title: Barriers to early pediatric cochlear implantation.
abstract: OBJECTIVE
  Universal newborn hearing screening has significantly improved the ability to identify patients with congenital sensorineural hearing loss (SNHL), which results in earlier treatment and better hearing and development outcomes. It is recommended that patients born with SNHL who meet criteria receive cochlear implants (CIs) by a target age of 12 months, however many children are being implanted at an older age. This study aims to describe populations of pre-lingual patients with SNHL that are at risk for delayed implantation and to identify and analyze barriers that cause this delay.
  
  
  METHODS
  Charts of patients receiving a CI between January 2008 and June 2012 at a tertiary care cochlear implant center were reviewed retrospectively. We looked at patient demographics, age at hearing loss diagnosis, age at implantation, and etiology of hearing loss. Barriers to implantation were identified through surveys completed by team members.
  
  
  RESULTS
  Fifty-seven CI recipients were identified of which 42 were in patients with pre-lingual SNHL. SNHL etiology included: cochlear dysplasia (18%), GJB2/GJB6 (17%), acquired (10%) extreme prematurity (9%), and idiopathic (46%). The median age of SNHL diagnosis for pre-lingual patients was 15 months. Compared to private insurance, public insurance status was associated with SNHL diagnosis at a significantly later median age (20.0 vs. 4.0 months, p=0.024), and with a significantly longer median interval from diagnosis to implantation (25.5 vs. 11.0 months, p=0.029). While cochlear implant team members identified delayed insurance approval and medical comorbidities as reasons for delayed implantation, the most significant factor identified was parental, with delayed/missed appointments or reluctance for evaluations or surgery.
  
  
  CONCLUSIONS
  52% of patients with pre-lingual SNHL that met criteria for CI were implanted more than 12 months after diagnosis. Having public or no insurance was significantly associated with delayed implantation. Parental barriers were most common factors cited for delays in implantation. Overcoming these delays necessitates appropriate identification of at risk patients and creating a system to educate families and chaperone them through the process.
authors.affiliation: Division of Pediatric Otolaryngology, Children's National Medical Center, Washington, DC, United States.
authors.forename: Michael
authors.initials: M
authors.lastname: Armstrong
authors.forename: Alison
authors.initials: A
authors.lastname: Maresh
authors.forename: Claire
authors.initials: C
authors.lastname: Buxton
authors.forename: Patricia
authors.initials: P
authors.lastname: Craun
authors.forename: Lauren
authors.initials: L
authors.lastname: Wowroski
authors.forename: Brian
authors.initials: B
authors.lastname: Reilly
authors.forename: Diego
authors.initials: D
authors.lastname: Preciado
mesh_terms: D000367:Age Factors; D001299:Audiometry / Q000191:economics / Q000379:methods; D002675:Child, Preschool; D019929:Cochlear Implantation / Q000191:economics* / Q000379:methods / Q000706:statistics & numerical data; D003054:Cochlear Implants / Q000191:economics* / Q000706:statistics & numerical data; D015331:Cohort Studies; D000072259:Connexin 26; D017630:Connexins; D042241:Early Diagnosis; D005260:Female; D005500:Follow-Up Studies; D054625:Healthcare Disparities; D006319:Hearing Loss, Sensorineural / Q000175:diagnosis* / Q000209:etiology / Q000601:surgery*; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D019458:Insurance Coverage; D008297:Male; D020380:Needs Assessment; D015997:Neonatal Screening / Q000191:economics / Q000592:standards; D012189:Retrospective Studies; D018570:Risk Assessment; D012959:Socioeconomic Factors; D016896:Treatment Outcome; D014481:United States
chemical_list: D017630:Connexins; C000607042:GJB2 protein, human; D000072259:Connexin 26
keywords: Barriers to healthcare access; Cochlear implantation; Insurance status; Sensorineural hearing loss