Proceedings of the annual conference of the American Cochlear … · 2019-12-11 · addressed ‘Executive Functioning and Language Development in Children with Cochlear Implants.’

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Proceedings of the annual conference of theAmerican cochlear implant alliance

Donna Sorkin

To cite this article: Donna Sorkin (2019) Proceedings of the annual conference of theAmerican cochlear implant alliance, Cochlear Implants International, 20:sup1, 1-17, DOI:10.1080/14670100.2019.1600772

To link to this article: https://doi.org/10.1080/14670100.2019.1600772

Published online: 12 Jun 2019.

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Proceedings of the annual conference of theAmerican Cochlear Implant Alliance

Introduction

Emerging issues in cochlear implantationDonna Sorkin

The American Cochlear Implant Alliance (ACIAlliance) is a not-for-profit membership organizationorganized in 2012 by a group of professionals in thefield with the purpose of eliminating barriers tocochlear implantation. Despite important quality oflife benefits for children and adults with moderate toprofound hearing loss, cochlear implants remain agreatly underutilized health intervention.The organization’s membership spans scientists and

clinicians from across the cochlear implant continuumof care including otolaryngologists, audiologists,speech pathologists, educators, psychologists andothers on CI teams. Parents of children with hearingloss, adult recipients, and other advocates for accessare also active members. It’s diverse membership andfocus on CI access makes ACI Alliance a uniqueentity. The mission has remained unchanged since itsfounding – to advance access to the gift of hearing pro-vided by cochlear implantation through research,advocacy and awareness. Extensive resources are pro-vided for those in and outside of the cochlear fieldon the website www.acialliance.orgDuring the 2017-2018 timeframe, the organization

undertook an aggressive program to achieve itsmission. Some of the organization’s major accomplish-ments included:Research• Awarded a three-year grant to conduct a study to

develop and validate Quality of Life instrumentsspecifically targeted to cochlear implant recipients.

• Funded a planning grant designed to lead to a com-prehensive assessment of the cost effectiveness ofcochlear implants in children, a project designed toupdate the seminal Project Hope study published in2000.

• Continued a multi-center study for the Centers ofMedicare and Medicaid Services with the aim ofexpanding candidacy under Medicare.

• Collected data on Medicaid utilization across 30+states demonstrating widespread dependence onMedicaid coverage for pediatric CI.

• Initiated a program to support survey research activi-ties undertaken by ACI Alliance members with bi-annual push-outs of approved survey instruments tothe membership.

Awareness• Carried out programs in collaboration with consu-

mer organization Hearing Loss Association ofAmerica (HLAA) to improve consumer understand-ing of CI candidacy, residual hearing, hearing aiduse, insurance and outcomes associated withcochlear implantation in adults.

• Initiated outreach to the national organizations offamily physicians, internists and pediatriciansseeking to organize presentations at national andstate conferences. Conducted state talks and pre-sented at the October 2018 Family MedicalExperience (FMX) annual meeting of the AmericanAcademy of Family Physicians.

• Developed a new resource for primary care physi-cians and nurses, Adult Candidacy for CochlearImplantation: Clinical Guidance, being used forprimary care physician and nurse outreach.

• Initiated a focused effort to expand website visibilityand reach the general public and primary care phys-icians/nurses on key cochlear implant topics.

• Collaborated with Stanford Universityand University of California San Francisco on acooperative pediatric CI symposium held July26-29, 2017 in San Francisco with over 1300 atten-dees. Conducted a consumer workshop onSaturday afternoon for parents and adults with 130+ attendees.

• Expanded consumer blog resources for adults cover-ing wide ranging rehabilitation topics.

• Initiated a PR outreach campaign in preparation forthe March 2018 launch of a powerful documentaryby filmmakers Jane Madell and Irene TaylorBrodsky profiling the journeys of 15 young adults,deaf from childhood, who benefitted from advancedhearing technology.Advocacy

• Continued expansion of ACI Alliance StateChampion program, which now includes over 100Champs representing 42 states.

[email protected]

© 2019 Informa UK Limited, trading as Taylor & Francis GroupDOI 10.1080/14670100.2019.1600772 Cochlear Implants International 2019 VOL. 20 NO. S1 1

• Collaborated with other organizations to advancereauthorization of the Early Hearing Detection andIntervention Act, which passed through Congressand was signed into law in 2017. Language suggestedby ACI Alliance on the need for accurate, comprehen-sive, up-to-date information for families on optionswas included in the final bill.

• Conducted research and highlighted problems ofaccess to appropriate cochlear implant care at theVeterans Health Administration.

• Worked with other organizations to support the reten-tion of Essential Health Benefits (EHBs) in anyhealthcare reforms.

• Actively participate in coalitions in the hearing lossand general disability field to address access andawareness. Assumed leadership for coordinatingFriends of the Congressional Hearing HealthCaucus.

• Initiated a new coalition to protect Parent Choice indecision-making for children with hearing loss andaddress efforts to interrupt parental decision-making on technology and options for their ownchildren. Published a strong Parent Choice PositionPaper.

Build an Effective Organization• Grew the number of active members to 1450 with 90

Organizational members.• Continued expansion of social media with website

visibility Twitter and Facebook.• Expanded interactions with healthcare organizations

and disciplines outside of hearing care to increasecochlear implant visibility in the larger healthcarecommunities.

Annual Clinical Research SymposiumAmerican Cochlear Implant Alliance has conducted

an annual clinical research symposium bringingtogether clinicians, educators, and scientists since2013. Attendees address cochlear implants in a rangeof settings – universities, hospitals, private clinics,non-profit organizations, schools, and governmentalagencies. CI 2018 Emerging Issues in CochlearImplantation was the third conference that used thisparticular format. It was held in Washington, DCMarch 7-10, 2018. The symposium provided attendeeswith the opportunity to explore in depth four topicsthat have significant potential for improving outcomesacross the age span. These included:• Quality of Life and Cochlear Implantation• CI Candidacy in 2018• Parental Engagement in Pediatric CI Outcomes• Cochlear Implant Practice Management

The annual Dr. John K. Niparko MemorialLecture, given by William G. Kronenberger PhD,addressed ‘Executive Functioning and LanguageDevelopment in Children with Cochlear Implants.’We are grateful to the individuals who shared their

knowledge and experiences as presenters, panelistsand audience participants.

Donna L. Sorkin Executive DirectorColin Driscoll Chair, Board of DirectorsEmail: [email protected]

Funding for the development of these proceedingswas made possible [in part] by R13DC017086 fromthe National Institute on Deafness and OtherCommunication Disorders of the National Institutesof Health. The views expressed in written conferencematerials or publications and by the speakers andmoderators do not necessarily reflect the official pol-icies of the Department of Health and HumanServices, nor does mention of trade names, commer-cial practices, or organizations imply endorsement bythe US Government.

Executive functioning and languagedevelopment in children with cochlear implants†

William G. Kronenberger1,21Department of Psychiatry, Indiana University School ofMedicine, Indianapolis, IN, USA, 2DeVault OtologicResearch Laboratory, Department of Otolaryngology-Headand Neck Surgery, Indiana University School of Medicine,Indianapolis, IN, USA

Hearing loss is primarily a brain issue, not an earissue (Flexer, 2011)

… deaf children are not simply hearing childrenwho cannot hear (Marschark and Knoors, 2012)

The benefits of cochlear implants (CIs) are well-estab-lished for restoring some attributes of hearing andallowing for spoken language development in prelin-gually-deaf children. However, effects of hearing lossmay extend beyond spoken language skills alone toinclude other domains of neurocognitive functioning.Because the brain is an integrated organ that developsbased on experience, changes in exposure to hearing,language, and other experience-related factors havedownstream influences on neurocognitive functioning.

†Dr. John K. Niparko Memorial Lecture.Correspondence to: William G. Kronenberger, [email protected] RileyChild and Adolescent Psychiatry Clinic, 705 Riley Hospital Drive,Indianapolis, IN 46202, USA. Email: [email protected]

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Furthermore, because language is supported by mul-tiple neurocognitive functions such as attention,reasoning, and memory, a reciprocal relationshipexists between language and other domains of neuro-cognitive functioning, with each influencing and sup-porting the other. Therefore, understanding andexplaining neurocognitive functioning in childrenwith CIs is critical for improving language functioningand quality of life.A subdomain of neurocognitive functioning that is

dependent in part on auditory and language experi-ences is executive functioning (EF). EF is an umbrellaset of neurocognitive functions responsible for theactive regulation of cognitive, behavioral, andemotional processes in the service of planned, orga-nized, controlled, goal-driven thinking and behavior(Diamond, 2013). Multiple subdomains of EF exist,including working memory (WM), inhibition, flexi-bility-shifting, planning, organization, and controlledattention for efficient/fast processing (Barkley, 2012;Kronenberger and Pisoni, 2018). Hearing providesvaluable stimulation and practice with EF to the devel-oping child through experiences such as selectiveattention (focusing on a specific auditory stimulus),resisting distraction (screening out competing auditorystimuli that are not the focus of attention), sequentialprocessing/tracking (sustaining attention and proces-sing effort on a sequence of auditory stimuli), andsensory integration (integrating auditory stimuli withvisual, tactile, olfactory, and other stimuli) (Kralet al., 2016; Kronenberger and Pisoni, 2018).Evidence from studies of music exposure (Bialystokand DePape, 2009; Slevc et al., 2016), sequential pro-cessing (Conway et al., 2011), and early deafness (Kralet al., 2016) support the beneficial role of auditoryexperience for development of EF. Spoken language,which is facilitated by auditory experience, alsoenhances the development and use of EF by servingas a tool to control focus and behavior (self-talk), tomaintain goals and sequential steps in mind (by repre-senting goals and steps using language), to assist WM(actively holding information in mind using language),and to organize complex information (representingideas with language) (Byrd et al., 2004; Fatzer andRoebers, 2012; Petersen et al., 2015; Zelazo et al.,2003). Thus, deprivation of early auditory experiencefrom deafness, and restoration of some componentsof hearing (and spoken language) with a CI, may influ-ence EF outcomes in prelingually deaf children whoreceive CIs.EF is also a significant factor supporting the devel-

opment and deployment of language skills by provid-ing concentration and mental effort to enhancelanguage learning and processing. Research supportsthe important role of domains of EF such as WM inthe acquisition of language skills and fund of verbal

information in normal hearing (NH) children(Gathercole and Baddeley, 1993; Gathercole et al.,2003). Furthermore, several models (such as theEase of Language Understanding [ELU] (Rönnberget al., 2013) and Framework for UnderstandingEffortful Learning [FUEL] (Pichora-Fuller et al.,2016) models) have been developed to explain theimportant role that controlled mental effort andworking memory have during complex, challengingspeech-language processing. According to thesemodels, simple language processing, such as speechperception under ideal conditions by NH children orrapid access to well-specified vocabulary in themental lexicon, occurs through a fast, automatic pro-cessing channel that requires little concentration ormental effort. However, challenging, complex proces-sing, including speech perception under challengingconditions, requires active, controlled processingthat places more demands on EF components suchas controlled effort and WM. For children with CIs,speech perception and access to the mental lexiconis more demanding and challenging than for NH chil-dren, making the use of EF more important forlanguage processing for children with CIs(Kronenberger and Pisoni, 2018).In order to explain the relationship between hearing,

spoken language, and EF in children with CIs in thecontext of many other biological, psychological, andsocial influences on language and EF, we have pro-posed an Auditory Neurocognitive Model (ANM;Figure 1) (Kronenberger and Pisoni, 2018). Thismodel recognizes the influences of auditory experienceon language and EF, as well as the influence of EF onlanguage, which occur within a broader context ofbiopsychosocial influences on the neurocognitivedevelopment of the child. By identifying the networkof influences on the reciprocal relationship betweenlanguage and EF, the ANM specifies importantdomains of neurocognitive functioning that mayexplain outcomes and serve as targets for intervention.Empirical research has supported the basic tenets of

the ANM. Children with CIs are at elevated risk for EFdelays relative to NH children, although the majorityof children with CIs develop EF skills in the averagerange (Kronenberger et al., 2013b, 2014a, 2014b).Approximately 1/3 of children with CIs have beenfound to have clinically significant EF delays, a rate2–5 times that of NH peers (Kronenberger et al.,2013b, 2014a). Cross-sectional and longitudinalstudies have consistently found associations betweensome components of EF – especially verbal workingmemory, controlled fluency-speed, inhibition, and con-centration – and language outcomes, and associationsbetween EF and language are stronger in childrenwith CIs than in NH children (Harris et al., 2013;Kronenberger et al., 2013a, 2014b; Pisoni et al.,

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2011). Recently, a pilot experimental study has foundthat reducing access to EF adversely affects real-timespeech-language processing of children with CIs morethan NH peers (Kronenberger et al., 2018). Reviewsof research in this area have found overwhelming andconsistent evidence of the reciprocal/bidirectionalhearing-language-EF relationship, and have identifiedsignificant limitations in research studies that contra-dict this relationship (Kronenberger and Pisoni, 2018).Models linking hearing, language, and EF in prelin-

gually deaf children with CIs have important clinicaland translational implications: Routine assessment ofneurocognitive functioning, especially EF, should beintegrated into outcome evaluations for children whoreceive CIs. Children who are at-risk for EF delaysshould be targeted for EF interventions, guided bytenets of models such as the ANM as well as existingevidence-based EF treatments (Diamond and Lee,2011). Because speech-language skills and EF skillsare closely intertwined, improvement in EF may be atarget or a by-product of speech-language interven-tions, and, conversely, treatment components thatimprove EF may be effective in producing betterspoken language performance in challenging settings.Families may benefit from education about EF andlanguage outcomes in order to embed children withCIs in family environments that model, encourage,and teach EF. Finally, new research should evolvebeyond comparisons of CI and NH samples to inves-tigate factors explaining the wide variability in EF out-comes within the population of CI users and to testnovel interventions to improve EF.

Disclaimer statementsContributors David B. Pisoni, Ph.D.

Funding This work was supported by the NationalInstitute on Deafness and Other CommunicationDisorders (grant number [R01DC015257] to WilliamG. Kronenberger and David B. Pisoni).

Conflicts of interest William Kronenberger is a paidconsultant for the Indiana Hemophilia andThrombosis Center and Shire/TakedaPharmaceuticals.

Ethics approval Approved by the Indiana UniversityInstitutional Review Board (#1612692493).

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work, and why they evolved. New York, NY: Guilford Press.Bialystok, E., DePape, A.M. 2009. Musical expertise, bilingualism,

and executive functioning. Journal of Experimental Psychology:Human Perception and Performance, 35(2): 565–574. doi:10.1037/a0012735.

Byrd, D.L., Van Der Veen, T.K., McNamara, J.P.H., Berg, W.K. 2004.Preschoolers don’t practice what they preach: preschoolers’ plan-ning performances with manual and spoken response require-ments. Journal of Cognition and Development, 5(4): 427–449.

Conway, C.M., Pisoni, D.B., Anaya, E.M., Karpicke, J., Henning,S.C. 2011. Implicit sequence learning in deaf children withcochlear implants. Developmental Science, 14(1): 69–82. doi:10.1111/j.1467-7687.2010.00960.x.

Diamond, A. 2013. Executive functions. Annual Review of Psychology,64: 135–168. doi:10.1146/annurev-psych-113011-143750.

Diamond, A., Lee, K. 2011. Interventions shown to aid executivefunction development in children 4 to 12 years old. Science,333(6045): 959–964. doi:10.1126/science.1204529.

Fatzer, S.T., Roebers, C.M. 2012. Language and executive functions:the effect of articulatory suppression on executive functioningin children. Journal of Cognition and Development, 13(4):454–472.

Flexer, C. 2011. Cochlear implants and neuroplasticity: linking audi-tory exposure and practice. Cochlear Implants International, 12(Suppl 1): S19–S21. doi:10.1179/146701011X13001035752255.

Gathercole, S.E., Baddeley, A.D. 1993. Working memory andlanguage. Hillsdale, NJ: Lawrence Erlbaum Associates, Inc.

Gathercole, S.E., Brown, L., Pickering, S.J. 2003. Working memoryassessments at school entry as longitudinal predictors ofNational Curriculum attainment levels. Educational and ChildPsychology, 20(3): 109–122.

Figure 1 Auditory-neurocognitive model.

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Harris, M.S., Kronenberger, W.G., Gao, S., Hoen, H.M.,Miyamoto, R.T., Pisoni, D.B. 2013. Verbal short-termmemory development and spoken language outcomes in deafchildren with cochlear implants. Ear and Hearing, 34(2):179–192. doi:10.1097/AUD.0b013e318269ce50.

Kral, A., Kronenberger, W.G., Pisoni, D.B., O’Donoghue, G.M.2016. Neurocognitive factors in sensory restoration of earlydeafness: a connectome model. The Lancet Neurology, 15(6):610–621. doi:10.1016/S1474-4422(16)00034-X.

Kronenberger, W.G., Beer, J., Castellanos, I., Pisoni, D.B.,Miyamoto, R.T. 2014a. Neurocognitive risk in children withcochlear implants. JAMA Otolaryngology–Head & NeckSurgery, 140(7): 608–615. doi:10.1001/jamaoto.2014.757.

Kronenberger, W.G., Colson, B.G., Henning, S., Pisoni, D.B. 2014b.Executive functioning and speech-language skills followinglong-term use of cochlear implants. Journal of Deaf StudiesAnd Deaf Education, 19: 456–470.

Kronenberger, W.G., Henning, S.C., Ditmars, A.M., Pisoni, D.B.2018. Language processing fluency and verbal workingmemory in prelingually deaf long-term cochlear implant users:a pilot study. Cochlear Implants International, 19: 312–323.

Kronenberger, W.G., Pisoni, D.B. 2018. Neurocognitive functioningin deaf children with cochlear implants. In: Knoors H.,Marschark M., (eds.) Evidence-based practice in deaf education.London: Oxford.

Kronenberger, W.G., Pisoni, D.B., Harris, M.S., Hoen, H.M., Xu,H., Miyamoto, R.T. 2013a. Profiles of verbal workingmemory growth predict speech and language development inchildren with cochlear implants. Journal of Speech, Language,and Hearing Research, 56(3): 805–825. doi:10.1044/1092-4388(2012/11-0356).

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Rönnberg, J., Lunner, T., Zekveld, A., Sörqvist, P., Danielsson, H.,Lyxell, B., et al. 2013. The ease of language understanding(ELU) model: theoretical, empirical, and clinical advances.Frontiers in Systems Neuroscience, 7: 31–31. doi:10.3389/fnsys.2013.00031.

Slevc, L.R., Davey, N.S., Buschkuehl, M., Jaeggi, S.M. 2016.Tuning the mind: exploring the connections between musicalability and executive functions. Cognition, 152: 199–211. doi:10.1016/j.cognition.2016.03.017.

Zelazo, P.D., Müller, U., Frye, D., Marcovitch, S. 2003. The devel-opment of executive function in early childhood: I. The devel-opment of executive function. Monographs of the Society forResearch in Child Development, 68(3): 11–27.

CI2018 DC emerging issue: Quality of life andcochlear implantationCo-Chairs: Ivette Cejas (University of Miami, Department ofOtolaryngology) and Theodore R. McRackan (MedicalUniversity of South Carolina)

Presenters: Theodore R. McRackan, Ivette Cejas, DebTucci (Duke University), Howard Francis (Duke University),Andrea Warner-Czyz (University of Texas at Dallas)

Measures of health-related quality of life (QOL) provideunique information about the impact of a disability andits treatment. The NIH, FDA and CMS have all addedQOL as outcome measures for healthcare interventions.Conventional measures of CI outcomes such as auditoryand communicative competence (i.e. word and sentencerecognition) are essential but do not adequately capturethe broad impact of deafness on a patient’s physical, be-havioral, social and emotional functioning. A poor cor-relation between self-report and such typicallymeasured outcomes represents a significant gap in howwe assess CIs in adults, which impairs clinicians’ abilityto comprehensively quantify CI benefits, preoperativelycounsel patients on CI expectations, and provide inter-vention in areas not related to communication. The useof QOL instruments allows direct input from the CIpopulation and families regarding CI benefits on an indi-vidual’s daily functioning, beyond speech understanding.

QOL-CI: development and clinical utility of apediatric quality of life instrumentIvette CejasDepartment of Otolaryngology, University of Miami MillerSchool of Medicine, Miami, FL, USA

Keywords: Cochlear Implants, Pediatrics, Quality of Life

More than 50 years ago, the World HealthOrganization proposed the first definition of HRQoLas ‘a state of complete physical, mental, and socialwell-being, and not merely the absence of disease’(World Health Organization [WHO], 1947, p. 29). Aconsensus definition of HRQoL has now emerged,with agreement that it is multidimensional andincludes four core domains: (1) disease state and phys-ical symptoms, (2) functional status (e.g. performingdaily activities), (3) emotional functioning, and (4)social functioning (Palermo et al., 2008). Morerecently, the Food and Drug Administration (FDA)and the National Institute of Health have formallyrecognized the importance of patient-reported out-comes (PROs) and their relevance to the approval ofnew medications and treatments (FDA, 2009; NIH,2005). A PRO instrument is defined as any measureof a patient’s health status that comes directly fromthe patient/parent proxy and assesses how a patient‘feels, functions, or survives with respect to his or herhealth condition’ (FDA Guidance, 2009, p. 2).Severe to profound hearing loss is associated with

measurable deficits in HRQoL, reflecting the broadeffects of hearing loss and its concomitant effects onlanguage learning, social and emotional functioning,and academic performance (Barker et al., 2009;

Correspondence to: [email protected]

Correspondence to: Ivette Cejas, Department of Otolaryngology,University of Miami, 1120 NW 14th Street, Miami, FL 33146, USA. Email:[email protected]

Cejas QOL-CI

Cochlear Implants International 2019 VOL. 20 NO. S1 5

Cejas et al., 2014; Hoffman et al., 2015; Niparko et al.,2010; Quittner et al., 2007). Studies of cochlearimplantation (CI) typically focus on clinical measuresof efficacy related to communication (e.g. auditoryskills, speech), which does not represent the overallCI benefit. HRQoL measures provide a crucial assess-ment of the impact of CI’s on everyday functioning(physical, emotional, social; Lin and Niparko, 2006).Condition-specific HRQoL measures have showngreater sensitivity and responsivity to interventionsthan generic measures because they include itemsthat are more relevant and deemed as important bypatients/parents (Quittner et al., 2013).The Quality of Life-CI is the first HRQoL measure

for pediatric patients using cochlear implants(Hoffman et al., in press). These measures were devel-oped using the recommended FDA guidance, includ-ing stakeholder focus groups and open-endedinterviews with parents and children. Data obtainedshowed that the most frequent areas of concernreported by families were: parental acceptance (e.g.allowing children to wear short hair/colored processorsand magnets), device management (e.g. pieces break-ing), receptive and expressive language skills (e.g.hearing in the cafeteria), processing fatigue (e.g.exhaustion at the end of the school day from listening),academic difficulties (e.g. reading, writing), andemotional functioning (e.g. feeling ‘different’ frompeers). Ratings of frequency and severity indicatedthat both health care providers and parents consideredexpressive and receptive language, academic perform-ance, peer relationships, and self-esteem as the primarydomains impacted by hearing loss/use of CI(s).The QOL-CI can be used to generate a profile of the

strengths and weaknesses of the ‘whole child’. It is rec-ommended that CI centers administer these toolsannually to identify those at-risk, target interventionsand track patient outcomes. As noted in our study,despite age-appropriate language skills, children reportedchallenges in other areas, including social functioningand fatigue. These tools could also be used to compareCI outcomes across centers, changes in HRQoL overtime, predictors of better quality of life (e.g. age atimplantation, socioeconomic status) and the effects ofmedical comorbidities on daily functioning.To request a copy of the QoL-CI or to obtain

further information, please contact Dr. Ivette Cejasat [email protected].

Disclaimer statementsContributors None.

Funding None.

Conflicts of interest None.

Ethics approval None.

ReferencesBarker, D.H., Quittner, A.L., Fink, N., Eisenberg, L., Tobey, E.,

Niparko, J.K. 2009. Predicting behavior problems in deaf andhearing children: the influences of language and attention.Development and Psychopathology, 21: 373–392.

Cejas, I., Barker, D.H., Quittner, A.L., Niparko, J.K. 2014.Development of joint engagement in young deaf and hearing chil-dren: effects of chronological age and language skills. Journal ofSpeech, Language, and Hearing Research, 57: 1831–1841.

FDA Guidance. 2009. Guidance for industry patient-reportedoutcome measures: use in medical product development tosupport labeling claims. US Department of Health andHuman Services: Food and Drug Administration. Availablefrom http://www.fda.gov/downloads/Drugs/Guidances.

Hoffman, M.F., Cejas, I., Quittner, A.L. in press. Health-relatedquality of life instruments for children with cochlear implants:development of child and parent-proxy measures. Ear &Hearing.

Hoffman, M.F., Quittner, A.L., Cejas, I. 2015. Comparisons ofsocial competence in young children with and withouthearing loss: a dynamic systems framework. Journal of DeafStudies and Deaf Education, 20: 115–124.

Lin, F.R., Niparko, J.K. 2006. Measuring health-related quality oflife after pediatric cochlear implantation: a systematic review.International Journal of Pediatric Otorhinolaryngology, 70(10):1695–1706.

National Institutes of Health. 2005. NIH roadmap for medicalresearch [cited 2006 Oct 30]. Available from http://nihroadmap.nih.gov.

Niparko, J.K., Tobey, E.A., Thal, D.J., Eisenberg, L.S., Wang, N.Y.,Quittner, A.L., et al. 2010. Spoken language developmentin children following cochlear implantation. JAMA, 303(15):1498–1506.

Palermo, T.M., Long, A.C., Lewandowski, A.S., Drotar, D.,Quittner, A.L., Walker, L.S. 2008. Evidence-based assessmentof health-related quality of life and functional impairment inpediatric psychology. Journal of Pediatric Psychology, 33(9):983–996.

Quittner, A.L., Barker, D.H., Snell, C., Cruz, I., McDonald, L.,Grimley, M.E., et al. 2007. Improvements in visual attentionin deaf infants and toddlers after cochlear implantation.Audiological Medicine, 5: 242–249.

Quittner, A.L., Cejas, I., Blackwell, L.S. 2013. Advances in measure-ment and utilization of health related quality of life. In:O’Donohue W., Benuto L., Woodward Tolle L., (eds.)Handbook of adolescent health psychology. New York:Springer Publishing Co, p. 153–163.

World Health Organization 1947. The constitution of the WorldHealth Organization. WHO Chronicles, 1: 29–30.

Development of new cochlear implant quality oflife instruments for adultsTheodore R. McRackan, Judy R. DubnoMedical University of South Carolina, Charleston, SC, USA

Based on expanding cochlear implant (CI) indicationsand an increased number of adults with hearing lossdue to an aging population, the number of adultcochlear implantations performed annually continuesto increase. Health-related quality of life (QOL) instru-ments have become increasingly important in under-standing the impact of a medical intervention on apatient’s life. This is especially true for low-risk pro-cedures where outcomes such as mortality are notthe primary end-point. Patient-reported outcomemeasures (PROMs) are instruments devised tocapture a patient’s perspective about their overallhealth or treatment. The use of PROMs to assess

Correspondence to: Theodore R. McRackan. Email: [email protected]

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QOL allows the affected population to provide directinput about how disease processes and interventionsimpact patients’ lives. The increased importance ofPROMs is perhaps best highlighted by the Center forMedicaid and Medicare Services (CMS) targetingQOL improvement as a primary outcome measure inthe Quality Strategy Report and the FDA requirementthat PROMs be included in all clinical trials where anintervention seeks FDA approval.Cochlear implant outcomes have been traditionally

assessed using word and sentence recognition, which,although important, do not capture the diverse listen-ing and communication experiences of CI users.Clinical protocols remain limited to the same metrics(speech understanding) that have been used for thepast 30 years. Importantly, whether using words inquiet, sentences in quiet, or sentences in noise,speech recognition poorly correlates with CI userself-report of real-world communication ability(Capretta and Moberly 2016; McRackan et al.,2018; McRackan et al., 2018). This is likely relatedto the controlled manner in which speech recognitiontesting is done and the known reliance of most CIusers on audio and visual cues and other informationfor communication that are not represented in tra-ditional speech testing (Stevenson et al., 2017).The positive effects of CI on QOL have been demon-

strated using a wide variety of health-related andhearing-related QOL instruments (McRackan et al.,2018, McRackan et al., 2018), but there is no univer-sally accepted QOL instrument for CI patients. Thisgap may partially explain the results of a poll takenat the American Cochlear Implant Alliance conferencein 2018, which showed only a quarter of CI centerswere including QOL as a CI outcome measure (Fig. 1).The NIH established the Patient-Reported

Outcomes Measurement Information System(PROMIS) in 2004 to develop, evaluate, and dissemi-nate PROMs that assess well-being from a patient per-spective. Since that time, PROMIS has established amultiple-step process for developing and validatingPROMs (PROMIS). Following the PROMIS

guidelines, our team at MUSC has made significantprogress in developing a suite of new CI-specificQOL instruments for adults, including systematic lit-erature search (McRackan et al., 2018; McRackanet al., 2018), patient focus groups (McRackan et al.,2017), and psychometric evaluation of our item (ques-tion) bank (McRackan et al., 2018). To enroll the largenumber of research subjects required, the CochlearImplant Quality of Life Development Consortiumwas established in 2017 to help recruit a diverse,nationwide sample of subjects. The Consortium con-sists of 29 CI centers that represent all regions of theUnited States.We now have a psychometrically valid item bank

with 81 question representing 6 domains (communi-cation, emotion, entertainment, environment, listeningeffort, and social). Using this item bank, we have devel-oped a 35-item profile CIQOL instrument (CIQOL-35Profile) and a 10-item global CIQOL instrument(CIQOL-10 Global) with strong face, content, and con-struct validity. The next step will be to psychometricallyevaluate the profile instrument against legacy QOLoutcome measures.

ReferencesCapretta, N.R., Moberly, A.C. 2016. Does quality of life depend on

speech recognition performance for adult cochlear implantusers? The Laryngoscope, 126(3): 699–706.

McRackan, T.R., Bauschard, M., Hatch, J.L., Franko-Tobin, E.,Droghini, H.R., Nguyen, S.A., et al. 2018. Meta-analysis ofquality-of-life improvement after cochlear implantation andassociations with speech recognition abilities. TheLaryngoscope, 128(4): 982–990.

McRackan, T.R., Bauschard, M., Hatch, J.L., Franko-Tobin, E.,Droghini, H.R., Velozo, C.A., et al. 2018. Meta-analysis ofcochlear implantation outcomes evaluated with generalhealth-related patient-reported outcome measures. Otology &Neurotology, 39(1): 29–36.

McRackan, T.R., Hand, B.N., Cochlear Implant Quality of LifeConsortium, Velozo, C.A., Dubno, J.R. Development of thecochlear implant-quality of life (CI-QOL) item bank. Ear andHearing. 2018; under revision

McRackan, T.R., Velozo, C.A., Holcomb, M.A., Camposeo, E.L.,Hatch, J.L., Meyer, T.A., et al. 2017. Use of adult patientfocus groups to develop the Initial item bank for a cochlearimplant quality-of-life instrument. JAMA Otolaryngology–Head & Neck Surgery, 143(10): 975–982.

PROMIS. Instrument Development and Validation ScientificStandards.

Figure 1 Survey results from participants of poll (n= 128) during American Cochlear Implant Alliance 2018 meeting.

McRackan and Dubno Development of new cochlear implant quality of life instruments for adults

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Stevenson, R.A., Sheffield, S.W., Butera, I.M., Gifford, R.H.,Wallace, M.T. 2017. Multisensory integration in cochlearimplant recipients. Ear and Hearing, 38(5): 521–538.

Exploring psychosocial determinants of CIoutcome in older adultsHoward W. FrancisDivision of Head and Neck Surgery & CommunicationSciences, Department of Surgery, Duke University School ofMedicine, Durham, NC, USA

ABSTRACT: Evidence of strong associations betweenhearing loss and several health outcomes in olderadults suggests that cochlear implantation has signifi-cant potential to positively impact health. At the sametime variability in the psychosocial and cognitive con-sequences of hearing loss in older adults can pose sig-nificant challenges to realizing full benefit from thisintervention. This paper summarizes efforts to charac-terize predictors of cochlear implant outcome andpatient participation using a conceptual model thattakes into consideration individual, environmentaland intervention variables. Preliminary findingssuggest psychosocial, socioeconomic and cognitivefactors that may be used to triage candidates accordingto their need for supplemental rehabilitation or logisti-cal support to maximize benefit.

There is growing evidence that unmitigated hearingloss is associated with impaired function and adegraded aging experience with significant financialimplications (Huddle et al., 2017). As cochlear implan-tation (CI) professionals, we should consider how thisapparent interaction between auditory deprivationand the aging experience impact the quality of engage-ment in the CI intervention process as well as func-tional and QoL outcomes. Increasing social isolation,impaired self-efficacy, and other mechanisms havebeen proposed to mediate the cascade of downstreameffects that may accelerate dependence, morbidity,andmortality (Genther et al., 2015). If so, our interven-tions ought to take these mechanisms into account asthey are also likely to impact the quality of partici-pation and outcome. Contrera et al. (2017) has demon-strated higher loneliness scores among patients who areCI candidates compared to those who use hearing aids(HA) and are not CI candidates. It is also encouragingto see that isolation improves following CI.Older patients therefore appear to be experiencing

the interactive effects of aging and auditory depri-vation, which increase over time and with greaterdegrees of hearing loss. Patients enter the CI interven-tion process with these cumulative effects, some of

which may be reversed with improvements in speechperception (SP) and communication. The quality ofengagement in the intervention process and the magni-tude of communication benefit, however, are likelyinfluenced by a number of psychosocial factors,some of which are in turn influenced by the cumulativedownstream effects of hearing loss. In order to deci-pher which clinical and psychosocial determinantsare important and worthy of action in the CI interven-tion process, we have found it useful to adopt a con-ceptual model proposed by Wilson and Cleary(Clark et al., 2012), which prompts us to considerpotentially important individual, environmental, bio-logical, and technological determinants of functionaland quality of life outcome with a cochlear prosthesis.

We tested hypotheses related to this conceptualmodel by retrospectively collecting as much infor-mation as was available for 219 consecutive adultpatients, age 60 years or older (Francis et al., 2015).The primary outcome of interest was change inopen-set SP scores at 3, 6, and 12 months after acti-vation compared to 1 month pre-operative scores(CNC word, phonemes, and HINT sentences inquiet). Independent variables explored the impact ofage, and extent of auditory deprivation measured asproportion of life using a HA. We also examined theimpact of socioeconomic status captured by educationlevel, as well as access to social interaction and supportas reflected by living arrangement and cohabitationstatus. A history of depression and health status asreflected by the Charlson index was also studied. Itwas important to record the rate at which SP datawere missing (missingness), as a potential real-worldindication of level of participation, and to identifypotential analysis bias associated with missingoutcome data. A step-wise approach was used toestablish multivariate models that evaluated therelationships between these patient characteristicsand SP gains. The criteria for a factor’s inclusion inthe final model was a P-value for entry of ≤0.1 anda P-value for removal of ≥0.2.

In our step-wise multivariate analysis, we found thatearly SP gains at 3 m were consistently associated withthe proportion of life using aHA – a presumed correlateof the extent of hearing deprivation (Fig. 1). There wasan inverse relationship to baseline SP scores, presum-ably due to ceiling effects. Chronological age was notfound to influence SP gain. Later SP gains between 6and 12 months after activation were positively corre-lated to higher education level relative to high schoolor non-HS graduates. Relative to residence in assisted-living facilities other residential categories were associ-ated with larger SP gains in the second half of the firstpost-operative year. Whereas lower health status wasinversely proportional to later SP benefit, the diagnosisof depression was actually associated with higher gains.

Correspondence to: Howard W. Francis, Division of Head and NeckSurgery & Communication Sciences, Department of Surgery, DukeUniversity School of Medicine, Durham, NC, USA. [email protected]

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There was no effect of chronological age. Educationlevel, residential status and co-morbidities were alsoassociated with overall 12 m gains, and there was aninverse relationship with missing data. Patients withmissing data at 3 months on average hadmore extensiveperiods of hearing deprivation, and at 12 months hadless family support, more co-morbidities, and weremore likely to be female and reside in assisted-livingfacilities.We conducted a follow-up prospective study of 76

patients who received their CIs at age 65 years andolder in 2013 and 2014 (Tang et al., 2017). Higher 1-year AzBio scores were associated with higher edu-cation level and cohabitation. There was also higherSP performance in patients who were active users oftablet devices possibly indicating greater comfort andcompetence in using technology. Patients whoengaged with aural rehabilitation scored significantlylarger improvements in quality of life at 1 year afterCI as measured using the Glasgow Benefit Inventory

(GBI). There was no effect of age. Missing data wasassociated with mild cognitive impairment and lowersocial engagement scores on the GBI, which supportsthe practice of keeping track of missing data in conven-ience clinical cohorts to reduce bias and to provide awindow into how marginal performers could be ident-ified and possibly helped earlier. An updated concep-tual model shows the feedback effect of functionalstatus, and the places where post-operative rehabilita-tion presumably exerted benefit leading to better QoLoutcomes in this subgroup of patients (Fig. 2).Our findings suggest that delays in intervention and

associated increase in the cumulative effects of audi-tory deprivation may lead to deficits in SP benefitwith a CI. Furthermore sustained growth of SP isinfluenced by psychosocial, socioeconomic andgeneral health factors. There is evidence that earlydeclines in cognition and frail health are associatedwith reduced access or ability to engage in on-goingCI services. Risk assessment and appropriate adjunct

Figure 1 Positive and negative (in parentheses) correlations between SP gain and psychosocial and health-related variables. C13-month interval, C2 6-month interval, C3 12-month interval; SP speech perception.

Figure 2 Findings by Tang et al. (2017) placed within a conceptual model for cochlear implant outcomes in older adults (Clarket al., 2012) showing the influence of individual and environmental characteristics as well as functional consequences of hearingloss (A) on SP results (B) and ultimately, quality of life outcome.

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measures may mitigate these sources of variability andenhance benefits in social functioning and quality oflife. The presented studies support a growing effortto identify the impact of reimbursement policy, com-munity-based intervention models, and practice guide-lines that promote more consistent restoration ofcommunication health and successful aging (Linet al., 2012; Nieman and Lin, 2017).

AcknowledgementsMembers of the Johns Hopkins Listening Centercochlear implant team.

ReferencesClark, J.H.,Yeagle, J.,Arbaje,A.I., Lin,F.R.,Niparko, J.K., Francis,

H.W. 2012. Cochlear implant rehabilitation in older adults:Literature review and proposal of a conceptual framework.Journal of the American Geriatrics Society, 60(10): 1936–1945.

Contrera, K.J., Sung, Y.K., Betz, J., Li, L., Lin, F.R. 2017. Changein loneliness after intervention with cochlear implants orhearing aids. The Laryngoscope, 127(8): 1885–1889.

Francis, H.W., Yeagle, J.A., Thompson, C.B. 2015. Clinical and psy-chosocial risk factors of hearing outcome in older adults withcochlear implants. The Laryngoscope, 125(3): 695–702.

Genther, D.J., Betz, J., Pratt, S., Martin, K.R., Harris, T.B.,Satterfield, S., et al. 2015. Association between hearing impair-ment and risk of hospitalization in older adults. Journal of theAmerican Geriatrics Society, 63(6): 1146–1152.

Huddle, M.G., Goman, A.M., Kernizan, F.C., Foley, D.M., Price,C., Frick, K.D., et al. 2017. The economic impact of adulthearing loss: a systematic review. JAMA Otolaryngology –Head & Neck Surgery, 143(10): 1040–1048.

Lin, F.R., Chien, W.W., Li, L., Clarrett, D.M., Niparko, J.K.,Francis, H.W. 2012. Cochlear implantation in older adults.Medicine (Baltimore), 91(5): 229–241.

Nieman, C.L., Lin, F.R. 2017. Increasing access to hearing rehabili-tation for older adults. Current Opinion in Otolaryngology &Head and Neck Surgery, 25(5): 342–346.

Tang, L., Thompson, C.B., Clark, J.H., Ceh, K.M., Yeagle, J.D.,Francis, H.W. 2017. Rehabilitation and psychosocial determi-nants of cochlear implant outcomes in older adults. Ear andHear, 126(3): 236–240.

Current state of knowledge: Quality of life inadolescents with hearing loss using cochlearimplantsAndrea D. Warner-CzyzThe University of Texas at Dallas, Richardson, TX, USA

Speech perception, speech production, and languageoutcomes dominate the pediatric cochlear implant(CI) literature, but good communication skills do notguarantee positive ratings of life satisfaction, orquality of life (QoL). QoL refers to a uniquely per-sonal perception of life satisfaction across multipledimensions in diverse situations. This paper reviewsthree realms of QoL – physical, mental, and socialwell-being – in adolescents with CIs.Physical well-being includes physical health, pain,

and fatigue. Adolescents with CIs show no differencein overall physical well-being compared to peers withtypical hearing (TH) (Loy et al., 2010). However,parent proxy and self-report measures reveal signifi-cantly higher levels of fatigue in children and

adolescents using hearing aids or CIs versus TH age-mates (Bess and Hornsby, 2014; Werfel andHendricks, 2015). This documented fatigue echoesanecdotal reports of lower energy and higher listeningeffort in individuals with hearing loss of all ages.Fatigue particularly may affect adolescents, whoexperience increased academic and social listeningdemands in difficult sound environments (Stoff et al.,1989). Greater fatigue in children could have cascadingeffects such as higher absenteeism and lower attention,concentration, and school achievement. In sum, audi-tory status does not affect overall physical health, butdoes influence levels of fatigue and listening effort.

Communication and social-emotional deficitsrelated to hearing loss can affect mental well-being,including internalizing symptoms (e.g. anxiety,depression), externalizing symptoms (e.g. aggression),and self-esteem. Compared to TH peers, childrenwith hearing loss experience higher rates of depression(26% vs. 15–20%) and aggression (15–23% vs. 5%), butnot anxiety (Brown and Cornes, 2015; Theunissenet al., 2012, 2014). Participation in mainstream edu-cation and use of oral speech corresponds to lowerlevels of depression (Theunissen et al., 2014).Adolescents with hearing loss report slightly but sig-nificantly higher ratings of global self-esteem versusTH peers (Warner-Czyz et al., 2015). Affiliation,attention, and fewer depressive symptoms were associ-ated with higher self-esteem (Warner-Czyz et al.,2015). In summary, adolescents with CI show higherrates of depression, but similar levels of anxiety andself-esteem to hearing peers.

Social well-being reflects the integration of com-munication skills and theory of mind into real-worldinteractions. Historically, adolescents with hearingloss feel lonelier and have more difficulty makingand maintaining friendships than hearing age-mates(Huber et al., 2015; Kouwenberg et al., 2012;Moeller, 2007; Nicholas and Geers, 2003; Wiefferinket al., 2012). Preliminary data in our laboratoryshow no effect of auditory status on friendship quan-tity. However, adolescent CI users appraise friendshipquality less positively than hearing peers, particularlyfor conflict and betrayal, and more similarly tochronologically younger children (Evans andWarner-Czyz, 2018). Auditory status also affects peervictimization (i.e. bullying) rates. Adolescents withhearing loss using auditory technology report signifi-cantly higher rates of bullying versus the general popu-lation (50% vs. 28%), especially for social exclusion(26% vs. 5%), mimicking patterns in children withexceptionalities (Warner-Czyz et al., 2018) (Fig. 1).Thus, adolescents with hearing loss report similarquantity but different quality of friendships, whichmay underscore higher rates of peer victimizationand social exclusion.Correspondence to: Andrea D. Warner-Czyz [email protected]

Warner-Czyz Current state of knowledge

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Clinicians and researchers should think beyondspeech, language, and hearing performance to con-sider how hearing loss and/or the impoverished CIsignal influences fatigue levels, mental health, andsocial interactions. Asking questions about experi-ences outside the clinic will inform the need to referpatients to other health professionals to improveQoL in adolescents with CI.

ReferencesBess, F.H., Hornsby, B.W. 2014. Commentary: listening can be

exhausting–fatigue in children and adults with hearing loss.Ear and Hearing, 35(6): 592–599.

Brown, P.M., Cornes, A. 2015. Mental health of deaf and hard-of-hearing adolescents: what the students say. Journal of DeafStudies and Deaf Education, 20(1): 75–81.

Evans, C.S., Warner-Czyz, A.D. 2018. The relationship betweencommunication abilities and friendship quality in adolescentswith cochlear implants. In: CI2018 DC Emerging issues incochlear implantation. Washington, DC.

Huber, M., Burger, T., Illg, A., Kunze, S., Giourgas, A., Braun, L.,et al. 2015. Mental health problems in adolescents withcochlear implants: peer problems persist after controlling foradditional handicaps. Frontiers in Psychology, 6: 953.

Kouwenberg, M., Rieffe, C., Theunissen, S.C.P.M., de Rooij, M.,Scott, J.G. 2012. Peer victimization experienced by childrenand adolescents who are deaf or hard of hearing. PLoS One,7(12): e52174.

Loy, B., Warner-Czyz, A.D., Tong, L., Tobey, E.A., Roland, P.S.2010. The children speak: an examination of the quality oflife of pediatric cochlear implant users. Otolaryngology–Headand Neck Surgery, 142(2): 247–253.

Moeller, M.P. 2007. Current state of knowledge: psychosocial devel-opment in children with hearing impairment. Ear and Hearing,28(6): 729–739.

Nicholas, J.G., Geers, A.E. 2003. Personal, social, and familyadjustment in school-aged children with a cochlear implant.Ear and Hearing, 24(1 Suppl): 69S–81S.

Stoff, E., Bacon, M.C., White, P.H. 1989. The effects of fatigue,distractibility, and absenteeism on school achievement in chil-dren with rheumatic diseases. Arthritis Care Research, 2:49–53.

Theunissen, S.C., Rieffe, C., Kouwenberg, M., De Raeve, L., Soede,W., Briaire, J.J. et al. 2012. Anxiety in children with hearingaids or cochlear implants compared to normally hearing con-trols. The Laryngoscope, 122(3): 654–659.

Theunissen, S.C., Rieffe, C., Netten, A.P., Briaire, J.J., Soede, W.,Schoones, J.W. et al. 2014. Psychopathology and its risk andprotective factors in hearing-impaired children and

adolescents: a systematic review. JAMA Pediatrics, 168(2):170–177.

Warner-Czyz, A.D., Loy, B.A., Evans, C., Wetsel, A., Tobey, E.A.2015. Self-esteem in children and adolescents with hearingloss. Trends in Hearing, 19.

Warner-Czyz, A.D., Loy, B., Pourchot, H., White, T.,Cokely, E. 2018. Effect of hearing loss on peer victimiza-tion in school-age children. Exceptional Children, 84(3):280–297.

Werfel, K., Hendricks, A.E. 2015. The relation between child versusparent report of chronic fatigue and langauge/literacy skills inschool-age children with cochlear implants. Ear and Hearing,37(2): 216–224.

Wiefferink, C.H., Rieffe, C., Ketelaar, L., Frijns, J.H.M. 2012.Predicting social functioning in children with a cochlearimplant and in normal-hearing children: the role of emotionregulation. International Journal of PediatricOtorhinolaryngology, 76(6): 883–889.

CI 2018 emerging issue: CI candidacy in 2018Co-Chairs: Craig Buchman (Washington University), TeresaZwolan (University of Michigan)Presenters: Maura Cosetti (Ear Institute of the New YorkEye and Ear Infirmary of Mount Sinai), Sandra Prentiss(University of Miami), Oliver Adunka (Ohio StateUniversity), Jill Firszt (Washington University)

When cochlear implants were first introduced, candi-dacy determination was a straightforward process:patients were expected to have bilateral profound deaf-ness and demonstrate no benefit from hearing aids,which often meant 0% speech recognition. As technol-ogy has improved, CI candidacy has expanded toinclude patients with greater amounts of residualhearing and greater speech recognition skills. Thissession will review recent changes in CI Candidacy,including the use of contemporary measures to evalu-ate traditional candidates, medical/surgical consider-ations when determining CI Candidacy, the role thatage and cognition play in candidacy considerations,and expansion of candidacy to include patients withSSD and asymmetric hearing losses.

Figure 1 Effect of auditory status on type of peer victimization experienced by adolescents.

Email: [email protected]

Buchman and Zwolan CI candidacy in 2018

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Cochlear implantation candidacy: Elderly andcognition ‘Of sound mind, the role of advancedage and cognition in cochlear implantcandidacy’Maura CosettiNew York Eye and Ear Infirmary of Mount Sinai, New York,NY, USA

Keywords: cochlear implant, cognition, cognitive testing, elderly

Changes in US and global demographics have broughtage-related health issues to the forefront of healthcareacross many specializes. Hearing loss and cognitivedecline, or dementia, are two of the most prominentage-related diseases and recent data suggests thatthese may be closely related.Hearing loss in older adults is prevalent and growing

affecting 2/3 of individuals over age 70. Recent datahas led to a greater recognition of the impact ofhearing loss on health and function in aging, andspecifically on cognitive decline. In large scale, longi-tudinal population-based studies of community dwell-ing elderly individuals, Lin and colleagues foundhearing loss was independently associated with a 40%rate of accelerated cognitive decline (Lin et al. 2013).Compared with their normal-hearing peers, individ-uals with mild moderate and severe hearing loss had2, 3, and 5-fold (respectively) increased risk of all-cause dementia over 10 years of follow-up. This wassupported by additional epidemiologic data in whichthe degree of hearing loss was found to be an indepen-dent risk factor for faster cognitive decline (Deal et al.2017; Gurgel et al. 2014).Taken together, these and other studies broadly

suggest a linear relationship between severity ofhearing loss and risk for cognitive impairment and/ordementia. The implications for cochlear implantation(CI) in this at-risk group, including both candidacyevaluation and outcomes, are complex and currentlyunknown. CI is safe and effective in elderly patientsand consistent improvement in speech understandinghas been reliably shown in many studies. Early andlimited studies suggest some improvement in cognitivefunction after CI in elderly patients, however muchmore data is needed (Claes et al. 2018a, Claes et al.2018b; Cosetti et al. 2016; Mosnier et al. 2015).At present, there are no broad standards or protocols

to guide CI candidacy evaluation in this population.Cognitive testing is, in itself, fraught with bias in thehearing impaired population and issues of timing,patient fatigue and stress, cost and availability ofappropriately trained personnel are just a few chal-lenges that limit incorporation into a busy CI setting.Perhaps even most importantly is a lack of clear under-standing of how results of neurocognitive testing may

influence the decision to proceedwith CI. Recent devel-opment and availability of cognitive testing specific to-and adapted for - the hearing impaired population(such as the Hearing-Impaired Montreal CognitiveAssessment, or HI-MoCA) may assist with these chal-lenges moving forward (Claes et al. 2018a, Claes et al.2018b; Lin et al. 2017). On the horizon may be a betterunderstanding of not just which tests to use, but howthe test results may predict post-operative outcome,improve patient and family counseling, and direct orinfluence post-operative programming and auditoryhabilitation in this emerging candidacy group.

Disclaimer statementsContributors None.

Funding None.

Conflicts of interest None.Ethics approval None.

ReferencesClaes, A.J., Van de Heyning, P., Gilles, A., Van Rompaey, V.,

Mertens, G., et al. 2018a. Cognitive outcomes after cochlearimplantation in older adults: A systematic review. CochlearImplants International, 19(5): 239–254.

Claes, A.J., Van de Heyning, P., Gilles, A., Van Rompaey,V.Mertens, G. 2018b. Cognitive Performance of Severelyhearing-impaired older adults before and after cochlear implan-tation: Preliminary results of a prospective, longitudinal cohortstudy using the RBANS-H. Otology & Neurotology, 39(9):e765–e773.

Cosetti, M.K., Pinkston, J.B., Flores, J.M., Friedmann, D., Jones,C., Roland, Jr, J.T., Waltzman, S., et al. 2016. Neurocognitivetesting and cochlear implantation: insights into performancein older adults. Clinical Interventions in Aging, 11: 603–613.

Deal, J.A., Betz, J., Yaffe, K., Harris, T., Purchase-Helzner, E.,Satterfield, S., et al. 2017. Health ABC Study group: hearingimpairment and Incident dementia and cognitive decline inolder adults: The health ABC Study. The Journals ofGerontology Series A Biological Sciences and MedicalSciences, 72(5): 703–709.

Gurgel, R.K., Ward, P.D., Schwartz, S., Norton, M.C., Foster,N.L.Tschanz, J.T. 2014. Relationship of hearing loss anddementia: a prospective, population-based study. Otology &Neurotology, 35(5): 775–781.

Lin, V.Y., Chung, J., Callahan, B.L., Smith, L., Gritters, N., Chen,J.M., Black, S.E.,Masellis,M., et al. 2017. Development of cog-nitive screening test for the severely hearing impaired: hearing-impaired MoCA. The Laryngoscope, 127(Suppl 1): S4–S11.

Lin, F.R., Yaffe, K., Xia, J., Xue, Q.-L., Harris, T.B., Purchase-Helzner, E., Satterfield, S., Ayonayon, H.N., Ferrucci, L.,Simonsick, E.M., et al. 2013. Health ABC Study group:hearing loss and cognitive decline in older adults. JAMAInternal Medicine, 173(4): 293–299.

Mosnier, I., Bebear, J.P., Marx, M., Fraysse, B., Truy, E., Lina-Granade, G., Mondain, M., et al. 2015. Improvement of cogni-tive function after cochlear implantation in elderly patients.JAMAOtolaryngology –Head&Neck Surgery, 141(5): 442–450.

Medical considerations for children and adultswhen determining cochlear implant candidacyJameson K. Mattingly, Oliver F. AdunkaDepartment of Otolaryngology-Head & Neck Surgery, TheOhio State University, Columbus, OH, USA

Correspondence to: Maura Cosetti. Email: [email protected]

Correspondence to: Jameson K. Mattingly, Department ofOtolaryngology-Head & Neck Surgery, The Ohio State University,Columbus, OH, USA. Email: [email protected]

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Cochlear implantation continues to be the most suc-cessful treatment approach to restore hearing in bothchildren and adults with moderate-to-profound sen-sorineural hearing loss (SNHL). A number offactors, however, need to be considered during pre-operative evaluation, as these groups have a significantamount of heterogeneity within them. These factorsinclude many different etiologies, different baselineauditory perceptual abilities, variable outcomes, andother medical considerations that can complicateimplantation and/or post-op rehabilitation.With the pediatric population, a multi-disciplinary

approach should be in place, and the role of thefamily should not be underestimated. Timing ofimplantation must also be heavily considered. Earlydiagnosis with screening programs and subsequentdiagnostic testing (e.g. frequency-specific auditorybrainstem response), preferably by 3 months of ageor earlier, is critical to optimize outcomes (AAP,2007). Once a permanent hearing loss has been diag-nosed, other important factors include early hearingaid fitting, ongoing evaluation by Speech LanguageTherapists and Audiologists to ensure assessment(and treatment) of communication milestones, identifi-cation of cochlear implant candidacy if indicated, anda thorough medical work-up.The medical work-up of pediatric hearing loss

includes investigation of pre-, peri-, and post-natalfactors that could lead to hearing loss, evaluation forsyndromic or infectious etiologies, consideration ofgenetic screening, an Ophthalmologic examination,and imaging to detect malformations that couldpredict outcomes or preclude implantation alltogether. Imaging is particularly important for thepediatric group, where routine MRI is valuable toinvestigate the presence of cochlear nerve deficiency,signs suggestive of congenital CMV (e.g. dilated ven-tricles cerebellar hyperplasia), or an EVA. In somecases, a CT of the temporal bones can add furtherinformation on middle ear and labyrinthineanatomy, such as evaluating the bony cochlear modio-lus (i.e. bony cochlear nerve canal).While the possible causes of congenital hearing loss

are extensive, etiologies such as Connexin (GJB2)mutations and congenital CMV are worth furthermentioning. Connexin is a gap junction protein thatis required to maintain ionic balance within thecochlear duct. Its primary importance is that thisetiology may account for about 40–50% of childrenwith severe-to-profound SNHL, but these patientsdemonstrate a tendency to perform very well withcochlear implantation, as co-morbidities are lesslikely to complicate implantation and rehabilitation(Prosser et al., 2015; Vivero et al., 2010). As for con-genital CMV, it is thought to be the most commoncause of non-genetic hearing loss (Fowler, 2013).

The clinical spectrum is variable, especially withregard to hearing loss. It may be progressive,delayed, and difficult to diagnose, especially ashearing loss may be the only manifestation of a peri-natal CMV infection. Studies examining anti-viraltherapy are ongoing and may be beneficial in improv-ing hearing (Bilavsky et al., 2016; Kimberlin et al.,2015; Pasternak et al., 2018). Cochlear implantationis also a very viable option, but outcomes may belimited by other factors, such as cognitive impairment(Kraaijenga et al., 2018).Considerations with the adult population have

many similarities. A medical work-up is needed toensure the patient is able to undergo surgery, especiallyin those with multiple co-morbidities. Imaging is alsoperformed to better understand middle ear andcochlear anatomy. CT and MRI have both been suc-cessfully used, and the priority of one can changedepending upon the clinical circumstances.Additionally, recent evidence has shown the impor-tance of both peripheral auditory health and cognitivefunction in cochlear implant outcomes post-opera-tively (Holden et al., 2013). Specifically, the interplaybetween these two will determine most, if not all, ofthe large variability that is commonly seen withoutcomes.

ReferencesAmerican Academy of Pediatrics JCoIH. 2007. Year 2007 position

statement: Principles and guidelines for early hearing detectionand intervention programs. Pediatrics, 120(4): 898–921. doi:10.1542/peds.2007-2333. PubMed PMID: 17908777.

Bilavsky, E., Shahar-Nissan, K., Pardo, J., Attias , J, Amir , J, et al.2016. Hearing outcome of infants with congenital cytomegalo-virus and hearing impairment. Archives of Disease in Childhood,101(5): 433–438. doi:10.1136/archdischild-2015-309154.PubMed PMID: 26826174.

Fowler, K.B. 2013. Congenital cytomegalovirus infection: audiolo-gic outcome. Clinical Infectious Diseases, 57(Suppl 4):S182–S184. doi:10.1093/cid/cit609. PubMed PMID:24257423; PubMed Central PMCID: PMCPMC3836573.

Holden, L.K., Finley, C.C., Firszt, J.B., Holden , TA, Brenner , C,Potts , LG 2013. Factors affecting open-set word recognition inadults with cochlear implants. Ear and Hearing, 34(3): 342–360. doi:10.1097/AUD.0b013e3182741aa7. PubMed PMID:23348845; PubMed Central PMCID: PMCPMC3636188.

Kimberlin, D.W., Jester, P.M., Sanchez, P.J., Ahmed, A, Arav-Boger, R, Michaels, MG, et al. 2015. Valganciclovir for symp-tomatic congenital cytomegalovirus disease. The New EnglandJournal of Medicine, 372(10): 933–943. doi:10.1056/NEJMoa1404599. PubMed PMID: 25738669; PubMedCentral PMCID: PMCPMC4401811.

Kraaijenga, V.J.C., Van Houwelingen, F., Van der Horst, S.F.,Visscher, J, Huisman, JML, Hollman, EJ, et al. 2018.Cochlear implant performance in children deafened by conge-nital cytomegalovirus – a systematic review. ClinicalOtolaryngology, 5(43): 1283–1295. doi:10.1111/coa.13142.PubMed PMID: 29768731.

Pasternak, Y., Ziv, L., Attias, J., Amir, J, Bilavsky , E 2018.Valganciclovir is beneficial in children with congenital cytome-galovirus and isolated hearing loss. The Journal of Pediatrics,199: 166–170. doi:10.1016/j.jpeds.2018.02.028. PubMedPMID: 29605391.

Prosser, J.D., Cohen, A.P., Greinwald J.H. 2015. Diagnosticevaluation of children with sensorineural hearingloss. Otolaryngologic Clinics of North America, 48(6):975–982. doi:10.1016/j.otc.2015.07.004. PubMed PMID:26429334.

Mattingly and Adunka Medical considerations for children and adults

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Vivero, R.J., Fan, K., Angeli, S., Balkany, TJ, Liu, XZ, et al. 2010.Cochlear implantation in common forms of genetic deafness.International Journal of Pediatric Otorhinolaryngology, 74(10): 1107–1112. doi:10.1016/j.ijporl.2010.06.010. PubMedPMID: 20655117; PubMed Central PMCID:PMCPMC2939287.

Expanding indications to include patients withsingle-sided deafness and asymmetricalhearing lossJill B. FirsztWashington University School of Medicine, St. Louis, USA

As a part of ongoing longitudinal studies of cochlearimplantation in adults with asymmetric hearing loss(Firszt et al., 2018), the present study focused onadults with considerable hearing in the better ear(BE) and no usable hearing in the poor ear.Specifically, the participants were those with BE air-conduction thresholds less than 40 dB HL and severeto profound hearing loss (SPHL) in the poor ear thatreceived a cochlear implant (CI). Pre- and post-implant results of 23 participants were examined:mean age at CI= 56.7 yrs (SD 10.9), mean length ofSPHL in the poor ear= 8.8 yrs (SD 10.8), mean BEpure tone average (PTA, .5, 1 and 2 kHz)= 19.5 dBHL (SD 12.3), and mean poor ear PTA= 102.4 dBHL (SD 18.0). Etiology varied, however, the majority(n= 15) had sudden onset of SPHL. Prior to implan-tation, 15 either used or had trialed a contralateralrouting device (CROS, BiCROS), 4 used a BEhearing aid (HA), 1 used bilateral HAs, and 3 hadnot tried or purchased any type of amplification.Post-implant, the poor ear alone (CI) demonstrated

significant improvement compared to pre-implant per-formance. Group mean consonant-vowel nucleus-con-sonant (CNC, Peterson and Lehiste, 1962) wordrecognition scores improved from 2.5 to 56% andAzBio Sentence (Spahr and Dorman, 2005) under-standing improved from 1.6 to 65% (ps< 0.001). Aswith traditional CI recipients, performance variedwith ranges from 14 to 89% for CNC words andfrom 30 to 93% for AzBio sentences. The primaryinterest for participants was the ‘everyday listeningcondition’ post-implant compared to pre-implant.Post-implant this was a CI+ BE; 7 wore a HA onthe BE and 16 had hearing levels that did not requirea HA. Cochlear implantation resulted in significant6-month post-implant improvement (everyday listen-ing condition) for localization, understanding speechin noise whether noise was surrounding the listeneror on either side of the participant, and perceivedability in everyday listening environments.Group data identified significant benefit for

speech recognition and localization, however therewas substantial individual variability which

remains unexplained. Because of this, it is importantto counsel patients that improvements may be rea-lized in some but not all listening environments.Pre-implant evaluation of individual performancefor speech recognition in noise and localization isneeded to assess abilities when listening with oneear and to address possible benefits from bilateral lis-tening when a CI is used in the poor ear combinedwith contralateral acoustic hearing. Continuedresearch is needed to understand performance varia-bility, predict individual outcomes, refine clinicalprotocols, and ensure appropriate candidacy selec-tion of individuals who have substantial hearing inthe better ear.

Funding This work was Supported by NIH/NIDCD[R01DC009010].

ReferencesFirszt, J.B., Reeder, R.M., Holden, L.K., Dwyer, N.Y., the

Asymmetric Hearing Study Team 2018. Results in adultcochlear implant recipients with varied asymmetric hearing:A prospective longitudinal study of speech recognition, localiz-ation, and participant report. Ear and Hearing, 39(5): 845–862.

Peterson, G.E., Lehiste, I. 1962. Revised CNC lists for auditory tests.The Journal of Speech and Hearing Disorders, 27: 62–70. 201.

Spahr, A.J., Dorman, M.F. 2005. Effects of minimum stimulationsettings for the Med El Tempo+ speech processor on speechunderstanding. Ear and Hearing, 26(4 Suppl): 2S–6S.

CI 2018 emerging issue: Parent engagement inpediatric CI outcomesModerators: Karen Johnson (Keck School of Medicine ofUSC), Dana Suskind (University of Chicago), SallyTannenbaum Katsaggelos (University of Chicago)Speakers: Roberta Golinkoff (University of Delaware), DanaSuskind, Jean DesJardin (Moravian College), Karen Johnson

Parents and the home routines they create play centralroles in a child’s development. Research in pediatric CIoutcomes has identified specific ways in which signifi-cant caregivers can promote acquisition and growth inspoken language and literacy skills in children withhearing loss. This research also highlights the effective-ness of providing parents and caregivers with specificknowledge and strategies that can be woven intofamily life to support their child’s communicationand literacy development.

Empowering parents through TMW interventionsDana SuskindUniversity of Chicago, Chicago, IL, USA

The TMWCenter for Early Learning+ Public Healthworks to empower parents and caregivers with tools andsupports they need to support the healthy developmentof their children’s brains, beginning at birth. TheTMW Center develop and test evidence-based

Correspondence to: Jill B. Firszt. Email: [email protected]: [email protected]: [email protected]

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interventions and use the scientific process to learnconstantly about what works and what doesn’t. Our‘public health approach’ focuses on prevention ratherthan remediation, places parents and caregivers atthe center of their children’s education and develop-ment and embeds proven practices that supportparents’ and caregivers’ behavior change in existingearly learning and public health systems.Research shows that as early as nine months of age,

infants born into poverty score lower on cognitivedevelopment tests than their more affluent peers.This disparity triples by the age of two. By age five,less than half of children growing up in low-incomefamilies are ready for school compared to 75% of chil-dren raised in high-income families. There is a criticalconnection between parent and child interactions andthe development of language, literacy, math, andexecutive functioning, regardless if a child hasnormal hearing or a hearing loss. Children’s parentsare the most important source of language input tochildren and, as such, are also a primary source ofvariation in input. Despite substantial evidence thatearly parent language input is critical to children’s aca-demic and life outcomes, parents remain an untappedresource, lacking the knowledge and tools to providelanguage rich environments to their children.TMW’s evidence-based interventions reach parents

at multiple touchpoints; TMW-Newborn (maternityward), TMW-Well Baby (Pediatrician offices) andTMW-Home Visiting. Deployed through a web-based platform, TMW’s behavioral interventionstranslate emerging brain science into strategies (3Ts)caregivers can use in everyday settings. To date, inter-ventions developed by TMW have been tested through11 studies, 7 of which were randomized control trialsor quasi-experimental trials, and have reached morethan 3000 families in the Chicagoland area. Earlyresults from these trials indicate the TMW interven-tions are effective in increasing caregivers’ knowledgeand encouraging behaviors that support young chil-dren’s’ brain development by enriching their languageenvironments.

Summer literacy intervention for children whoare deaf and hard of hearing from bilingualhomes: parents as partnersKaren C. Johnson1, Debra K. Schrader1, DianneHammes Ganguly1, Cindy Rodriguez2, Marta Kulich3,Pamela Pyrzynski1, Laurel M. Fisher11Keck School of Medicine of USC, Los Angeles, CA, USA,2Downey (CA) Unified School District, 3NorthwesternUniversity Feinberg School of Medicine, Evanston, IL, USA

Despite advances in the early identification andsensory intervention in children with hearing loss,

many children who are deaf and hard of hearing (D/HH) continue to lag behind their typical hearingpeers in the development of reading and writing.These delays are further compounded for childrenfor whom English is not the home language andwhose families may lack resources that support literacyengagement.We have developed and implemented an intensive 3-

week summer literacy intervention program inresponse to a need we observed among the childrenwho are deaf and hard-of- hearing (D/HH) and theirfamilies in our center. The program is offered toyoung, school-aged children from bilingual (Spanish-English) or monolingual Spanish-speaking homes,who are developing spoken language with the assist-ance of cochlear implants or hearing aids.Children receive twelve 3-hour sessions (36 h) of

small group instruction, centered around phonologicalawareness, print awareness, word knowledge, sharedreading and writing, storybook conversations, andoral language. These skills have been identified asfoundational in supporting literacy for typicallyhearing children (Shanahan and Lonigan, 2010) andareas of specific need for children who are D/HH(e.g. Ambrose et al., 2012; DesJardin et al., 2009,2014; Geers amd Hayes, 2011; Werfel et al., 2016).They are also skills for which parents can acquire strat-egies (e.g. Justice and Ezell, 2000; Lonigan andWhitehurst, 1998) that can be applied in the primarylanguage of the home.Parents attend four 3-hour seminars (12 h), con-

ducted in Spanish by a bilingual teacher of the deaf,who is also a certified Auditory-Verbal Educator(AVEd). The parent sessions are designed to conveythe importance of joint parent–child literacy activities.Parents are also provided with strategies that supportshared reading and writing activities; strategies towhich the child is also exposed through interactionswith his or her teacher during small group instruction.At the conclusion of the 2017 summer program,

parents were asked to complete a short-answerParent Survey, in English or Spanish, to assess theimpact of the parent training and whether theprogram was meeting their perceived needs. Parents’written responses were entered into a softwareprogram (NVivo; QSR International, 2018) for quali-tative analysis. Two coders unfamiliar with thesummer literacy intervention used line-by-line analysisto identify meaningful units of text, which were thencategorized into nodes. The coders met with a thirdmember of our research team to review coding defi-nitions and agreement, and to synthesize codes intocorresponding themes.Thematic analysis (Braun and Clarke, 2006) of the

parental feedback demonstrated that parents wereable to develop strategies that could be implementedCorrespondence to: Karen C. Johnson. Email: [email protected]

Johnson et al. Summer Literacy Intervention for Children who are Deaf and Hard of Hearing from Bilingual Homes

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at home. Furthermore, parents perceived that use ofthese strategies were yielding positive shared literacyexperiences with their child within the 3 weeks of theprogram. Particularly reinforcing for parents was theenthusiasm, self-motivation, and increasing indepen-dence that their children were demonstrating aroundreading and writing, many for the first time.Over the past four years, a community of families

has come together around the summer literacy inter-vention. In any given summer, approximately half offamilies who enroll are returning after participationthe previous year. Importantly, parents report continu-ing to use the strategies they acquired through parentseminars in their homes throughout the year.

ReferencesAmbrose, S.E., Fey, M.E., Eisenberg, L.S. 2012. Phonological

awareness and print knowledge of preschool children withcochlear implants. Journal of Speech, Language, and HearingResearch, 55(3): 811–823. doi:10.1044/1092-4388(2011/11-0086).

Braun, V.Clarke, V. 2006. Using thematic analysis in psychology.Qualitative Research in Psychology, 3(2): 77–101. doi:10.1191/1478088706qp063oa.

DesJardin, J.L., Ambrose, S.E., Eisenberg, L.S. 2009. Literacy skillsin children with cochlear implants: The importance of early orallanguage and joint storybook reading. Journal of Deaf Studiesand Deaf Education, 14(1): 22–43. doi:10.1093/deafed/enn011.

DesJardin, J.L., Doll, E.R., Stika, C.J., Eisenberg, L.S., Johnson,K.C., Hammes Ganguly, D., Colson, B.G., et al. 2014.Parental support for language development during joint bookreading for young children with hearing loss. CommunicationDisorders Quarterly, 35(3): 167–181. doi:10.1177/1525740113518062.

Geers, A.E., Hayes, H. 2011. Reading, writing, and phonologicalprocessing skills of adolescents with 10 or more years ofcochlear implant experience. Ear and Hearing, 32(1 Suppl):49S–59S. doi:0196/0202/10/3201-0049S/0.

Justice, L.M., Ezell, H.K. 2000. Enhancing children’s print andword awareness through home-based parent intervention.American Journal of Speech-Language Pathology, 9(3):257–269. doi:10.1044/1058-0360.0903.257.

Lonigan, C.J., Whitehurst, G.J. 1998. Relative efficacy of parent andteacher involvement in a shared-reading intervention for pre-school children from low-income backgrounds. EarlyChildhood Research Quarterly, 13(2): 263–290. doi:10.1016/S0885-2006(99)80038-6.

QSR International. 2018. NVivo qualitative data analysis Software.Version 12.1. http://www.qsrinternational.com/nvivo/nvivo-products/nvivo-12-pro.

Shanahan, T., Lonigan, C.J. 2010. The National early literacy Panel:A summary of the process and the report. EducationalResearcher, 39(4): 279–285. doi:10.3102/0013189X10369172.

Werfel, K.L., Douglas, M., Ackal, L. 2016. Small-group phonologi-cal awareness training for pre-kindergarten children withhearing loss who wear cochlear implants and/or hearing aids.Deafness & Education International, 18(3): 134–140. doi:10.1080/14643154.2016.1190117.

CI 2018 emerging issue: Cochlear implantpractice management: maximizing value foroptimal delivery of careCo-Chairs: David Haynes (Vanderbilt University), MeredithHolcomb (Medical University of South Carolina), HollyTeagle (University of North Carolina)

As indications for cochlear implantation continue toexpand, constraints in serving patients at already busycochlear implant centers will worsen. Some centershave instituted innovative practices to optimize effi-ciency in delivering clinical services. This session willexamine techniques and technologies already in placeas well as possible future innovations that couldimprove efficiency and value for CI centers andpatients. Such innovations include telehealth in theevaluation, pre-operative, and post-operative elementsof CI; in-center programing efficiencies; outsourcedaudiology services; and industry utilization. Patientsmay benefit from satellite centers in smaller cities orrural areas that are now poorly served.• Pre-Implant and Surgical Issues Panel, Moderator:

David Haynes Panelists: Loren Bartels (Tampa BayHearing and Balance Center), Brendan O’Connell(University of North Carolina), Charles Syms (EarMedical Group), Mark Syms (Arizona HearingCenter)

• Post-Implant Immediate and Long-Term Care Panel,Moderator: Meredith Holcomb Panelists: AllisonBiever (Rocky Mountain Ear Center), CamilleDunn (University of Iowa), Alejandra Ullauri(Chicago Hearing Care)

• CI Company Solutions for Increased ClinicalEfficiency Panel, Moderator: Holly Teagle Panelists:Judy Horvath (MED-EL), Bobby Sheinin(Cochlear), Tony Spahr (Advanced Bionics)

Management options for further research andassessmentMeredith HolcombDepartment of Otolaryngology – Head and Neck Surgery,Medical University of South Carolina, Charleston, SC, USA

Three sections reviewed management concerns fromvarying perspectives: pre-implant and surgical issues,post-implant immediate and long-term care, andcompany solutions for increased efficiency. The firstpanel was comprised of surgeons who providedwidely varying perspectives, some of which wererefuted by audience members. Some surgeons reportedmodest audiology revenue from providing cochlearimplant (CI) services while others indicated theirclinics operated at a deficit by providing post-operativeaudiological care to CI patients. Solutions that werediscussed and which should be researched includedecreasing CI programming appointment times,increasing the number of CI patients seen in a day,and off-loading non-billable tasks such as orderingand accessory training to others such as a CI adminis-trative coordinator, audiology assistant or CI compa-nies. Other solutions reviewed include moving to a

Email: [email protected] Email: [email protected]

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one-processor contract, negotiating for lower hospitalpricing for the CI devices, and partnering with oneor all of the CI companies to provide counseling,CI programming, and CI troubleshooting at anoffice in the CI center. A grant funded, institutioninitiated project was also discussed as an effectivemethod of subsidizing costs for hearing aid, cochlearimplant, and speech therapy services for childrenwith hearing loss.Common themes emerged from the three audiolo-

gists in the second panel. All agreed that standardiz-ation of test protocols for pre- and post-CI visits areneeded. Many clinics utilize different test batteries atvarying presentation levels and test conditions (noisevs. quiet). Without standardization, it is difficult forreferring physicians and audiologists to understandwho meets the qualification for a CI. It was rec-ommended that hearing aid (HA) audiologists testHA patients in an aided condition with speech percep-tion measures to more appropriately refer patients forCI evaluations. With over 11,000 hearing aid clinics inthe US, screening for CI candidacy in the HA officewill likely provide a more timely mechanism for refer-ring patients to CI centers for evaluation. Other high-lighted tools for further research and evaluation thatcould improve access to CI care include remote pro-gramming/telehealth, cochlear provider networks(CPNs), and automated patient-driven CI program-ming software. While several speakers discussedCPNs as viable, appropriate options for the continuedgrowth of surgical numbers and increased access tocare, others expressed concerns that simply program-ming a CI device is not the same as providing appro-

priate CI care. Care provision includes counseling,educating patients, and addressing the emotionalimpact of the hearing loss. When considering outsour-cing programming to a satellite audiologist/CPN, CIsurgical centers should thoroughly evaluate the satel-lite location to ensure the level of care meets patientneeds.The third panel included representatives from the

three FDA approved CI companies. A commonconcept for clinical efficiency was simplification.Each representative discussed available online toolsfor patients to access information about their CIjourney, their CI equipment and their post-operativeaural rehabilitation. Access to information leads tomore informed patients and can reduce the amountof time necessary for an audiologist to spend on pre-operative counseling. The CI companies offer stream-lined ordering, programming, and equipment trouble-shooting to CI centers which drastically reduces thenon-billable time for the audiologist. Lastly, the CIcompanies stressed their commitment to improvingclinical efficiency is evident by their increase in clinicaland consumer specialists who assist with problemcases, patient counseling, insurance reimbursement,and completion of order forms for new surgeries andupgrades.While many problems and advancements were dis-

cussed regarding the evaluation, pre-operative, andpost-operative elements of cochlear implantation, itis clear more research is needed in the area of clinicalefficiency and practice management to guide adoptionand use of such innovative practices and service deliv-ery models.

Holcomb Management options for further research and assessment

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