Download Changing Trends in Referrals for Consideration of Cochlear

Changing Trends in Referrals for Consideration of Cochlear Implantation
Introduction
Over the past ten years 746 deaf children and adults have been referred to the South of England Cochlear Implant Centre (SOECIC)
for an assessment for cochlear implantation. In the year 2001 SOECIC received 50 referrals for assessment and by 2010 this had
risen to 125 per annum.
Assessment outcomes
439 of the patients referred during this decade have now received a cochlear implant. On average
SOECIC has implanted around two-thirds of the patients referred for an assessment. Reasons
for discharge include patients that are not suitable candidates and SOECIC is looking at ways
to reduce the number of inappropriate referrals by offering training to local services to ensure
that patients/parents have a clearer understanding of what a cochlear implant can offer prior to
referral. For others the reasons for discharge are complex and it is not until a full assessment has
taken place that a decision not to proceed to implant can be made. Fig 3 shows the current status of
patients that were referred to SOECIC for an assessment, several have now had a second cochlear
implant and have the potential for binaural hearing. Twenty patients implanted at SOECIC have
transferred on to other programmes as they have moved areas.
Conclusion
SOECIC is continuing to receive more referrals year on year. This partly due to the increased
acceptance of cochlear implantation as a treatment for severely and profoundly deaf children
and adults. The issue of the NICE TAG has increased awareness among ENT and audiology
professionals and ensured that patients across England and Wales have equal access to this
treatment. Patient groups such as NCIUA and CICs have been instrumental in promoting the
potential benefits of cochlear implants. At the beginning of 2001 there were just 144 adults and
43 children with cochlear implants under the care of SOECIC. At the end of 2010 there were 320
adults and 251 children (over 120 patients using two implants). Whilst dealing with the increased
rate of referral, SOECIC also needs to service the needs of the patients that have been been
implanted. SOECIC is therefore looking at ways to manage this growing caseload whilst ensuring
that patients continue to derive optimal use of their technology.
Number of Referrals
100
80
Adult
Child
60
40
20
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
Year of Referral
Fig 1
Current Status of Patients by Year of Referral
100%
100
90%
90
80%
80
70%
70
60%
Pending
Implanted
Discharged
50%
40%
30%
Number of Patients
Percentage
Outcome of Referral by Year
60
40
30
20
10%
10
0%
Bilateral
Unilateral
Pending
Non-User
50
20%
0
2001
2002
2003
2004
2005
2006
2007
2008
2009
2001
2010
2002
2003
2004
Year of Referral
2005
2006
2007
2008
2009
2010
Year of Referral
Fig 2
Fig 3
Paeds: Age at Implant by Year of Referral
Paeds: Youngest at Referral and Implant
25
60-119
54-59
20
referral
implant
Linear (referral)
Linear (implant)
10
Number of Children
48-53
15
42-47
36-41
2001
2005
2010
30-35
24-29
18-23
5
12-17
0-11
0
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
0
2
4
6
8
10
12
Age in Months
Year of Referral
Fig 5
Fig 4
Adults: Oldest at Referral and Implant
Adults: Age at Implant by Year of Referral
95
80 - 90
90
70 - 80
85
80
referral
implant
Linear (implant)
75
60 - 70
2001
2005
2010
50 - 60
40 - 50
70
30 - 40
65
20 - 30
60
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
0
1
2
3
4
5
6
7
Age in Years
Year of Referral
Fig 6
Fig 7
Aetiology of Implanted Patients Referred between 2001 and 2010
Abnormal Inner Ear
ANSD
CMV
Genetic (inc Connexin 26)
Meningitis
Other known
Syndrome
Prematurity
References
NICE Technology Appraisal Guidance 166. Cochlear
implants for children and adults with severe to
profound deafness. (2009). National Health Service
National Institute for Health and Clinical Excellence
Bench, J., Kowal, A., & Bamford, J. (1979). The BKB
(Bamford-Kowal-Bench) sentence lists for partiallyhearing children. Br J Audiol, 13(3), 108-112.
Unknown
© May 2011
Fig 8
Sarie Cross
South of England Cochlear Implant Centre
Email: [email protected] | www.soecic.org
120
Number of Adults
Aetiology
During the decade SOECIC has been implanting more patients with additional difficulties. The
aetiology of the patients implanted from this cohort is shown in Fig 8. For most of the patients
the cause of deafness remains unknown. In the past two years there has been an increase in the
number of patients (including some children) that have had meningitis. Since 2001 26 children
that were either premature or had cytomegalovirus (CMV) now have cochlear implants. Children
with an aetiology of meningitis, prematurity or cytomegalovirus may also have special needs, some
of which may become obvious as the child matures. There have been 23 patients with an identified
syndrome implanted including 5 with Ushers Syndrome. Since 2004 there have been 10 children
implanted with Auditory Neuropathy Spectrum Disorder and the normal audiological criteria has
not been relevant so funding has been secured on an exceptional basis.
140
0
Age in Months
Criteria
During the decade the criteria for cochlear implantation have undergone several changes. In 2001
SOECIC was implanting adults who scored <50% on BKB Sentences and had a severe hearing loss.
In 2008 criteria changed to <60% on BKB with a profound hearing loss in the high frequencies.
In 2009 following production of the NICE TAG 166 the cut off reverted to a score of <50%. Some
adults are therefore no longer eligible. Children assessed in 2001 needed to have aided thresholds
in the high frequencies of >55dB(HL), now the criteria is based on unaided thresholds of 90dB(HL)
at 2 and 4kHz. Therefore some children who would not have been in criteria for an implant in 2001
have returned to SOECIC for a re-assessment and have now been implanted.
Outcomes of
Referrals made
to SOECIC in
2001–2010
Age in Years
Age
Following the onset of neonatal screening for hearing in the UK there has been a trend to refer
younger children. Fig 4 shows the age of the youngest deaf child at referral and the age of the
youngest congentially deaf child to be implanted that year. At SOECIC the policy is to implant
congenitally deaf children around their first birthday and by 2010 the most common age of implant
was between 12 and 18 months (Fig 5) compared to 2001 when most of the children implanted were
2-2 years (post meningitic children were not included). Throughout the decade SOECIC was
receiving referrals for older adults (Fig 6) but they were often discharged before any assessment
took place - in some cases the NHS commissioners had refused funding for assessment and in
other cases the patient decided not to commence assessment. There has been a trend for SOECIC
to implant older adults and 2009 saw the first nonagenerian to receive an implant. Figs 5 and 7
show how the age profile of the implanted patients has changed over the decade.
Referral to SOECIC for Cochlear Implantation
8