Table 1 Baseline Characteristics of the Study Cohort (N=29)

2.  Results

2.1. Patient characteristics

Table 1 Baseline characteristics of the study cohort (N=29)

Frequency (%) or Mean (SD)
Mean age at CI / 3.9 (2.7) yrs
Age at implantation (%)
< 1 yrs / 6.9% (2/29)
1-2 yrs / 20.7% (6/29)
2-4 yrs / 34.5% (10/29)
>=4 yrs / 37.9% (11/29)
Type of hearing loss (%)
Congenital / 82.7% (24/29)
Progressive / 17.2% (5/29)
Cause of hearing loss (%)
Large vestibular aqueduct syndrome / 10.3% (3/29)
Congenital atresia / 3.4% (1/29)
Choric otitis media / 3.4% (1/29)
Other / 82.8% (24/29)
Mode of communication prior to CI (%)
Auditory-oral / 17.2% (5/29)
Total communication a / 79.3% (23/29)
Other / 3.5% (1/29)
HA-users prior to CI (%)
Bilateral HA / 31.0% (9/29)
Unilateral HA / 13.8% (4/29)
Implant type (%)
Nucleus® Freedom - CI24RE (CA) / 51.7% (15/29)
Nucleus® Freedom - CI24RE (ST) / 20.7% (6/29)
Nucleus® 24 Contour Advance - CI24R(CA) / 24.1% (7/29)
Nucleus® CI512 / 3.4% (1/29)
Sound processor type (%)
Nucleus® Freedom / 41.4% (12/29)
Nucleus® CP810 / 20.7% (6/29)
Nucleus® CP802 / 13.8% (4/29)
ESPrit™ 3G / 3.4% (1/29)
Education level of parents (%)
Mother
Primary school / 24.1% (7/29)
Secondary school / 58.6% (17/29)
Tertiary (academic) / 3.4% (1/29)
Not formal schooling / 13.8% (4/29)
Father
Primary school / 17.2% (5/29)
Secondary school / 58.6% (17/29)
Tertiary (non-academic) / 10.3% (3/29)
Tertiary (academic) / 3.4% (1/29)
Not formal schooling / 10.3% (3/29)
Employment (%)
Mother
First/ Mid-Level Manager / 3.4% (1/29)
Sales Worker / 3.4% (1/29)
Administrative Support Worker / 3.4% (1/29)
Craft Worker / 10.3% (3/29)
Labourer and Helper / 3.4% (129)
Service Worker / 10.3% (3/29)
Not employed / 65.5% (19/29)
Father
First/ Mid-level Manager / 6.9% (2/29)
Technician / 3.4% (1/29)
Sales Worker / 6.9% ( 2/29)
Craft Worker / 17.2% (5/29)
Operatives / 17.2% (5/29)
Labourer and Helper / 34.4% (10/29)
Not employed / 13.8% (4/29)
Family income level (%)
Low income / 82.7% (24/29)
Middle income / 17.2% (5/29)

Abbreviations: CA, contour advance; CI, cochlear implant; HA, Hearing Aids, SD, standard deviation; ST, Straight;

Notes: a. ‘Total Communication’, defined as a combination of visual cues, audition, and cued speech.

2.2. Decision tree model

Figure 1 Decision tree for comparison of CI versus no CI from the healthcare payer plus patient perspective.

Abbreviations: CI, cochlear implantation; HA, hearing aid; QALY, quality-adjusted life years; SNHL, sensorineural hearing loss.

Note: The ‘no CI’ comparator group includes patients who sought no treatment for bilateral severe-to-profound SNHL (55%) or used HAs

2.3. One-way sensitivity analysis results

2.3.1.  Healthcare payer plus patient perspective

HA RRP
Basecase / Parameter values
Assumed RRP of HA / 10,000 / 3,000 / 9,000 / 15,000 / 20,000 / 25,000 / 30,000 / 35,000 / 40,000 / 45,000 / 50,000
ICUR / 100,561 / 106,906 / 101,468 / 96,029 / 91,497 / 86,965 / 82,434 / 77,902 / 73,370 / 68,838 / 64,306
Cost of SP replacement
Basecase / Parameter values
SP replacement cost / 48,000 / 30,000 / 35,000 / 40,000 / 45,000 / 50,000 / 55,000 / 60,000 / 65,000 / 69,000 / 75,000
ICUR / 100,561 / 86,224 / 90,206 / 94,189 / 98,172 / 102,154 / 106,137 / 110,119 / 114,102 / 117,288 / 122,067
Speech therapy (no. of years)
Basecase / Parameter values
No. of years attending hearing habilitation / 1 / 0 / 2 / 3 / 5 / 6 / 8 / 10 / 12 / 15 / 20
ICUR / 100,561 / 87,012 / 114,110 / 127,659 / 154,757 / 168,306 / 195,404 / 222,502 / 249,600 / 290,247 / 357,992
Spare parts - out of pocket for CI accessories
Basecase / Parameter values
Spare parts - out of pocket expense per annum - CI accessories / 5,083 / 2585 / 3000 / 3299 / 4000 / 4875 / 5000 / 5434 / 6000 / 7000 / 9000
ICUR / 100,561 / 94,338 / 95,372 / 96,117 / 97,863 / 100,043 / 100,354 / 101,436 / 102,846 / 105,337 / 110,319
Spare parts - out of pocket for HA accessories
Basecase / Parameter values
Spare parts - out of pocket expense per annum - HA accessories / 1,233 / 0 / 200 / 300 / 600 / 800 / 1000 / 2500 / 3000 / 3500 / 5000
ICUR / 100,561 / 103,358 / 102,905 / 102,678 / 101,997 / 101,544 / 101,090 / 97,689 / 96,555 / 95,421 / 92,019
HA device failure rate
Basecase / Parameter values
HA failure % / 1.00% / 0.00% / 0.20% / 0.25% / 0.40% / 0.60% / 0.80% / 1.25% / 1.50% / 1.80% / 2.00%
ICUR / 100,561 / 100,572 / 100,568 / 100,567 / 100,563 / 100,559 / 100,554 / 100,544 / 100,539 / 100,532 / 100,528
% HA non-use
Basecase / Parameter values
HA Non-use / 5.1% / 0.00% / 0.50% / 1.00% / 1.50% / 2.00% / 2.50% / 3.50% / 4.00% / 5.00% / 6.00%
ICUR / 100,561 / 102,962 / 102,721 / 102,481 / 102,242 / 102,005 / 101,769 / 101,300 / 101,068 / 100,607 / 100,151
% CI non-use
Basecase / Parameter values
CI Non-use / 1.1% / 0% / 2% / 3% / 4% / 5% / 6% / 7% / 8% / 9% / 10%
ICUR / 100,561 / 99,930 / 101,109 / 101,717 / 102,337 / 102,969 / 103,614 / 104,273 / 104,946 / 105,633 / 106,335
Frequency of hearing appointments per year (after 1st year)
Basecase / Parameter values
Frequency of hearing appointments per year (after 1st year) / 2 / 0 / 1 / 3 / 4 / 5 / 6 / 7 / 8 / 9 / 10
ICUR / 100,561 / 98,808 / 99,276 / 100,211 / 100,678 / 101,145 / 101,613 / 102,080 / 102,547 / 103,015 / 103,482
Frequency of hearing appointments per year (in the 1st year)
Basecase / Parameter values
Frequency of hearing appointments in the first year / 4 / 0 / 1 / 2 / 3 / 5 / 6 / 7 / 8 / 9 / 10
ICUR / 100,561 / 100,441 / 100,471 / 100,501 / 100,531 / 100,591 / 100,621 / 100,652 / 100,682 / 100,712 / 100,742

2.3.2.  Healthcare payer perspective

Frequency of hearing appointments per year (after 1st year)
Basecase / Parameter values
Frequency of hearing appointments per year (after 1st year) / 2 / 0 / 1 / 3 / 4 / 5 / 6 / 7 / 8 / 9 / 10
ICUR / 40,929 / 98,808 / 99,276 / 100,211 / 100,678 / 101,145 / 101,613 / 102,080 / 102,547 / 103,015 / 103,482
Speech thearapy (no. of years)
Basecase / Parameter values
No. of years attending hearing habilitation / 1 / 0 / 2 / 3 / 5 / 6 / 8 / 10 / 12 / 15 / 20
ICUR / 40,929 / 34,487 / 47,372 / 53,814 / 66,699 / 73,142 / 86,027 / 98,912 / 111,797 / 131,124 / 163,336

2.4. Two-way sensitivity analyses

2.4.1.  Healthcare payer plus patient perspective

From the perspective of the healthcare payer plus patient, increasing frequency of CI replacements (less than every six years) whilst holding the frequency of HA replacement constant (at every five years), increased the ICER, while vice versa, improved the ICER. As expected, favourable ICERs were observed for CI when higher discount rates were applied for costs than QALYs.

Duration between replacements (HAs)
Duration between replacements of CI SPs / 100,561 / 1 / 2 / 3 / 4 / 5 / 6 / 7 / 8
1 / 213,153 / 226,426 / 230,850 / 233,063 / 234,390 / 235,275 / 235,907 / 236,381
2 / 132,856 / 146,129 / 150,553 / 152,765 / 154,093 / 154,977 / 155,610 / 156,084
3 / 106,090 / 119,363 / 123,787 / 126,000 / 127,327 / 128,212 / 128,844 / 129,318
4 / 92,707 / 105,980 / 110,405 / 112,617 / 113,944 / 114,829 / 115,461 / 115,935
5 / 84,677 / 97,950 / 102,375 / 104,587 / 105,914 / 106,799 / 107,431 / 107,905
6 / 79,324 / 92,597 / 97,022 / 99,234 / 100,561 / 101,446 / 102,078 / 102,552
7 / 75,500 / 88,774 / 93,198 / 95,410 / 96,737 / 97,622 / 98,254 / 98,728
8 / 72,633 / 85,906 / 90,330 / 92,542 / 93,870 / 94,755 / 95,387 / 95,861
Discount rate - Costs
Discount rate - QALYs / 100,561 / 0.00% / 0.50% / 1.00% / 1.50% / 2.50% / 3.50% / 4.00% / 6.00% / 8.00% / 10.00%
0.00% / 100,561 / 91,014 / 82,414 / 74,664 / 61,370 / 50,539 / 45,895 / 31,355 / 21,575 / 14,948
0.50% / 111,110 / 100,561 / 91,059 / 82,496 / 67,807 / 55,840 / 50,709 / 34,644 / 23,838 / 16,516
1.00% / 122,704 / 111,055 / 100,561 / 91,104 / 74,883 / 61,667 / 56,000 / 38,260 / 26,326 / 18,239
1.50% / 135,441 / 122,583 / 111,000 / 100,561 / 82,656 / 68,068 / 61,814 / 42,231 / 29,059 / 20,132
2.50% / 164,781 / 149,137 / 135,045 / 122,345 / 100,561 / 82,813 / 75,204 / 51,380 / 35,353 / 24,494
3.50% / 200,095 / 181,099 / 163,987 / 148,565 / 122,112 / 100,561 / 91,321 / 62,391 / 42,930 / 29,743
4.00% / 220,342 / 199,423 / 180,580 / 163,597 / 134,468 / 110,736 / 100,561 / 68,704 / 47,274 / 32,752
6.00% / 322,513 / 291,895 / 264,314 / 239,457 / 196,820 / 162,084 / 147,191 / 100,561 / 69,195 / 47,940
8.00% / 468,711 / 424,213 / 384,130 / 348,004 / 286,041 / 235,558 / 213,914 / 146,146 / 100,561 / 69,671
10.00% / 676,525 / 612,298 / 554,442 / 502,300 / 412,864 / 339,998 / 308,757 / 210,944 / 145,147 / 100,561

2.4.2.  Healthcare payer perspective

From the perspective of the healthcare payer only, increasing or decreasing frequency of CI or HA replacements had no impact on the ICER, as all costs related to these events were borne by the families of children implanted. As expected, favourable ICERs were observed for CI when higher discount rates were applied for costs than QALYs.

Duration between replacements (HAs)
Duration between replacements of CI SPs / 40,929 / 1 / 2 / 3 / 4 / 5 / 6 / 7 / 8
1 / 40,929 / 40,929 / 40,929 / 40,929 / 40,929 / 40,929 / 40,929 / 40,929
2 / 40,929 / 40,929 / 40,929 / 40,929 / 40,929 / 40,929 / 40,929 / 40,929
3 / 40,929 / 40,929 / 40,929 / 40,929 / 40,929 / 40,929 / 40,929 / 40,929
4 / 40,929 / 40,929 / 40,929 / 40,929 / 40,929 / 40,929 / 40,929 / 40,929
5 / 40,929 / 40,929 / 40,929 / 40,929 / 40,929 / 40,929 / 40,929 / 40,929
6 / 40,929 / 40,929 / 40,929 / 40,929 / 40,929 / 40,929 / 40,929 / 40,929
7 / 40,929 / 40,929 / 40,929 / 40,929 / 40,929 / 40,929 / 40,929 / 40,929
8 / 40,929 / 40,929 / 40,929 / 40,929 / 40,929 / 40,929 / 40,929 / 40,929
Discount rate - Costs
Discount rate - QALYs / 40,929 / 0.00% / 0.50% / 1.00% / 1.50% / 2.50% / 3.50% / 4.00% / 6.00% / 8.00% / 10.00%
0.00% / 40,929 / 37,043 / 33,543 / 30,389 / 24,978 / 20,570 / 18,680 / 12,762 / 8,781 / 6,084
0.50% / 45,222 / 40,929 / 37,062 / 33,576 / 27,598 / 22,727 / 20,639 / 14,101 / 9,702 / 6,722
1.00% / 49,941 / 45,200 / 40,929 / 37,080 / 30,478 / 25,099 / 22,793 / 15,572 / 10,715 / 7,423
1.50% / 55,126 / 49,892 / 45,178 / 40,929 / 33,642 / 27,704 / 25,159 / 17,188 / 11,827 / 8,194
2.50% / 67,067 / 60,700 / 54,965 / 49,795 / 40,929 / 33,706 / 30,609 / 20,912 / 14,389 / 9,969
3.50% / 81,440 / 73,709 / 66,744 / 60,467 / 49,701 / 40,929 / 37,168 / 25,394 / 17,473 / 12,106
4.00% / 89,681 / 81,167 / 73,497 / 66,585 / 54,730 / 45,071 / 40,929 / 27,963 / 19,241 / 13,330
6.00% / 131,265 / 118,803 / 107,578 / 97,461 / 80,107 / 65,970 / 59,908 / 40,929 / 28,163 / 19,512
8.00% / 190,769 / 172,658 / 156,344 / 141,640 / 116,421 / 95,874 / 87,065 / 59,483 / 40,929 / 28,357
10.00% / 275,351 / 249,210 / 225,662 / 204,440 / 168,039 / 138,382 / 125,667 / 85,856 / 59,076 / 40,929

2.5. Structural sensitivity analysis

2.5.1.  One-way sensitivity analysis of discount rates, and time horizon

2.5.1.1.  Healthcare payer plus patient perspective

Discount rate costs - impact on expected costs for CI
Basecase / Parameter values
Discount rate for costs / 3.00% / 0.00% / 0.50% / 1.00% / 1.50% / 2.50% / 3.50% / 4.00% / 6.00% / 8.00% / 10.00%
Expected discounted costs - CI (20 yrs) / 252,506 / 456,054 / 412,758 / 373,757 / 338,607 / 278,317 / 229,197 / 208,137 / 142,200 / 97,846 / 67,790
Discount rate QALYs - impact on expected QALYs for CI
Basecase / Parameter values
Discount rate for QALYs / 3.00% / 0.00% / 0.50% / 1.00% / 1.50% / 2.50% / 3.50% / 4.00% / 6.00% / 8.00% / 10.00%
Expected discounted QALYs - CI (20 yrs) / 8.93 / 16.13 / 14.60 / 13.22 / 11.98 / 9.84 / 8.11 / 7.36 / 5.03 / 3.46 / 2.40
Discount rate costs - impact on expected costs for HA
Basecase / Parameter values
Discount rate for costs / 3.00% / 0.00% / 0.50% / 1.00% / 1.50% / 2.50% / 3.50% / 4.00% / 6.00% / 8.00% / 10.00%
Expected discounted costs - HA (20 yrs) / 29,005 / 52,386 / 47,412 / 42,932 / 38,895 / 31,969 / 26,327 / 23,908 / 16,334 / 11,239 / 7,787
Discount rate QALYs - impact on expected QALYs for HA
Basecase / Parameter values
Discount rate for QALYs / 3.00% / 0.00% / 0.50% / 1.00% / 1.50% / 2.50% / 3.50% / 4.00% / 6.00% / 8.00% / 10.00%
Expected discounted QALYs - HA (20 yrs) / 6.71 / 12.12 / 10.97 / 9.93 / 9.00 / 7.39 / 6.09 / 5.53 / 3.78 / 2.60 / 1.80
Time horizon
Basecase / Parameter values
Time horizon / 20 / 5 / 8 / 10 / 12 / 15 / 25 / 30 / 40 / 60 / 76
ICUR / 100,561 / 264,382 / 182,472 / 155,168 / 136,966 / 118,763 / 89,640 / 82,359 / 73,258 / 64,157 / 60,324

2.5.1.2.  Healthcare payer perspective

Discount rate costs - impact on expected costs for CI
Basecase / Parameter values
Discount rate costs / 3.00% / 0.00% / 0.50% / 1.00% / 1.50% / 2.50% / 3.50% / 4.00% / 6.00% / 8.00% / 10.00%
Expected discounted costs - CI (20 yrs) / 93,821 / 169,452 / 153,364 / 138,873 / 125,813 / 103,411 / 85,161 / 77,335 / 52,836 / 36,356 / 25,188
Discount rate QALYs - impact on expected QALYs for CI
Basecase / Parameter values
Discount rate QALYs / 3.00% / 0.00% / 0.50% / 1.00% / 1.50% / 2.50% / 3.50% / 4.00% / 6.00% / 8.00% / 10.00%
Expected discounted QALYs - CI (20 yrs) / 8.93 / 16.13 / 14.60 / 13.22 / 11.98 / 9.84 / 8.11 / 7.36 / 5.03 / 3.46 / 2.40
Discount rate costs - impact on expected costs for HA
Basecase / Parameter values
Discount rate costs / 3.00% / 0.00% / 0.50% / 1.00% / 1.50% / 2.50% / 3.50% / 4.00% / 6.00% / 8.00% / 10.00%
Expected discounted costs - HA (20 yrs) / 2,854 / 5,155 / 4,666 / 4,225 / 3,828 / 3,146 / 2,591 / 2,353 / 1,607 / 1,106 / 766
Discount rate QALYs - impact on expected QALYs for HA
Basecase / Parameter values
Discount rate QALYs / 3.00% / 0.00% / 0.50% / 1.00% / 1.50% / 2.50% / 3.50% / 4.00% / 6.00% / 8.00% / 10.00%
Expected discounted QALYs - HA (20 yrs) / 6.71 / 12.12 / 10.97 / 9.93 / 9.00 / 7.39 / 6.09 / 5.53 / 3.78 / 2.60 / 1.80
Time horizon
Basecase / Parameter values
Time horizon / 20 / 5 / 8 / 10 / 12 / 15 / 25 / 30 / 40 / 60 / 76
ICUR / 40,929 / 159,593 / 100,261 / 80,484 / 67,299 / 54,114 / 33,018 / 27,744 / 21,152 / 14,559 / 11,784

2.5.2.  Scenario analysis

Model output when assuming hearing habilitation (speech therapy) of CI recipients was fully reimbursed by the healthcare payer