Do Current Guidelines Prevent Access to Cochlear Implantation?
In the era of single channel cochlear implants, nothing less than bilateral profound deafness was an indication for surgery. But as CI performance improved, auditory guidelines for candidacy expanded. And as safety and efficacy of implantation were confirmed, young children and older adults were included. It has been anticipated that, consistent with improving outcomes, the candidate field would continue to expand.
So it is not surprising that in clinical practice, hearing impaired people with conditions that once contraindicated implantation are now candidates. Some of these prior contraindications include (1):
Significant residual hearing
Auditory neuropathy spectrum disorder
Pre-linguistically deaf adolescents and adults
Non-auditory developmental or cognitive delay
Single sided deafness
Unfortunately, written guidelines for candidacy may not reflect best practices, which tend to respond quickly to evidence-based, peer-reviewed research. Too often, CI professionals must challenge regulatory and insurance authorities in the best interest of their patients. As a result, inappropriate guidelines and regulations tend to prevent access to CI for many candidates who could be expected to benefit. A special issue of Cochlear Implants International (ed., John Graham) addresses this concern (2).
Restricted access to CI may be especially important in children. Hanvey et al.(3) report evidence of harm being done to patients because “…guidelines may be interpreted as strict criteria whereby clinicians adhere to specific audiometric thresholds without accounting for the acceptable range of performance…or a child’s functional development.” Most would also agree that reliance on audiometric thresholds is inappropriate in the first place although threshold hearing remains the standard guideline for implantation in most regions.
Prof. Paul Govaerts of the Eargroup and Antwerp University addresses this issue from the clinical as well as ethical perspectives. From the clinical perspective, Govaerts(4) correctly asserts that,
“…CI selection must be highly individual, whereas the current criteria are general, not valid, not based on a wide consensus, and not up-to-date.”
Factors that are specific to each candidate, such as cause and duration of hearing loss, age, motivation, family support, prior successful imbedding of children in Deaf cultures, availability of auditory-verbal therapy and socio-economic factors, are universally considered important by CI teams but ignored by governmental agencies and insurance companies (4,5). Further, today’s outcomes are significantly better than those of the previous decade (4). By the time new CI candidacy criteria achieve consensus approval by bureaucratic agencies, they are often out of date.
From the ethical perspective, CI teams often face a moral dilemma pitting the obligation to act in the best interest of the patient against the restrictions imposed by strict criteria. Govaerts4 provides the following example:
Although evidence has long demonstrated the value of CI in young children,
“There are entire cohorts of babies who did not receive a CI at the necessary early age because of the administrative criteria of many countries. For the rest of their lives these children are doomed to a disability that is much greater than what should have been.”
CI criteria may still have a role to play in training of new generations of CI specialists, general guidance for teams and in the clinical evaluation of new methods and technology. However, if strict criteria are used to deny services to appropriate candidates and primarily serve administrative or financial interests, the system must adapt or be abandoned.
1. Arnolder C, Lin VY Expanded selection criteria in adult cochlear implantation. Cochlear Implants Int. 2013. 14: S10-3.
2. Cochlear Implants International Volume 17, Supplement 1, 2016
3. Hanvey K, Ambler M, Maggs J, Wilson K. Criteria versus guidelines: Are we doing the best for our paediatric patients? Cochlear Implants Int. 2016. 17 Suppl 1: 78-82.
4. Govaerts PJ. Expert opinion: Time to ban formal CI selection criteria? Cochlear Implants Int. 2016. 17 Suppl 1: 74-77.
5. Blamey P, Atieres F, Baskent D, Bergeron F, et al. Factors affecting auditory performance of post-linguistically deaf adults using cochlear implants: an update with 2251 patients. Audiology and Neurotology 2012. 18(1): 36-47.