International Journal of Pediatric Otorhinolaryngology
Health-service costs of pediatric cochlear implantation: multi-center analysis
Introduction
The cost of providing cochlear implants to children raises significant issues in many countries. Commissioners of health care are concerned that costs appear high in relation to other elective interventions. Many providers of health care are concerned that reimbursement rates are low in relation to the real cost of provision. These concerns are expressed most strongly in the publicly-funded parts of health-care systems, particularly in countries such as the United States (US) and United Kingdom (UK) which spend a relatively low percentage of their Gross Domestic Product on publicly-funded health care.
In these circumstances, a multi-center cost analysis of an intervention can be beneficial in six ways. (i) It can identify resources which account for a high percentage of costs. (ii) It can determine where differences in cost between centers arise. (iii) It can identify the likely causes of such differences. (iv) It can enable the generalisability of results to be assessed. (v) Therefore, it can indicate which efforts at cost-reduction might be most effective. (vi) It provides a basis for analysis of cost-effectiveness. This paper addresses the first two issues by reporting the results of a multi-center analysis of the costs of providing cochlear implantation (CI) to children in the UK. A related paper [1] addresses the third, fourth and fifth issues.
Clinical management of children undergoing CI involves four phases: assessment of suitability, surgical implantation, tuning, and ongoing maintenance. Tuning entails matching the stimulation from the implant system to the electro-auditory sensitivity of the child. Maintenance entails repair and replacement of the external components of implant hardware, along with management of adverse medical/surgical events. Maintenance continues for as long as the implant is used—potentially a child's lifetime. The UK model for the provision of CI to children involves a high degree of centralization: children travel to one of a limited number of hospitals to receive all four phases of management. This pattern simplifies the analysis because the great majority of health-service costs are incurred in a single setting. We believe that the results have relevance outside the UK because similar health-care resources are likely to be incurred in each phase of management, regardless of the setting.
Costs of assessment, implantation, tuning, and maintenance were estimated for three time periods following implantation: 1 year, 15 years, and 73 years. One-year costs could be estimated for each child implanted since the inception of each program, allowing an assessment of whether the use of resources had stabilised within programs. Fifteen years is a plausible period over which CI is likely to remain the main intervention for profound-total deafness in children. Estimates of lifetime (73-year) costs allow comparison with the results of previous studies. Five previous studies are relevant [2], [3], [4], [5], [6] although they each display some or all of three limitations: (i) they were based on single hospitals; (ii) they projected future costs from data measured in the early period of provision of CI; and/or (iii) they based estimates of some significant costs on charges (hospital reimbursement rates). These are limitations because costs measured in one hospital may not generalise to other hospitals, [7], [8], levels of resource use may fall as experience is gained, [9] and charges do not always approximate the true costs of resources. [10], [11]. The present study addressed these issues by measuring resource use in more than one hospital, by collecting data retrospectively over a number of years to assess whether patterns of resource use had stabilised, and by adhering to economic guidelines for identification, measurement, and valuation when estimating costs [12], [13].
The present study estimated the costs of assessing, implanting, tuning, and maintaining children in order to quantify the profile of resource-use across time. In addition, because policy makers consider the total cost of interventions when allocating resources, [14] total costs to the UK Health Service were estimated and predicted for the next 15 years.
Section snippets
Identification of resources
Resources used in providing pediatric CI were identified from earlier reports [2], [3], [4] through observing clinical practice, and by discussion with clinicians. The 16 UK hospitals that provided cochlear implants to children in the 1998/1999 financial year (April 1998–1999) were invited to participate. Data were obtained through the clinical co-ordinator of the pediatric CI program in each hospital by questionnaire, telephone calls, e-mail, and a face-to-face interview. Data were collected
Health-service costs
Twelve hospitals provided information on most resources. Four hospitals were excluded because they were unable to provide sufficient information to avoid excessive imputation. The excluded hospitals undertook a low annual volume of activity, only one having implanted more than 20 children by the end of the year 2000 [15]. All programs provided both current and retrospective information on staff costs. At least eight programs provided data on each other resource.
One-year costs were estimated for
Ongoing costs
The average life-time health-service cost of implanting and maintaining a child in the UK is estimated to be €95 000. Analyses of uncertainty has shown that this figure is not highly sensitive to the value of any one individual cost component nor to assumptions about the relative cost of outpatient and outreach visits. However, estimated lifetime costs vary by a factor of two between hospitals. Maintenance of existing implantees is estimated to have accounted for nearly a quarter of the total
Conclusions
This study estimated the cost of providing pediatric CI in more than one hospital, used economic methods to identify, measure, and value resource use, and explicitly estimated the costs of adverse events and of repairs and replacements to implant hardware. The study has the weakness that some data were gathered retrospectively, but the strength that data were gathered for several years of each program's existence allowing confirmation that costs had stabilised by 1998/1999—the year from which
Acknowledgements
We thank the lead surgeons and clinical co-ordinators of the 12 UK pediatric implant programs which participated. Costs of the study were met partly by a grant from the National Lottery Charities Board administered by Defeating Deafness—The Hearing Research Trust.
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