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Bilateral cochlear implants in kids may not be cost-effective for Singapore

Tristan Manalac
21 Aug 2019

Bilateral cochlear implantations for children with severe-to-profound sensorineural hearing loss may not be a cost-effective healthcare investment for Singapore, unless the cost of the implants decrease appropriately, according to a recent study.

Researchers developed a microsimulation model to determine the cost-effectiveness of simultaneous and sequential bilateral cochlear implantations as compared to bimodal hearing. The population for modelling included children born with severe-to-profound sensorineural hearing loss in both ears. The incremental cost-effectiveness ratio (ICER) was calculated using quality-adjusted life-year (QALY) as a measure of effectiveness.

In the base case analysis, the corresponding ICERs of simultaneous and sequential bilateral cochlear implantations were USD 60,607 and USD 81,782 per QALY gained. [PLoS One 2019;14:e0220439]

A subsequent one-way sensitivity analysis found that the ICER of simultaneous bilateral cochlear implants was highly and independently sensitive to the utility gained from the second implant. For instance, when the incremental utility gain from the second implant was halved, the resulting ICER almost doubled to USD 121,143 per QALY gained.

Simultaneous bilateral implantation was also sensitive to the cost of the first implant. That is, when the initial cost rose by 10 percent, the resulting ICER increased to USD 67,883 per QALY gained. Other factors had smaller effects.

Sequential bilateral cochlear implants were similarly largely dependent on the gained benefits from the second implant. Cutting the incremental utility gain in half resulted in a jump in ICER to USD 163,575 per QALY gained. On the other hand, when the cost of the first implant dropped by 10 percent, ICER was also reduced to USD 74,011 per QALY gained.

Notably, a Monte Carlo simulation showed that the willingness-to-pay threshold between simultaneous bilateral cochlear implants and bimodal hearing was USD 61,000 per QALY gained. In absolute terms, patients who were willing to pay less than USD 61,000 would extract more benefit from bimodal hearing and vice versa.

Sequential bilateral cochlear implantation was outperformed by both simultaneous implantation and bimodal hearing at willingness-to-pay thresholds ranging from USD 0 to USD 100,000 per QALY gained.

“Sequential bilateral cochlear implantation was dominated by simultaneous bilateral cochlear implantation, mainly due to its slower accrual of QALYs and higher postsurgery rehabilitation costs,” the researchers explained.

The study has several limitations worth noting, they said. Chief among this is the uncertainty surrounding the actual incremental benefits associated with second cochlear implants. These may include educational and career achievements, whether as gains or losses.

“In view of the considerable uncertainty in the incremental clinical benefits, bilateral cochlear implantation may not represent good value for limited healthcare dollars in Singapore context unless the cost of bilateral cochlear implants is appropriately reduced,” the researchers added.

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