Objectives: The objectives of this study were to identify variables which are associated with differences in outcome among hearing-impaired children, and to control those variables while assessing the impact of cochlear implantation. Study design:In a cross-sectional study, the parents and teachers of a representative sample of hearing-impaired children were invited to complete questionnaires about children's auditory performance, spoken communication skills, educational achievements, and quality of life. Multiple regression was used to measure the strength of association between these outcomes and variables related to the child (average hearing level, age at onset of hearing impairment, age, gender, number of additional disabilities), the family (parental occupational skill level, ethnicity, and parental hearing status), and cochlear implantation.Results: Questionnaires were returned by the parents of 2858 children, 468 of whom had received a cochlear implant, and by the teachers of 2241 children, 383 of whom had received an implant. Across all domains, reported outcomes were better for children with fewer disabilities in addition to impaired hearing. Across most domains, reported outcomes were better for children who were older, female, with a more favourable average hearing level, with a higher parental occupational skill level, and with an onset of hearing-impairment after 3 years. When these variables were controlled, cochlear implantation was consistently associated with advantages in auditory performance and spoken communication skills, but less consistently associated with advantages in educational achievements and quality of life.Significant associations were found most commonly for children who were younger than 5 years when implanted, and had used implants for more than 4 years. TheseHearing-impaired children in the UK, I. 2 children, whose mean (pre-operative, un-aided) average hearing level was 118 dB, performed at the same level as non-implanted children with average hearing levels in the range from 80 dB to 104 dB, depending on the outcome measure. Conclusion:When rigorous statistical control is exercised in comparing implanted and non-implanted children, paediatric cochlear implantation is associated with reported improvements both in spoken communication skills and in some aspects of educational achievements and quality of life, provided that children receive implants before 5 years of age.(342 words)

Objective: To estimate the cost-effectiveness of pediatric cochlear implantation by conducting a costutility analysis from a societal perspective. Design:In a cross-sectional survey, the parents of a representative sample of hearing-impaired children assessed the health utility of their child using a revised version of the Health Utilities Index Mark III questionnaire. Linear regression was used to estimate the gain in health utility associated with implantation while controlling for eight potentially confounding variables: average (4-frequency, unaided, preoperative) hearing level (AHL), age at onset of hearing-impairment, age, gender, number of additional disabilities, parental occupational skill level, ethnicity, and parental hearing status. The gain in health utility was accumulated to estimate the number of quality-adjusted life years (QALYs) that would be gained from implantation over 15 yr and over a child's lifetime. The incremental societal cost of implantation, calculated in euros (€) at 2001/2 levels, was estimated by summing the incremental costs of implantation that are incurred in the health sector, in the education sector, and by the child's family. The cost-effectiveness of cochlear implantation was estimated by calculating the incremental societal cost per QALY gained and was compared with an upper limit of acceptability of €50,000 per QALY. Results:The parents of 403 implanted children, and 1863 nonimplanted children, completed the health utility questionnaire. Higher health utility was associated with a more favorable AHL, an older age at onset of hearing impairment, female gender, having fewer additional disabilities, having parents with a greater occupational skill level, white ethnicity, and implantation. The gain in health utility associated with implantation was estimated to be higher for children with a worse preoperative AHL and who were implanted when younger. Over 15 yr, for a child implanted at age 6 with a preoperative loss of 115 dB, 2.23 QALYs were estimated to be gained, compared with a mean incremental societal cost of €57,359, yielding a mean cost per QALY of €25,629.Cost-effectiveness was more favorable: (1) when estimated over a child's lifetime rather than 15 yr, (2) for children with a worse preoperative AHL, and (3) for children who were implanted when younger. Conclusions:The mean cost of gaining a QALY for the children in the present sample falls within acceptable limits. The strategy of giving highest priority for implantation to children with the greatest loss of hearing, and who are younger, maximizes benefit for a given cost.