aid and CI users could be offered service contracts that provide the patient with an outstanding level of service and another source of revenue for the practice. Finally, indirect sources of revenue could flow to a practice simply from involvement in cochlear implants. Cochlear implant services are often unique to a community and, as such, are a point of differentiation from competitors who do not offer CI as part of their clinical armamentarium.

Fact: Independent audiology and ENT-audiology practices can provide an elevated level of care and support to severely impaired adults in their community … and make money.

Although cochlear implants have made enormous technological progress over the past few decades, these successes have not translated into greater activity or awareness within hearing aid clinics. Holder et al (2018) offers both proof and guidance on how adults, who often struggle with conventional hearing aids, might obtain better day-to-day benefit from implantable technology. In the emerging era of direct-to-consumer healthcare and deregulated hearing aid distribution, non-CI audiologists would be wise to get more involved in CI selection, mapping and follow-up care.

Given the positive results that CI recipients experience, which are often substantially improved compared to their previous hearing aids, audiologists looking for a way to differentiate their practices from big-box retail and chain-retail audiology centers have an opportunity to provide care to a segment of the hearing-impaired market that has ordinarily consulted with an audiologist who specializes in CI.

Making CI services more accessible to hearing impaired adults in your local market is a win-win-win proposition. Surgical centers that provide CI procedures benefit from referrals from a wider pool of pre-qualified candidates. Your audiology practice wins by enhancing your reputation as a multispecialty audiology center with an alternative revenue-generating opportunity. And, most importantly, patients in your community benefit when a local audiologist can provide much of the care that CI users need. When the clinical evidence and demographic data is carefully weighed, now is the time to take cochlear implants mainstream. Not only can non-CI audiologists change the course of care for those who can benefit from cochlear implants, they can change the outcome of care by practicing to their full scope of practice.    
References
Alice, B. et al (2013) Cochlear implantation in the elderly: surgical and hearing outcomes. BMC Surgery 13 (Suppl 2), S1.

Battmer, R et al (2015) Assessment of ‘Fitting to Outcomes Expert’ FOX™ with new cochlear implant users in a multi-centre study. Cochlear Implants International. 16, 2.

Bittencourt, A. et al (2012) Post-lingual deafness: benefits of cochlear implants vs. conventional hearing aids. Braz J Otorhinolarngol 78, 2, 124-127.

Blamey, P., Artieres, F., Baskent, D. et al (2013) Factors affecting auditory performance of postlinguistically deaf adults using cochlear implants: an update with 2251 patients. Audiol Neurotol. 18, 36–47.

Blanchfield, B. et al (2001) The severely to profoundly hearing-impaired population in the United States: prevalence estimates and demographics. JAAA 12, 183-189

Clark, J. et al (2012). Cochlear implant rehabilitation in older adults: Literature review proposal of a conceptual framework. Journal of the American Geriatric Society 60, 10, 1936-1945.

Friedlund, D. et al (2003) Choice of ear for cochlear implantation: The effect of history and residual hearing on predicted postoperative performance. Otol Neurotol 24, 582-589.

Gubbels, S.P. et al (2017) Can routine office-based audiometry predict cochlear implant evaluation results? Laryngoscope. 127, 1, 216-222

Holder, J. Reynolds, L. Sunderhaus, W. et al (2018) Current profile of adults presenting for preoperative cochlear implant evaluation. Trends in Hearing. Posted online 2-14-2018

Mahbub, H. et al (2017). Prevalence, Characteristics, and Treatment Patterns of Hearing Difficulty in the United States. JAMA Otolaryngol Head Neck Surg. Published online November 22, 2017.

Quall, D, (2018) As Our Profession Evolves, So Should Our KPI’s: Part 1. Hearing Economics section of HHTM, Editor: Amyn Amlani. Downloaded May 6, 2018: http://hearinghealthmatters.org/hearingeconomics/2018/audiology-evolves-so-should-kpis-part-1/

Turton, L. & Smith, P. (2013) Prevalence & characteristics of severe and profound hearing loss in adults in a UK National Health Services clinic. International Journal of Audiology, 52, 92-97.

Vaerenberg, B., De Ceulaer, G., Szlávik, Z., Mancini, P., Buechner, A., & Govaerts, P. J. (2014). Setting and Reaching Targets with Computer-Assisted Cochlear Implant Fitting. The Scientific World Journal, 2014, 646590. http://doi.org/10.1155/2014/646590