Cost Effectiveness Ci220509

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Georgina Sanderson's Presentation on the Cost Effectiveness of Cochlear Implants held in St. Petersburg at the First Monsana Conference.

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Cost Effectiveness Ci220509

  1. 1. The Value of Cochlear Implants Georgina Sanderson Director Reimbursement, Quality, Regulatory Affairs Cochlear Limited, Asia Pacific Region
  2. 2. 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
  3. 3. Key Population Statistics for HL Incidence and prevalence of severe to profound hearing loss. The quality of life and productivity of these individuals and their families may be significantly reduced. Incidence Addressable Incidence Age Group (1/1000) Australia Russia 0 - 3 y. 0.13 124 714 4 - 19 y 0.02 77 434 20 - 49 y 0.06 572 4115 50 -70 y 0.45 2101 14605 70+ 1.04 2042 13747 Total 4916 33615 Addressable: Disposable income per household > USD 5k p.a. SHI- PHI: a HL > 80dB at 1KHz 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 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
  4. 4. Consequences of unmanaged HL The reduced capacity to communicate resulting from a severe to profound HL has significant impacts family, friends and society. q Delayed auditory skills and limited speech and language development q (Sininger et al 1999, Ruben 1997, Davis et al 1997, Helfand et al, 2001) q Limited access to education and scholastic achievement q (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 economic impact of hearing loss in Australia = AUD 11 billion per annum
  5. 5. Economic Impact of HL The 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. q Productivity Loss (56%) Summary of Financial Costs q Lost earnings to individuals with hearing loss q Cost of Carers (27%) 9% 6% 2% Total health costs q Employment of informal carers Lost earnings q Deadweight costs (9%) q Loss of taxation revenue, finding alternate sources of taxation to fund increased welfare 27% Value of carers and health services 56% Education, support, q Direct Health System Costs (6%) aids q Direct health costs including hearing aids and Dead weight losses cochlear implants Average cost per year q Education & Support Services (2%) q Early intervention, Special Education services, =$ 3,314 per HI person Interpreters, Captioning, Specific social services, communication devices Source: Listen Hear! The Economic Impact and Cost of Hearing Loss in Australia, A report by Access Economi cs Pty Ltd
  6. 6. Comparison to key health priorities 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. Hearing Loss 0.2 Diabetes mellitus 0.7 Asthma 0.8 Cancer 2.9 Injuries 2.9 Mental health 3.7 Musculoskeletal 4.6 disease Cardiovascular 5.5 disease 0 1 2 3 4 5 6 AUD Million $A M Source: Listen Hear! The Economic Impact and Cost of Hearing Loss in Australia, A report by Access Economi cs Pty Ltd
  7. 7. 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 adulthood Summerfield & Marshall, 1998
  8. 8. Measuring the outcomes Benefit Measure Compliance Device use Complications Surgical, medical, device Cost of revision surgery, hospitalisation Auditory 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 graduation Employment status % Full employment Improved productivity tax revenue Quality of Life Health Utility Index (HUI), $/ QALYs Savings to society
  9. 9. Predictors of outcome q Age at implantation q Detection q Intervention q Cognitive ability q Expertise of CI team q CI infrastructure q Habilitation q Family involvement q Re/habilitation q Communication mode q Oral, Total, Cued.. Source: Hodges et al, 1999; Beadle et al 2005
  10. 10. Age at Implantation There is an established association between identification of hearing loss before 6 months of age and i mproved results in language at 3 years of age. Hearing outcomes may be opti mised by early identification and intervention. q Better audi tory performanc e q Yoshinago-Itano, 2000, Blamey et al 2001; Geers 2006; Sharma 2007 q Rate and level of language development q Yoshinago-Itano, 2000 q Better speech intelligibility q Coulter & Thomson, 2000, De Raeve, 2002 q Better parent attachment q Pressman, 1998; Lichert 2001, 2003 q Higher reading (literacy) level and number in mainstream q Archbold et al, 2002; Geers, 2003; Scherf et al 2008; Leigh, 2008 q On set of social-emotional development as normal hearing children q Wiefferink et al, 2008
  11. 11. UNHS supports earl y identification In 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% nati onal coverage. UNHS 2009 2009 57% > 98% 65% > 96% > 95% > 57% 95% > 90%
  12. 12. UNHS supports earl y identification The impact of early identification and intervention may be as sessed on a cohort of children across Australia, all receiving the same technology and with access to similar cochlear implant infrastructure. Hearing Screening Age at First Fitting (months) State Status Method Coverage n Median Mean New South Wales Universal 2-stage >95% 40 2.8 4.5 AABR Queensland Universal 2-stage > 97% 45 4.0 10.0 AABR Victoria Partial 2-stage ~30% 38 5.2 8.6 AABR Total 123 3.5 7.8 Leigh 2006, Ching et al 2006, Ching et al 2007
  13. 13. Language ski lls at 3 years Children who received an implant before 12 months of age devel oped expressive and receptive language within the range of normal hearing peers, when meas ured at 12 months after implantation and at 3 years of age. Effect of age at implant, p = 0.02 Source: Ching T, 2009 Outcomes of children with hearing impairment: a population-based, prospective study comparing early and later-identified children
  14. 14. Language devel opment The deafened child is at risk for listening & spoken language skill development q The rate of language development q after CI implantation - q exceeded that of non-implanted q children q was similar to that of children q with normal hearing Svirsky MA, Robbins AM, Kirk KI, Pisoni DB, Miyamoto RT. Psychological Research 2000;11:153-158. q Speech intelligibility improved q post-implantation q Allen MC, Nikolopoulos TP, O Donoghue G. q Am J Otol 1998;19:742-746.
  15. 15. Categories of Auditory Performance (CAP) 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. use of telephone discrimination of speech sounds response to speech sounds Source: Govaerts, et al, Otology & Neurotology 2002
  16. 16. Speech Intel ligibility 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). 100% 90% 80% 70% SIR at 4 y post CI 60% 50% 40% 30% 20% 10% 0% 9-18 mths 19-30mths <3y 3-5 y 5-7 y All Age Group at Implantation Little Experience Exerperince to Deaf Speech Source: Archbold 2001; De Raeve, 2006
  17. 17. Educational placement Children implanted before the age of 2 years were in mainstream education almost 6 times as often as children with hearing aids The Hannover Experience 100% 14 12 90% 29 80% 70% Type of School 69 60% Mainstream 50% Integrated 40% Hearing impaired 30% Hearing impaired + Deaf 20% Deaf 10% 0% Group 1 Group 2 Group 3 Group 4 CI 0-1.9 yr CI2-3.9 yr CI 4-6.9 yr Hearing 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) Schulze Gattermann, MHH 2000
  18. 18. Educational costs There are significant savings in education to be realized if a child is able to participate successfully in mainstream education system. $60,000 $53,200 Educational Placement $50,000 90% saving Annual Costs $40,000 compared to education in $28,200 $30,000 Residential Deaf $14,500 school $20,000 $6,100 $5,030 $10,000 $0 Residential School Residential School, Self-contained Resource Room Regular- Day Student Classroom Mainstream Education 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.
  19. 19. Employment Adults with a cochlear implant are twice as likely to be in paid work and more likely to have a hi gher income than peopl e with a moderate hearing loss Deafened adults 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 13 th National Confer ence. 28th April 1998, Sydney, Australia.
  20. 20. Employment 42% of the severe to profound hearing loss populat ion, between the ages of 18- 44 years, in USA are not working . 90% 82% 80% 73% 70% 58% 60% 46% 50% 40% 30% 16% 20% 11% 2% 3% 10% 0% 18-44 yrs 45-64 yrs 65-79 yrs 80+ yrs Severely to Profoundly Hearing Impaired US Population Source: Project HOPE calculations from the 1990-91 National Health Survey
  21. 21. Quality of Life - Health Utility Index (HUI 3) 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 Source: Cheng et al, JAMA, 2000
  22. 22. Quality of Life The improvement in quality of life resulting from a medi cal intervention may be calculated using validated assessment tools such as the Health Utilities Index (HUI). The quality (utility) and quantity (life expectancy) of life are calcuated. (Perfect health) 1.0 0.48 No treatment Health Related Cochlear Quality of Life QALYs implant (Utility) 0.11 (Death) 0.0 Duration 63.0 (Years) (QALYs) = (Life Years x Health Utility)
  23. 23. Health utility scores HUI 3 Pre-implantation Score Post-implantation Score Attribute Mean (95% CI) Mean (95% CI) (n = 48) Hearing 0.75 0.82 0.07 (0.74 0.76) (0.8 0.83) Speech 0.80 0.92 0.12 (0.78 0.82) (0.90 0.93) Emotion 0.58 0.94 0.36 (-0.03 0.61) (0.93 0.96) Cognition 1.0 1.0 0 Ambulation 0.99 0.99 0 (0.98 1.0) (0.98 1.0) Vision 1.0 1.0 0 Pain 1.0 1.0 0 Dexterity 1.0 1.0 0
  24. 24. Estimate lifetime costs of implantation Variables No of Years Costs (USD) Direct Costs Preoperative Costs 1 2863 Operative Costs Cochlear Implant 1 19,153 Hospital and Surgery 4612 Post-operative costs Audiology Follow-up 1 73 5148 Rehabilitation follow-up 1- 2 8984 Device failure (if any) 1 73 1007 Loss or Damage insurance 1 73 4013 Special batteries 1 73 1293 Speech processor upgrades 4 - 73 5104 Subtotal (Direct costs) $ 60 228 Indirect Costs Time off Work 1 73 4623 Travel expenses 1 73 4830 Car parking expenses 1 73 589 Change in educational costs 1 73 - 65 558 Change in Future Earnings 11 - 73 - 55 574 Total (Direct + Indirect) $- 53 198 Source: Cheng et al, JAMA, August 16, 2000
  25. 25. Calculation of Cost Utility The cost utility is calculated as the incremental costs associated with the provision of cochlear implantation, divided by the i ncremental gain in Quality Adjusted Life Years (QALYs). Costs ($) Cost Utility = (QALYs) = Discounted Lifetime Costs ($) (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
  26. 26. A cost effecti ve treatment Due to the cascade of benefits resulting from oral communi cation the cost utility of paediatric and adult cochlear implantation compares favourabl y with many other common funded interventions. More cost effective Paediatric cochlear 5,197 implant 7,500 Source: Cheng et al, JAMA, August 16, 2000, *Wyatt JR et al, Laryngoscope 106: July, 1996 Neonatal intensive 7,968 care (1.0-1.5kg) 7,968* Adult cochlear 11,125 implant 11,125 Implanted 34,836 34,836 defibrillator Knee replacement 59,292 59,292 0 10,000 20,000 30,000 40,000 50,000 60,000 Less cost effective Cost per Quality Adjusted Life Year (QALY) in $US
  27. 27. Summary q An unmanaged hearing loss has significant impact on the devel opment 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 opti mised by age of implantation and good infrastructure q Cochlear implantation is a cost effective medical intervention.

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