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Impact of cost-effectiveness analyses of bilateral cochlear implantation on health policies

Decisions about coverage and reimbursement of health interventions are based, more or less explicitly, on cost-effectiveness criteria. Unilateral cochlear implantation is clearly cost-effective (UCI) because it allows deaf people to hear and integrate into society. Bilateral cochlear implantation (BCI) offers additional benefits, such as improved speech understanding, mainly in noisy environments, the ability to localize the origin of sound, and the possibility of continuing hearing when one implant fails. For these reasons, experts in otology and audiology have unanimously recommended pediatric BCI for more than a decade. However, the first cost-effectiveness analyses concluded that BCI was not cost-effective, even in children. As a consequence ten years ago BCI was covered only in a few countries. In 2007 the PENTAG study, commissioned in England by the National Institute for Clinical Excellence (NICE), concluded that it is cost-effective for children, even though with a high degree of uncertainty. Since 2009 all the children suffering from severe to profound neurosensorial hearing loss in England and Wales receive now two cochlear implants. Further evidence accumulated in recent years has slowly spread the coverage of pediatric BCI to other countries—France, Ireland, New Zealand, the Netherlands, Brazil, etc.—but there are other countries, in which the coverage of BCI is very irregular, depending on the insurance policy hired (in the United States) or on the so-called “zip code lottery” (for example, in Spain). In many middle-income countries UCI is still the standard treatment. We argue that most cost-effectiveness analyses performed so far have underestimated the incremental effectiveness of BCI and overestimated its cost (mainly by disregarding the societal savings) and conclude with a call to action: it is necessary to develop rigorous country-specific analyses that prove, beyond all reasonable doubt, that BCI is cost-effective not only in children but also in many adults.

Francisco Javier Díez (POC,Primary Presenter), UNED, fjdiez@dia.uned.es;
Francisco Javier Díez was born in Burgos, Spain, in 1965. He earned a degree in Theoretical Physics at the Universidad Autónoma de Madrid and a PhD at the Spanish University for Distance Education (UNED). In 1992 he was a visiting scholar at UCLA, invited by Prof. Judea Pearl, and in 2013 at the Centre for Health Economics of the University of York, UK, invited by Prof. Mark Sculpher. He is currently Associate Professor—accredited as Full Professor—at the Department of Artificial Intelligence at UNED and director of the Research Centre for Intelligent Decision-Support Systems (CISIAD). His research focuses on probabilistic graphical models and their application to medical decision making, including Markov models and cost-effectiveness analysis. He is the father of a child wearing two cochlear implants.

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