Adapting Ourselves, Instead of the Environment: An Inquiry into Human Enhancement for Function and Beyond

Technology enables humans not only to adapt their environment to their needs but also to modify themselves. Means of Human Enhancement - embodied technologies to improve the human body's capabilities or to create a new one - are the designated means of adapting ourselves instead of the environment. The debate about these technologies is typically fought on ethical soil. However, alarmist, utopian, and science fiction scenarios distract from the fact that Human Enhancement is a historical and pervasive phenomenon incorporated into many everyday practices. In the vein of disentangling conceptual difficulties, we claim that means of Human Enhancement are either physiologically or psychologically embodied, rendering the merging with the human user their most defining aspect. To fulfill its purpose, an enhancement must pass the test-in-the-world, i.e., assisting with effective engagement with a dynamic world. Even if failing in this regard: Human Enhancement is the fundamental and semi-targeted process of changing the users relationship with the world through the physical or psychological embodiment of a hitherto external object and/or change of one's body. This can potentially change the notion of being human. Drawing on a rich body of theoretical and empirical literature, we aim to provide a nuanced analysis of the transformative nature of this phenomenon in close proximity to human practice. Stakeholders are invited to apply the theory presented here to interrogate their perspective on technology in general and Human Enhancement in particular.

Complex Language Use in Children With Hearing Loss: A Scoping Review

PURPOSE

Understanding what is known about the language profiles of children with hearing loss (CHL) is vital so that researchers and teachers can identify the specific complex syntactic structures that CHL may struggle to master. An understanding of which aspects of complex syntax pose difficulties for CHL is necessary to inform the kind of intervention that will facilitate learning complex syntax for this cohort of children. This scoping review aims to identify what is currently known about the complex syntax use of CHL who communicate through spoken language, and uncover gaps in the literature to guide further research.

METHOD

Ascoping review was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews guidelines. The Covidence software was utilized to manage the initial and full-text screening process for the search.

RESULTS

From a total of 304 studies, 42 studies were identified that met the eligibility criteria. The review highlights the use of broad-based language assessments and limited use of specific descriptions of the types of complex syntactic structures and skills.

CONCLUSIONS

Findings highlight the need for assessment protocols and analysis methods that better support the description of complex syntax profiles for CHL. School-age CHL continue to display challenges with complex syntax development. The review highlighted the need for further research to improve understanding of the complex syntax strengths and vulnerabilities of CHL. Further investigation is needed to better understand their ability to combine ideas and build complexity in their language use, which in turn can inform teaching in schools and interventions for children who require support.

SUPPLEMENTAL MATERIAL

https://doi.org/10.23641/asha.21980177.

Benefits of auditory-verbal intervention for adult cochlear implant users: perspectives of users and their coaches

OBJECTIVE

Post-implant rehabilitation is limited for adult cochlear implant (CI) recipients. The objective of this research was to capture the perspectives of CI users and their coaches regarding their experiences with auditory-verbal intervention as an example of post-implant rehabilitation and their views on perceived benefits and challenges related to the intervention.

DESIGN

This qualitative study involved semi-structured focus group interviews with adult CI users and their coaches who accompanied them in a 24-week auditory-verbal intervention program.

STUDY SAMPLE

A total of 17 participants (eight CI users and nine coaches) contributed to the interviews.

RESULTS

Three key topic areas emerged from the interviews capturing CI users' and coaches' experiences related to the intervention program: (1) benefits of the intervention, (2) factors affecting experiences, and (3) challenges and barriers. Benefits included increased confidence in hearing, communication, social participation, and new knowledge about technology and hearing. Factors affecting the experience were participants' motivation and the therapist's skills. The primary challenge was the time commitment for weekly therapy.

CONCLUSIONS

Both CI users and coaches perceived a focussed auditory-verbal intervention to be beneficial in improving speech understanding, confidence in using hearing, social interaction, and knowledge about technology. Participants recommended reducing the intensity of intervention to facilitate participation.

A Scoping Review of Studies Comparing Outcomes for Children With Severe Hearing Loss Using Hearing Aids to Children With Cochlear Implants

OBJECTIVES

Clinical practice regarding children's candidature for cochlear implantation varies internationally, albeit with a recent global trend toward implanting children with more residual hearing than in the past. The provision of either hearing aids or cochlear implants can influence a wide range of children's outcomes. However, guidance on eligibility and suitability for implantation is often based on a small number of studies and a limited range of speech perception measures. No recent reviews have catalogued what is known about comparative outcomes for children with severe hearing-loss using hearing aids to children using cochlear implants. This article describes the findings of a scoping review that addressed the question "What research has been conducted comparing cochlear implant outcomes to outcomes in children using hearing aids with severe hearing-loss in the better-hearing ear?" The first objective was to catalogue the characteristics of studies pertinent to these children's candidature for cochlear implantation, to inform families, clinicians, researchers, and policy-makers. The second objective was to identify gaps in the evidence base, to inform future research projects and identify opportunities for evidence synthesis.

DESIGN

We included studies comparing separate groups of children using hearing aids to those using cochlear implants and also repeated measures studies comparing outcomes of children with severe hearing loss before and after cochlear implantation. We included any outcomes that might feasibly be influenced by the provision of hearing aids or cochlear implants. We searched the electronic databases Medline, PubMed, and CINAHL, for peer-reviewed journal articles with full-texts written in English, published from July 2007 to October 2019. The scoping methodology followed the approach recommended by the Joanna Briggs Institute regarding study selection, data extraction, and data presentation.

RESULTS

Twenty-one eligible studies were identified, conducted across 11 countries. The majority of children studied had either congenital or prelingual hearing loss, with typical cognitive function, experience of spoken language, and most implanted children used one implant. Speech and language development and speech perception were the most frequently assessed outcomes. However, some aspects of these outcomes were sparsely represented including voice, communication and pragmatic skills, and speech perception in complex background noise. Two studies compared literacy, two sound localization, one quality of life, and one psychosocial outcomes. None compared educational attainment, listening fatigue, balance, tinnitus, or music perception.

CONCLUSIONS

This scoping review provides a summary of the literature regarding comparative outcomes of children with severe hearing-loss using acoustic hearing aids and children using cochlear implants. Notable gaps in knowledge that could be addressed in future research includes children's quality of life, educational attainment, and complex listening and language outcomes, such as word and sentence understanding in background noise, spatial listening, communication and pragmatic skills. Clinician awareness of this sparse evidence base is important when making management decisions for children with more residual hearing than traditional implant candidates. This review also provides direction for researchers wishing to strengthen the evidence base upon which clinical decisions can be made.

Evidence gaps in economic analyses of hearing healthcare: A systematic review

BACKGROUND

Hearing loss is a common and costly medical condition. This systematic review sought to identify evidence gaps in published model-based economic analyses addressing hearing loss to inform model development for an ongoing Lancet Commission.

METHODS

We searched the published literature through 14 June 2020 and our inclusion criteria included decision model-based cost-effectiveness analyses that addressed diagnosis, treatment, or prevention of hearing loss. Two investigators screened articles for inclusion at the title, abstract, and full-text levels. Data were abstracted and the studies were assessed for the qualities of model structure, data assumptions, and reporting using a previously published quality scale.

FINDINGS

Of 1437 articles identified by our search, 117 unique studies met the inclusion criteria. Most of these model-based analyses were set in high-income countries (n = 96, 82%). The evaluated interventions were hearing screening (n = 35, 30%), cochlear implantation (n = 34, 29%), hearing aid use (n = 28, 24%), vaccination (n = 22, 19%), and other interventions (n = 29, 25%); some studies included multiple interventions. Eighty-six studies reported the main outcome in quality-adjusted or disability-adjusted life-years, 24 of which derived their own utility values. The majority of the studies used decision tree (n = 72, 62%) or Markov (n = 41, 35%) models. Forty-one studies (35%) incorporated indirect economic effects. The median quality rating was 92/100 (IQR:72-100).

INTERPRETATION

The review identified a large body of literature exploring the economic efficiency of hearing healthcare interventions. However, gaps in evidence remain in evaluation of hearing healthcare in low- and middle-income countries, as well as in investigating interventions across the lifespan. Additionally, considerable uncertainty remains around productivity benefits of hearing healthcare interventions as well as utility values for hearing-assisted health states. Future economic evaluations could address these limitations.

FUNDING

NCATS 3UL1-TR002553-03S3.

Global Regulatory Review Needed for Cochlear Implants: A Call for FDA Leadership

INTRODUCTION

Using the United States Food and Drug Administration (FDA) as example, we argue that regulatory agencies worldwide should review their guidance on cochlear implants (CIs).

METHODS

This is a position paper, thus the methods are strictly argumentation. Here we give the motivation for our recommendation. The FDA's original approval of implantation in prelingually deaf children was granted without full benefit of information on language acquisition, on childcaregiver communication, and on the lived experience of being deaf. The CI clinical trials, accordingly, did not address risks of linguistic deprivation, especially when the caregiver's communication is not fully accessible to the prelingually deaf child. Wide variability in the effectiveness of CIs since initial and updated approval has been indicated but has not led to new guidance. Children need to be exposed frequently and regularly to accessible natural language while their brains are still plastic enough to become fluent in any language. For the youngest infants, who are not yet producing anything that could be called language although they might be producing salient social signals (Goldstein et al. Child Dev 80:636-644, 2009), good comprehension of communication from caregiver to infant is critical to the development of language. Sign languages are accessible natural languages that, because they are visual, allow full immersion for deaf infants, and they supply the necessary support for this comprehension. The main language contributor to health outcomes is this combination of natural visual language and comprehension in communication. Accordingly, in order to prevent possible language deprivation, all prelingually deaf children should be exposed to both sign and spoken languages when their auditory status is detected, with sign language being critical during infancy and early childhood. Additionally, all caregivers should be given support to learn a sign language if it is new to them so that they can comprehend their deaf children's language expressions fully. However, both languages should be made accessible in their own right, not combined in a simultaneous or total communication approach since speaking one language and signing the other at the same time is problematic.

RESULTS

Again, because this is a position paper, our results are our recommendations. We call for the FDA (and similar agencies in other countries) to review its approval of cochlear implantation in prelingually deaf children who are within the sensitive period for language acquisition. In the meantime, the FDA should require manufacturers to add a highlighted warning to the effect that results with CI vary widely and CIs should not be relied upon to provide adequate auditory input for complete language development in all deaf children. Recent best information on users' experience with CIs (including abandonment) should be clearly provided so that informed decisions can be made. The FDA should require manufacturers' guidance and information materials to include encouragement to parents of deaf children to offer auditory input of a spoken language and visual input of a sign language and to have their child followed closely from birth by developmental specialists in language and cognition. In this way parents can align with providers to prioritize cognitive development and language access in both audio-vocal and visuo-gestural modalities.

DISCUSSION

The arguments and recommendations in this paper are discussed at length as they come up.

Cost-effectiveness analysis of bilateral cochlear implants for children with severe-to-profound sensorineural hearing loss in both ears in Singapore

A cochlear implant is a small electronic device that provides a sense of sound for the user, which can be used unilaterally or bilaterally. Although there is advocacy for the benefits of binaural hearing, the high cost of cochlear implant raises the question of whether its additional benefits over the use of an acoustic hearing aid in the contralateral ear outweigh its costs. This cost-effectiveness analysis aimed to separately assess the cost-effectiveness of simultaneous and sequential bilateral cochlear implantations compared to bimodal hearing (use of unilateral cochlear implant combined with an acoustic hearing aid in the contralateral ear) in children with severe-to-profound sensorineural hearing loss in both ears from the Singapore healthcare payer perspective. Incremental quality-adjusted life year (QALYs) gained and costs associated with bilateral cochlear implants over the lifetime horizon were estimated based on a four-state Markov model. The analysis results showed that, at the 2017 mean cost, compared to bimodal hearing, patients receiving bilateral cochlear implants experienced more QALYs but incurred higher costs, resulting in an incremental cost-effectiveness ratio (ICER) of USD$60,607 per QALY gained for simultaneous bilateral cochlear implantation, and USD$81,782 per QALY gained for sequential bilateral cochlear implantation. The cost-effectiveness of bilateral cochlear implants is most sensitive to utility gain associated with second cochlear implant, and cost of bilateral cochlear implants. ICERs increased when the utility gain from bilateral cochlear implants decreased; ICERs exceeded USD$120,000 per QALY gained when the utility gain was halved from 0.03 to 0.015 in both simultaneous and sequential bilateral cochlear implantations. The choice of incremental utility gain associated with the second cochlear implant is an area of considerable uncertainty.

Minimal Reporting Standards for Active Middle Ear Hearing Implants

There is currently no standardized method for reporting audiological, surgical and subjective outcome measures in clinical trials with active middle ear implants (AMEIs). It is often difficult to compare studies due to data incompatibility and to perform meta-analyses across different centres is almost impossible. A committee of ENT and audiological experts from Germany, Austria and Switzerland decided to address this issue by developing new minimal standards for reporting the outcomes of AMEI clinical trials. The consensus presented here aims to provide a recommendation to enable better inter-study comparability.

The Costs and Valuation of Health Impacts of Measles and Rubella Risk Management Policies

National and global health policymakers require good information about the costs and benefits of their investments in measles and rubella immunization programs. Building on our review of the existing measles and rubella health economics literature, we develop inputs for use in regional and global models of the expected future benefits and costs of vaccination, treatment, surveillance, and other global coordination activities. Given diversity in the world and limited data, we characterize the costs for countries according to the 2013 World Bank income levels using 2013 U.S. dollars (2013$US). We estimate that routine immunization and supplemental immunization activities will cost governments and donors over 2013$US 2.3 billion per year for the foreseeable future, with high-income countries accounting for 55% of the costs, to vaccinate global birth cohorts of approximately 134 million surviving infants and to protect the global population of over 7 billion people. We find significantly higher costs and health consequences of measles or rubella disease than with vaccine use, with the expected disability-adjusted life year (DALY) loss for case of disease generally at least 100 times the loss per vaccine dose. To support estimates of the economic benefits of investments in measles and/or rubella elimination or control, we characterize the probabilities of various sequelae of measles and rubella infections and vaccine adverse events, the DALY inputs for health outcomes, and the associated treatment costs. Managing measles and rubella to achieve the existing and future regional measles and rubella goals and the objectives of the Global Vaccine Action Plan will require an ongoing commitment of financial resources that will prevent adverse health outcomes and save the associated treatment costs.

Expanding pediatric cochlear implant candidacy: A case study of electro-natural stimulation (ENS) in partial deafness treatment

BACKGROUND

Some adolescents have hearing impairments characterized by normal or slightly elevated thresholds in the low and mid-frequency bands (below 1500 Hz) and nearly total deafness in the high frequency range. These patients often remain beyond the scope of effective hearing aid treatment.

CASE REPORT

This study presents the case of a 16-year-old adolescent with good hearing in the range 125-1500 Hz and deafness at other frequencies. An implant was used to restore hearing at high frequencies, while preserving low and mid frequency acoustic hearing in the implanted ear. This is described as electro-natural stimulation (ENS) of the inner ear.

CONCLUSIONS

The results demonstrate that low and mid frequency hearing (up to 1500 Hz) can be preserved using the round window surgical technique. A substantial improvement in speech discrimination was also observed when electrical stimulation on one side was combined with acoustic stimulation on both sides. There is scope to extend qualifying criteria for cochlear implantation to include adolescents who are suited to ENS.

Cost effectiveness of cochlear implants

PURPOSE OF REVIEW

Health professionals would be well served to have as good an understanding of cost effectiveness as clinical effectiveness, as both are critical to their patients having access to better health care and achieving better health outcomes. Cost-effectiveness evaluations allow decision makers a means of comparing different interventions when deciding resource allocation. It is a powerful tool, but like any analysis, not understanding the processes and assumptions involved leads to misinterpretation.

RECENT FINDINGS

Cost effectiveness is an economic evaluation of cost and benefit. The threshold at which an intervention is considered cost effective is reflected by the payer's "willingness to pay", which can vary considerably from country to country. These evaluations are complex and can involve the use of incomplete financial data, and subjective impressions of benefit, while excluding broader social and economic benefits.

SUMMARY

Pediatric unilateral and simultaneous bilateral cochlear implantation, and adult unilateral cochlear implantation are felt to be cost effective in the United States. Pediatric sequential cochlear implantation, adult bilateral cochlear implantation, implantation in the aged and the long deaf are not. However, cost-effectiveness economic evaluations are only part of broader assessment of social and economic benefit when determining resource allocation.

Adequate formal language performance in unilateral cochlear implanted children: is it indicative of complete recovery in all linguistic domains? Insights from referential communication

OBJECTIVES

Referential communication (RC) is a key element in achieving a successful communication. This case series aimed to evaluate RC in children with unilateral cochlear implants (CIs) with formal language skills within the normal range.

METHODS AND MATERIALS

A total of 31 children with CIs, with language development within the normal range, were assessed using the Pragmatic Language Skills test (MEDEA).

RESULTS

Of the children with CIs, 83.9% reached performance levels appropriate for their chronological ages. The results confirmed a positive effect of cochlear implantation on RC development, although difficulties remained in some CI users.

CONCLUSIONS

The outcomes emphasize the need to pay greater attention to the pragmatic aspects of language, assessing them with adequate testing in the early phase after cochlear implantation. Clear knowledge of children's communicative competence is the key in optimizing their communicative environments in order to create the basis for future successful interpersonal exchanges and social integration.

Practitioners' perspectives on the functioning of school-age children with cochlear implants

OBJECTIVE

The availability of cochlear implants has increased the number of children with profound deafness educated in classrooms alongside peers with normal hearing. The purpose of this research was to better understand the functioning of these children from the perspective of their service providers.

METHODS

Semi-structured focus group interviews were conducted with 28 practitioners to elicit their perceptions of children's abilities in oral communication, academic, and social functioning. Data were coded inductively and examined through content analysis.

RESULTS

The central theme was that cochlear implantation has improved school functioning for children both in hearing and related spoken language abilities and beyond hearing in academic and social development. While these benefits were a consistent theme, a wide range of performance was identified across all areas of functioning. In particular, areas of concern included full participation in classroom activities and social interaction with peers.

CONCLUSIONS

The findings provide insights into functioning for children with cochlear implants from the perspective of those who interact with them in everyday settings. These findings underscore the challenges for children in achieving full participation despite improvements in communication skills. Practitioners identified areas where intervention is required to facilitate the inclusion of children in school programs.

Interdependence of linguistic and indexical speech perception skills in school-age children with early cochlear implantation

OBJECTIVES

This study documented the ability of experienced pediatric cochlear implant (CI) users to perceive linguistic properties (what is said) and indexical attributes (emotional intent and talker identity) of speech, and examined the extent to which linguistic (LSP) and indexical (ISP) perception skills are related. Preimplant-aided hearing, age at implantation, speech processor technology, CI-aided thresholds, sequential bilateral cochlear implantation, and academic integration with hearing age-mates were examined for their possible relationships to both LSP and ISP skills.

DESIGN

Sixty 9- to 12-year olds, first implanted at an early age (12 to 38 months), participated in a comprehensive test battery that included the following LSP skills: (1) recognition of monosyllabic words at loud and soft levels, (2) repetition of phonemes and suprasegmental features from nonwords, and (3) recognition of key words from sentences presented within a noise background, and the following ISP skills: (1) discrimination of across-gender and within-gender (female) talkers and (2) identification and discrimination of emotional content from spoken sentences. A group of 30 age-matched children without hearing loss completed the nonword repetition, and talker- and emotion-perception tasks for comparison.

RESULTS

Word-recognition scores decreased with signal level from a mean of 77% correct at 70 dB SPL to 52% at 50 dB SPL. On average, CI users recognized 50% of key words presented in sentences that were 9.8 dB above background noise. Phonetic properties were repeated from nonword stimuli at about the same level of accuracy as suprasegmental attributes (70 and 75%, respectively). The majority of CI users identified emotional content and differentiated talkers significantly above chance levels. Scores on LSP and ISP measures were combined into separate principal component scores and these components were highly correlated (r = 0.76). Both LSP and ISP component scores were higher for children who received a CI at the youngest ages, upgraded to more recent CI technology and had lower CI-aided thresholds. Higher scores, for both LSP and ISP components, were also associated with higher language levels and mainstreaming at younger ages. Higher ISP scores were associated with better social skills.

CONCLUSIONS

Results strongly support a link between indexical and linguistic properties in perceptual analysis of speech. These two channels of information appear to be processed together in parallel by the auditory system and are inseparable in perception. Better speech performance, for both linguistic and indexical perception, is associated with younger age at implantation and use of more recent speech processor technology. Children with better speech perception demonstrated better spoken language, earlier academic mainstreaming, and placement in more typically sized classrooms (i.e., >20 students). Well-developed social skills were more highly associated with the ability to discriminate the nuances of talker identity and emotion than with the ability to recognize words and sentences through listening. The extent to which early cochlear implantation enabled these early-implanted children to make use of both linguistic and indexical properties of speech influenced not only their development of spoken language, but also their ability to function successfully in a hearing world.

A systematic review of the effectiveness and cost-effectiveness of bilateral multichannel cochlear implants in adults with severe-to-profound hearing loss

BACKGROUND

In the UK, approximately 10 000 people have cochlear implants, more than 99% with a unilateral implant. Evidence shows that adults implanted bilaterally may benefit from binaural advantages; however, systematic review evidence is limited.

OBJECTIVES OF THE REVIEW

To conduct a systematic review to discover the evidence for effectiveness and cost-effectiveness of using bilateral cochlear implants in adults with severe-to-profound hearing loss by comparing their effectiveness with unilateral cochlear implantation or unilateral cochlear implantation and acoustic hearing aid in the contralateral ear.

TYPE OF REVIEW

Systematic review.

SEARCH STRATEGY

This examined 16 electronic databases, plus bibliographies and references for published and unpublished studies.

EVALUATION METHOD

Abstracts were independently assessed against inclusion criteria by two researchers, and disagreements were resolved. Selected papers were then retrieved and further independently assessed in a similar way. Included studies had their data extracted by one reviewer and checked by another.

RESULTS

Searches yielded 2892 abstracts producing 19 includable studies. Heterogeneity between studies precluded meta-analysis. However, all studies reported that bilateral cochlear implants improved hearing and speech perception: one randomised controlled trial found a significant binaural benefit over the first ear alone for speech and noise from the front (12.6 ± 5.4%, P < 0.001) and when noise was ipsilateral to the first ear (21 ± 6%, P < 0.001); and another found a significant benefit for spatial hearing at 3 and 9 months post-implantation compared with pre-implantation [mean difference (sd) scores: 3 months = 1.46 (0.83-2.09), P < 0.01].Quality of life results varied, showing bilateral implantation may improve quality of life in the absence of worsening tinnitus. Limited cost-effectiveness evidence showed that bilateral implantation is probably only cost-effective at a willingness-to-pay threshold above £62 000 per quality adjusted life year.

CONCLUSIONS

Despite inconsistency in the quality of available evidence, the robustness of systematic review methods gives weight to the positive findings of included studies demonstrating that bilateral implantation is clinically effective in adults but unlikely to be cost-effective.

Timing of cochlear implantation and parents' global ratings of children's health and development

OBJECTIVE

To assess children's health-related quality of life (HRQL) and development after cochlear implant (CI) surgery and compare improvements between different age of implantation categories.

STUDY DESIGN

Prospective, longitudinal study comparing outcomes of deaf children post-CI with hearing controls.

SETTING

Six US CI centers.

PATIENTS

Deaf children who received CI (n = 188) and hearing children of comparable ages (n = 97).

INTERVENTION

CI before 5 years of age.

MAIN OUTCOME MEASURE

Parental ratings of global HRQL and development, as assessed over the first 4 years of follow-up using visual analog scales. Development scores assess parental views of children's growth and development, motor skills, ability to express themselves and communicate with others, and learning abilities. Associations of baseline child and family characteristics with post-CI HRQL and development were investigated using multivariable analysis, controlling for factors that influence post-CI language learning.

RESULTS

Baseline deficits of CI candidates relative to hearing controls were larger in development than HRQL. Development scores improved significantly by 4 years after CI, particularly in the youngest CI recipients. Developmental deficits of older CI recipients with early, extended hearing aid use were only partially remediated by CI. Overall, no significant health deficits were observed in CI children after 4 years. Cognition and speech recognition were positively associated with both HRQL and development.

CONCLUSION

Parental perspectives on quality of their child's life and development provide practical insight into the optimal timing of interventions for early-onset deafness. Validity of parental global assessments is supported by clinical measures of speech perception and language learning and comparison with a well-validated health status instrument.

Cochlear implant programs: balancing clinical and financial sustainability

OBJECTIVES/HYPOTHESIS

In 2006, a tertiary academic medical center's adult and pediatric cochlear implant program was closed due to financial losses. Using business practices known as supply chain and revenue management, the objective was to establish a new cochlear implant program that was financially viable.

STUDY DESIGN

Retrospective cohort study using a nonequivalent historical comparison group design.

METHODS

Using available financial data from the period of 1999 to 2006, cost and revenue figures were estimated, and a business plan developed using supply chain and revenue management principles to re-establish the cochlear implant program in 2007. Actual cost and revenue data from 2007 to 2011, the current program, were assessed for current financial performance and compared to the historical data.

RESULTS

In comparing the period of 1999 to 2006 to the period of 2007 to 2011, the net loss per implanted patient went from $22,365 to $976. Profitable gross and net margins were achieved for all payers except Medicaid, for which the loss per case remained unchanged. This per case loss may change with receipt of pending Medicaid Upper Payment Limit supplemental payments.

CONCLUSIONS

Use of supply chain and revenue management principles markedly improved the financial performance of the re-established cochlear implant program. With improved cost and revenue outcomes, the overall negative net margin was reduced. Physicians who learn and use supply chain and revenue management methods can work to ensure that their patients will have continued access to cochlear implant surgery, and are applicable to any clinical services or procedures that must meet the challenge of achieving financial sustainability.