title: Cost Effectiveness of Childhood Cochlear Implantation and Deaf Education in Nicaragua: A Disability Adjusted Life Year Model.
abstract: BACKGROUND
  Cochlear implantation (CI) is a common intervention for severe-to-profound hearing loss in high-income countries, but is not commonly available to children in low resource environments. Owing in part to the device costs, CI has been assumed to be less economical than deaf education for low resource countries. The purpose of this study is to compare the cost effectiveness of the two interventions for children with severe-to-profound sensorineural hearing loss (SNHL) in a model using disability adjusted life years (DALYs).
  
  
  METHODS
  Cost estimates were derived from published data, expert opinion, and known costs of services in Nicaragua. Individual costs and lifetime DALY estimates with a 3% discounting rate were applied to both two interventions. Sensitivity analysis was implemented to evaluate the effect on the discounted cost of five key components: implant cost, audiology salary, speech therapy salary, number of children implanted per year, and device failure probability.
  
  
  RESULTS
  The costs per DALY averted are $5,898 and $5,529 for CI and deaf education, respectively. Using standards set by the WHO, both interventions are cost effective. Sensitivity analysis shows that when all costs set to maximum estimates, CI is still cost effective.
  
  
  CONCLUSIONS
  Using a conservative DALY analysis, both CI and deaf education are cost-effective treatment alternatives for severe-to-profound SNHL. CI intervention costs are not only influenced by the initial surgery and device costs but also by rehabilitation costs and the lifetime maintenance, device replacement, and battery costs. The major CI cost differences in this low resource setting were increased initial training and infrastructure costs, but lower medical personnel and surgery costs.
authors.affiliation: *Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, U.S.A.; †Department of Otolaryngology, Mayo Clinic Arizona, Phoenix, Arizona, U.S.A.; ‡Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, U.S.A.; §Duke University, Research Triangle Park, Durham, North Carolina, U.S.A.; ∥Department of Otolaryngology, Hospital Central Managua, Managua, Nicaragua; and ¶Duke University Medical Center, Durham, North Carolina, U.S.A.
authors.forename: James E
authors.initials: JE
authors.lastname: Saunders
authors.forename: David M
authors.initials: DM
authors.lastname: Barrs
authors.forename: Wenfeng
authors.initials: W
authors.lastname: Gong
authors.forename: Blake S
authors.initials: BS
authors.lastname: Wilson
authors.forename: Karen
authors.initials: K
authors.lastname: Mojica
authors.forename: Debara L
authors.initials: DL
authors.lastname: Tucci
mesh_terms: D001298:Audiology / Q000191:economics; D002675:Child, Preschool; D019929:Cochlear Implantation / Q000191:economics*; D003054:Cochlear Implants / Q000191:economics*; D003362:Cost-Benefit Analysis; D003638:Deafness / Q000191:economics* / Q000534:rehabilitation / Q000628:therapy*; D004493:Education / Q000191:economics*; D004868:Equipment Failure / Q000191:economics; D017048:Health Care Costs; D006319:Hearing Loss, Sensorineural / Q000191:economics / Q000628:therapy; D006801:Humans; D007223:Infant; D009527:Nicaragua / Q000453:epidemiology; D019057:Quality-Adjusted Life Years; D013070:Speech Therapy / Q000191:economics; D016896:Treatment Outcome