Cochlear implants have successfully improved hearing loss for decades, but few people who qualify for an implant actually get it. Even in countries with universal healthcare, the adoption rates are dismal.
Researchers are finding further disparities for marginalized communities, especially for Black and Asian patients, according to a recent study of British hospitals published Thursday in PLOS Medicine.
These findings did not particularly surprise co-author Chloe Swords, an otolaryngologist at the University of Cambridge.
“Sadly not. It’s disappointing, but now that we know what’s going on, we can do something about it,” she told STAT.
More than a million people in the world have a cochlear implant. The neural prosthesis, placed under the skin behind the ear, helps people with severe-to-profound hearing loss hear sounds more clearly by stimulating their auditory nerve. The technology is now the go-to treatment for children born congenitally deaf. Regardless of the patient’s age at the time of implementation, these implants can provide numerous benefits, including staving off dementia.
Very few people who qualify for an implant actually get one, however. In the United States alone, over two million people could benefit from a cochlear implant, but only roughly 5% of people get the hardware. Most countries have similarly poor rates of adoption. While financial and cultural factors turn patients away, this new PLOS Medicine paper illustrates how providers and the “leaky” referral network also keep people from receiving this critical care.
“The referral network to get a cochlear implant — these wheels are not greased. It is a very difficult process,” said Jacob Hunter, an otolaryngologist at Jefferson Hospital in Philadelphia who was not involved in the study.
The team gathered data from over 6,000 patients in audiology and otolaryngology clinics throughout Great Britain, with an average age of 72. Roughly 40% of those patients were eligible for the surgery, but less than 10% were actually referred.
The rates were even worse for certain groups. Black or Asian patients were 40% less likely to be told they were eligible compared to white patients, though there was no difference in referral rates once the conversation was had. Individuals from poorer neighborhoods were also less likely to be informed if eligible. (Two of the study’s authors have received grants from companies that make cochlear implants, but those companies did not fund this work.)
“If, as clinicians, we’re not presenting them with that information, then they don’t have a chance at knowing [that] this life changing intervention is an option for them,” Swords said.
To get cochlear implants, a patient must take many steps on this journey to surgery, each one a potential obstacle and opportunity for them to drop out from this “leaky pipeline” — as many as 15 appointments, according to a 2021 study.
Primary care physicians are often the first point of contact when patients complain of a hearing loss. Next, they would refer them to an audiologist. But hearing isn’t always the first thing on a primary care physician’s checklist, says Swords. She wants to develop systems that can make it easier for providers to refer the patient to an audiologist.
“They’ve got short appointments, so if we can do anything to facilitate, like, putting a pop-up that comes on [the] computer screen when they measure patients that would be eligible that says, ‘Oh, have you thought about recruiting for a cochlear implant?’ Something as simple as that,” said Swords.
Audiologists are not exempt from the blame, either.
“I remember doing outreach events when I first got into practice and talking to audiologists like, ‘These are the current criteria for cochlear implant,’ and they were like, ‘I appreciate that, but I’m comfortable with what I learned in training 20 years ago,’” said Hunter, who has performed cochlear implant surgeries for over 10 years.
Other otolaryngologists were surprised that Great Britain’s poor rates of adoption are comparable to low rates in the United States.
“You would have expected the U.K. to have maybe a higher penetration, given that they have more universal health care access for their people,” said Esther Ximena Vivas, an otolaryngologist who runs the cochlear implant program at Emory University School of Medicine. “So maybe it’s not just access to health care, but more cultural things and basic information and knowledge on the provider side.”
Hunter says this study helps demonstrate the problems from the provider side, but any attempt to fix this problem must include the patient side, as factors like a language barrier could partially explain the low referral rate. Another impediment to implantation is that most hospitals and clinics do not have the requisite technology to do the procedure, so people in rural areas or low-income neighborhoods often have to travel far for an outpatient surgery that only takes a few hours. Hunter likened the issue to food deserts.
“You don’t find grocery stores in poor economic areas,” he said. “I would argue you don’t find audiograms and hearing health care practitioners and basic health care right for people who live in these poor areas.”
Now that they have identified the problem, Swords says her research team is working on a follow-up study to understand why so few patients who need cochlear implants actually receive them.