Cost-effectiveness of pediatric bilateral cochlear implantation in Spain.

OBJECTIVES/HYPOTHESIS: To determine the incremental cost-effectiveness of bilateral versus unilateral cochlear implantation for 1-year-old children suffering from bilateral sensorineural severe to profound hearing loss from the perspective of the Spanish public health system. STUDY DESIGN: Cost-utility analysis. METHODS: We conducted a general-population survey to estimate the quality-of-life increase contributed by the second implant. We built a Markov influence diagram and evaluated it for a life-long time horizon with a 3% discount rate in the base case. RESULTS: The incremental cost-effectiveness ratio of simultaneous bilateral implantation with respect to unilateral implantation for 1-year-old children with severe to profound deafness is €10,323 per quality-adjusted life year (QALY). For sequential bilateral implantation, it rises to €11,733/QALY. Both options are cost-effective for the Spanish health system, whose willingness to pay is estimated at around €30,000/QALY. The probabilistic sensitivity analysis shows that the probability of bilateral implantation being cost-effective reaches 100% for that cost-effectiveness threshold. CONCLUSIONS: Bilateral implantation is clearly cost-effective for the population considered. If possible, it should be done simultaneously (i.e., in one surgical operation), because it is as safe and effective as sequential implantation, and saves costs for the system and for users and their families. Sequential implantation is also cost-effective for children who have received the first implant recently, but it is difficult to determine when it ceases to be so because of the lack of detailed data. These results are specific for Spain, but the model can easily be adapted to other countries. LEVEL OF EVIDENCE: 2C. Laryngoscope, 127:2866-2872, 2017.

Computer-assisted CI fitting: Is the learning capacity of the intelligent agent FOX beneficial for speech understanding?

OBJECTIVE: The software application FOX ('Fitting to Outcome eXpert') is an intelligent agent to assist in the programing of cochlear implant (CI) processors. The current version utilizes a mixture of deterministic and probabilistic logic which is able to improve over time through a learning effect. This study aimed at assessing whether this learning capacity yields measurable improvements in speech understanding. METHODS: A retrospective study was performed on 25 consecutive CI recipients with a median CI use experience of 10 years who came for their annual CI follow-up fitting session. All subjects were assessed by means of speech audiometry with open set monosyllables at 40, 55, 70, and 85 dB SPL in quiet with their home MAP. Other psychoacoustic tests were executed depending on the audiologist's clinical judgment. The home MAP and the corresponding test results were entered into FOX. If FOX suggested to make MAP changes, they were implemented and another speech audiometry was performed with the new MAP. RESULTS: FOX suggested MAP changes in 21 subjects (84%). The within-subject comparison showed a significant median improvement of 10, 3, 1, and 7% at 40, 55, 70, and 85 dB SPL, respectively. All but two subjects showed an instantaneous improvement in their mean speech audiometric score. DISCUSSION: Persons with long-term CI use, who received a FOX-assisted CI fitting at least 6 months ago, display improved speech understanding after MAP modifications, as recommended by the current version of FOX. This can be explained only by intrinsic improvements in FOX's algorithms, as they have resulted from learning. This learning is an inherent feature of artificial intelligence and it may yield measurable benefit in speech understanding even in long-term CI recipients.