cost effectiveness ci220509
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Georgina SandersonDirector Reimbursement, Quality, Regulatory AffairsCochlear Limited, Asia Pacific Region
The Value of Cochlear Implants
Agenda
q Incidence and prevalence of hearing loss
q Consequence of unmanaged hearing loss
q Economic impact of hearing loss
q Benefits of cochlear implants
q Cost effectiveness of cochlear implants
Key Population Statistics for HLIncidence and prevalence of severe to profound hearing loss. The quality of life and productivity of these individuals and their families may be significantly reduced.
Addressable: Disposable income per household > USD 5k p.a.
SHI- PHI: a HL > 80dB at 1KHz
IncidenceAge Group (1/1000) Australia Russia0 - 3 y. 0.13 124 7144 - 19 y 0.02 77 43420 - 49 y 0.06 572 411550 -70 y 0.45 2101 1460570+ 1.04 2042 13747
Total 4916 33615
Addressable Incidence
Fortnum, H.M. et al. (2001), Prevalence of permanent childhood hearing impairment in the United Kingdom and implications for universal neonatal hearing screening: questionnaire based ascertainment study, BMJ volume 323
Adrian Davis, Hearing in Adults, The prevalence and distribution of hearing impairment and reported hearing disability in the MRC Institute of Hearing Research's National Study of Hearing, MRC Institute of Hearing Research, Nottingham, Whurr Publishers Ltd London, 1995, ISBN 1-897635-40-0
Consequences of unmanaged HL
q Delayed auditory skills and limited speech and language developmentq (Sininger et al 1999, Ruben 1997, Davis et al 1997, Helfand et al, 2001)
q Limited access to education and scholastic achievementq (Punch et al 2004)
q Underemployment / Unemployment q (Hogan et al 1998, Project HOPE, Scherf et al 2008, Leigh 2008)
q Difficulty participating in social activities q (Pressman, Pipp-Siegal, 1999; Watson et al 1999; Wiefferink et al, 2008)
q Adverse health (physical and mental/ emotional) effects q Access Economics Report 2006
The reduced capacity to communicate resulting from a severe to profound HL has significant impacts family, friends and society.
The economic impact of hearing loss in Australia = AUD 11 billion per annum
Economic Impact of HLThe real financial cost of hearing loss may be 1-2% of GDP, with > 50% of the cost resulting from productivity. Direct health expenditure = 0.034% GDP.
2%9% 6%
56%27%
Total health costs
Lost earnings
Value of carers
Education, support,aidsDead weight losses
Average cost per year
= $ 3,314 per HI person
q Productivity Loss (56%)q Lost earnings to individuals with hearing loss
q Cost of Carers (27%)q Employment of informal carers
q Deadweight costs (9%)q Loss of taxation revenue, finding alternate
sources of taxation to fund increased welfare and health services
q Direct Health System Costs (6%)q Direct health costs including hearing aids and
cochlear implants
q Education & Support Services (2%)q Early intervention, Special Education services,
Interpreters, Captioning, Specific social services, communication devices
Source: Listen Hear! The Economic Impact and Cost of Hearing Loss in Australia, A report by Access Economics Pty Ltd
Summary of Financial Costs
Comparison to key health priorities
5.5
4.6
3.7
2.9
2.9
0.8
0.7
0.2
0 1 2 3 4 5 6
Cardiovasculardisease
Musculoskeletaldisease
Mental health
Injuries
Cancer
Asthma
Diabetes mellitus
Hearing Loss
$A M
Despite the significant economic impact of hearing loss, the allocated health expenditure for hearing health is AUD 0.2M, 0.35% of the money spent on the Australian national health priorities, 2001.
Source: Listen Hear! The Economic Impact and Cost of Hearing Loss in Australia, A report by Access Economics Pty LtdAUD Million
Maximising the return on heari ng health $Enhanced auditory receptive skills
Evidence of emerging aural/oral communication modes
Useful levels of ability in spoken language
Enhanced integration in process of primary education
Enhanced scholastic achievement (reading, writing, arithmetics)
Enhanced versatility and social robustness
Successful transition to secondary education
Enhanced opportunities in employment and further education
Enhanced social independence and Quality of Life in adulthoodSummerfield & Marshall, 1998
Measuring the outcomesBenefit Measure
Compliance Device use
Complications Surgical, medical, device
Cost of revision surgery, hospitalisationAuditory performance Expressive Language development
PLS-4, Categories of Auditory Performance (CAP)Speech development Communication ability
Speech Intelligibility Rating (SIR)Educational placement, % Mainstream school,
Savings in education, Academic achievement Numeracy and Literacy
% High School graduationEmployment status % Full employment
Improved productivity – tax revenueQuality of Life Health Utility Index (HUI), $/ QALYs
Savings to society
Predictors of outcome
q Age at implantationq Detectionq Intervention
q Cognitive ability
q Expertise of CI teamq CI infrastructureq Habilitation
q Family involvementq Re/habilitation
q Communication modeq Oral, Total, Cued..
Source: Hodges et al, 1999; Beadle et al 2005
Age at ImplantationThere is an established association between identification of hearing loss before 6 months of age and improved results in language at 3 years of age. Hearing outcomes may be optimised by early identification and intervention.
q Better audi tory performanceq Yoshinago-Itano, 2000, Blamey et al 2001; Geers 2006; Sharma 2007
q Rate and level of language developmentq Yoshinago-Itano, 2000
q Better speech intelligibilityq Coulter & Thomson, 2000, De Raeve, 2002
q Better parent attachmentq Pressman, 1998; Lichert 2001, 2003
q Higher reading (literacy) level and number in mainstreamq Archbold et al, 2002; Geers, 2003; Scherf et al 2008; Leigh, 2008
q On set of social-emotional development as normal hearing childrenq Wiefferink et al, 2008
UNHS supports earl y identificationIn 2001 an Australian National Newborn Heari ng Screening Committee agreed upon a Consensus Statement. Each State and Territory was then tasked with implementing a program. There is now 83% national coverage. UNHS 2009
65% > 96%
57%> 98%
> 95%
> 57%
> 90%
95%
2009
UNHS supports earl y identificationThe impact of early identification and intervention may be assessed on a cohort of children across Australia, all receiving the same technology and with access to similar cochlear implant infrastructure.
Leigh 2006, Ching et al 2006, Ching et al 2007
Hearing Screening Age at First Fitting (months)
State Status Method Coverage n Median Mean
New South Wales Universal 2-stage AABR
>95% 40 2.8 4.5
Queensland Universal 2-stage AABR
> 97% 45 4.0 10.0
Victoria Partial 2-stage AABR
~30% 38 5.2 8.6
Total 123 3.5 7.8
Language ski lls at 3 years
Effect of age at implant, p = 0.02
Children who received an implant before 12 months of age developed expressive and receptive language within the range of normal hearing peers, when measured at 12 months after implantation and at 3 years of age.
Source: Ching T, 2009 Outcomes of children with hearing impairment: a population-based, prospective study comparing early and later-identified children
Language devel opment
Svirsky MA, Robbins AM, Kirk KI, Pisoni DB, Miyamoto RT.
Psychological Research 2000;11:153-158.
• The deafened child is “at risk” for listening & spoken language skill development
q The rate of language developmentq after CI implantation -
q exceeded that of non-implanted q children q was similar to that of children q with normal hearing
q Speech intelligibility improved q post-implantationq Allen MC, Nikolopoulos TP, O’Donoghue G.
q Am J Otol 1998;19:742-746.
Categories of Auditory Performance (CAP)
Source: Govaerts, et al, Otology & Neurotology 2002
response to speech sounds
discrimination of speech sounds
use of telephone
Children implanted before the age of 3 years of age reach the CAP rating 7 after 2 years of implantation, however those implanted before the age of 18 months have an auditory development pathway close to that of normal hearing peers.
Speech Intel ligibility
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
SIR
at 4
y p
ost C
I
9-18 mths 19-30mths < 3 y 3-5 y 5-7 yAge Group at ImplantationAll Little Experience Exerperince to Deaf Speech
Children who receive a cochlear implant before the age of 18 months has a significant effect on their speech intelligibility at 4 years, compared with those children implanted at an older age (an do not have addi tional needs).
Source: Archbold 2001; De Raeve, 2006
Educational placement
•
•
• Schulze Gattermann, MHH 2000
The Hannover Experience
69
2914 12
0%10%20%30%40%50%60%70%80%90%
100%
Group 1 CI 0-1.9 yr
Group 2CI2-3.9 yr
Group 3 CI 4-6.9 yr
Group 4Hearing
Aid
Group 1: Average of grades 1 & 2 (6 to 8 years)Group 2: Average of grades 1 to 5 (6 to 11 years)Group 3: Average of grades 1 to 6 (6 to 12 years)Group 4: Average of grades 1 to 10 (6 to 16 years)
MainstreamIntegratedHearing impairedHearing impaired + DeafDeaf
Type of School
Children implanted before the age of 2 years were in mainstream education almost 6 times as often as children with hearing aids
$53,200
$28,200
$14,500
$5,030$6,100
$0
$10,000
$20,000
$30,000
$40,000
$50,000
$60,000
Residential School Residential School,Day Student
Self-containedClassroom
Resource Room Regular-MainstreamEducation
Ann
ual C
osts
Educational costs
Source: Department of Education’s Office of Special Education and Rehabilitative Services; Annual Report to Congress on the Implementation of Individual’s with Disabilities Education Act, 1997.
Educational Placement
There are significant savings in education to be real ized if a child is able to participate successfully in mainstream education system.
90% saving compared to education in
Residential Deaf school
Employment
Deafened adul ts
q Fewer educational qualifications
q Higher unemployment
q Lower incomes
q Greater under-employment
Hogan A, et al . Employment and Economic Outcomes for deafened adults with cochlear Implants.
Presented to Audiological Society of Australia 13th National Conference. 28th
April 1998, Sydney, Australia.
Adults with a cochlear implant are twice as likely to be in paid work and more likely to have a higher income than people with a moderate hearing loss
EmploymentEmployment
Source: Project HOPE calculations from the 1990-91 National Health Survey
58%
82%
46%
73%
11%16%
2% 3%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
18-44 yrs 45-64 yrs 65-79 yrs 80+ yrsSeverely to Profoundly Hearing Impaired US Population
42% of the severe to profound hearing loss populat ion, between the ages of 18- 44 years, in USA are not working .
q Multi-attribute health status classification
q Suitable for Cochlear Implantation
q Includes sensory attributes: Vision, Hearing, Speech
q Administered as a questionnaire
q Scoring system based on preferences of general public
Quality of Life - Health Utility Index (HUI 3)
Source: Cheng et al, JAMA, 2000
Quality of Life
Δ (QALYs) = Δ (Life Years x Health Utility)
Cochlear implant
63.00.0
1.0
Health RelatedQuality of Life
(Utility)
(Perfect health)
(Death)Duration (Years)
No treatment
QALYs
0.11
0.48
The improvement in quality of life resulting from a medical intervention may be calculated using validated assessment tools such as the Health Utilities Index (HUI). The qual ity (utility) and quantity (life expectancy) of life are calcuated.
Health utility scoresHUI 3
Attribute
(n = 48)
Pre-implantation Score
Mean (95% CI)
Post-implantation Score
Mean (95% CI) Δ
Hearing 0.75
(0.74 – 0.76)
0.82
(0.8 – 0.83)0.07
Speech 0.80
(0.78 – 0.82)
0.92
(0.90 – 0.93)0.12
Emotion 0.58
(-0.03 – 0.61)
0.94
(0.93 – 0.96)0.36
Cognition 1.0 1.0 0
Ambulation 0.99
(0.98 – 1.0)
0.99
(0.98 – 1.0)0
Vision 1.0 1.0 0
Pain 1.0 1.0 0
Dexterity1.0 1.0 0
Estimate lifetime costs of implantationVariables No of Years Costs (USD)
Direct Costs
Preoperative Costs 1 2863Operative Costs
Cochlear Implant
Hospital and Surgery
1 19,153
4612Post-operative costs
Audiology Follow-up
Rehabi litation follow-up
Device failure (if any)
Loss or Damage insurance
Special batteries
Speech processor upgrades
1 – 73
1- 2
1 – 73
1 – 73
1 – 73
4 - 73
5148
8984
1007
4013
1293
5104Subtotal (Direct costs) $ 60 228
Indirect Costs
Time off Work
Travel expenses
Car parking expenses
Change in educational costs
Change in Future Earnings
1 – 73
1 – 73
1 – 73
1 – 73
11 - 73
4623
4830
589
- 65 558
- 55 574Total (Direct + Indirect) $- 53 198
Source: Cheng et al, JAMA, August 16, 2000
Calculation of Cost Uti lity
Cost Utility =Costs ($)Δ (QALYs)
Discounted Lifetime Costs ($)Δ (Life Years x Health Utility)
=
USD 60 228 (Direct costs only)
11.59 QALYs=
USD 5,197 / QALYs=
Source: Cheng et al, JAMA, August 16, 2000
The cost utility is calculated as the incremental costs associated with the provision of cochlear implantation, divided by the incremental gain in Quality Adjusted Life Years (QALYs).
Adult cochlear implant
A cost effective treatment
59,292
34,836
11,125
7,968*
7,500Source: Cheng et al, JAMA, August 16, 2000, *Wyatt JR et al, Laryngoscope 106: July, 1996
More cost effective
Less cost effective
5,197
11,125
7,968
34,836
59,292
Paediatric cochlear implant
Neonatal intensive care (1.0-1.5kg)
Implanted defibrillator
Knee replacement
0 10,000 20,000 30,000 40,000 50,000 60,000
Cost per Quality Adjusted Life Year (QALY) in $US
Due to the cascade of benefits resulting from oral communication the cost utility of paediatric and adult cochlear implantation compares favourabl y with many other common funded interventions.
Summary
q An unmanaged hearing loss has significant impact on the development and socialisation of an individual
q Hearing loss has a significant economic impact a country’s gross domestic product (GDP)
q Appropriate hearing intervention provides hearing impaired people with access to spoken language, education and society
q Children fitted with a cochlear implant have an improved quality of life. These benefits may be optimised by age of implantation and good infrastructure
q Cochlear implantation is a cost effective medical intervention.
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