Relationship between proximity to a cochlear implant center and early presentation in children with congenital hearing loss.
The aim of this study is to determine whether among children with congenital SNHL, place of living and distance from a CI center influence the ages of presentation, diagnosis, hearing aid fitting, and discussion with CI committees. Secondary objectives include identification of the mean ages of suspicion of hearing loss, presentation to the hospital for audiological evaluation, hearing aid fitting, diagnosis, and discussion with CI committee, among the population in Saudi Arabia; moreover, this study aimed to study the delay before being fitted with hearing aids after establishing the diagnosis.
Methods. This cross-sectional retrospective study was performed in a tertiary hospital (King Abdullah Ear Specialist Center at King Abdulaziz University Hospital) in Riyadh, Saudi Arabia. The sample size in this study comprised 221 patients who presented to the CI committee at King Abdullah Ear Specialist Center for the first time during the period from March 2016 to March 2018 and fulfilled the following criteria. We included all pediatric patients with bilaterally severe to profound hearing loss who were prelingually deaf; we excluded any patient who was adult, who presented for the second ear, who had unilateral SNHL, who developed language pre-implant, or who had any psychological or neurological difficulties.
Using a custom-designed data collection sheet, we retrieved the following information through phone interviews with parents (or direct caregivers if parents were deceased) and patients' files: age at suspicion, age at audiology testing, age at diagnosis, age at hearing aid fitting, and age at CI discussion, as well as demographic information, place of residence, and distance from the nearest CI center. The data were stored as a hard copy, then entered in Excel sheet as a soft copy, then analyzed using IBM SPSS Statistics for Windows, version 22 (IBM Corp., Armonk, N.Y., USA). Patients were grouped as follows: Group 1 (those residing within 200 km of the CI center), Group 2 (those residing 200-500 km from the CI center), and Group 3 (those residing >500 km from the CI center). We selected 200 km as a threshold because patients' families residing within 200 km could reasonably drive to the CI center in one day.
All demographic data were analyzed using frequency with percentages. Groups were compared using mean, and groups' different means were compared using one-way analysis of variance (ANOVA) and post-hoc test.
Formal review and approval were received by institutional review board of King Saud University. Confidentiality was maintained. The research was fully explained to each patient's family, and verbal informed consent was obtained from them during the phone interview for all patients included in this analysis.
Results. A total of 221 patients met the inclusion criteria for this study: 99 currently resided within 200 km of the CI center, 33 resided 200-500 km from the nearest CI center, and 89 resided >500 km from the nearest CI center. Notably, 188 (85.1%) of the patients' fathers were working and served as the main provider for the family, and 160 (72.4%) of the patients' mothers were housewives without a job. Furthermore, 119 (54.8%) of the patients' fathers and 109 (49.5%) of the patients' mothers had a Bachelor's degree or higher for their level of education. A total of 64 (29%) patients were the first child in their families, 51 (23.1%) were the second, 33 (14.9%) were the third, 28 (12.7%) were the fourth, 16 (7.2%) were the fifth, and 29 (13.1%) were the sixth or higher. Additionally, 14 (6.5%) of patients had no siblings, 48 (22.1%) had only 1 sibling, 52 (24%) had 2 siblings, 32 (14.7%) had 3 siblings, 25 (11.5%) had 4 siblings, 15 (6.9%) had 5 siblings, and 31 (14.3%) had >6 siblings.
The mean ages at suspicion of hearing loss, presentation to the hospital for audiological evaluation, hearing aid fitting, diagnosis, and discussion with CI committee are shown in Figure 1. The mean ages for the different groups, based on their distance from the CI center, are shown in Table 1.
A comparison of the mean ages at each stage among the 3 groups, using one-way analysis of variance (ANOVA), showed no significant differences (p-values of age at suspicion, age at audiology testing, age at diagnosis, age at hearing aid fitting, and age at CI discussion are 0.792, 0.204, 0.214, 0.156, and 0.247 respectively). A subsequent post-hoc test also did not show any significant differences.
Discussion. Age at CI has been identified as an important predictor of language development outcomes in children with hearing loss. The location where the family's resides is a primary reason for delayed CI. (7) There is a proportional relationship between age at CI and distance to the CI center, as access to care is more limited for patients who live in rural areas than for those who live in urban areas. (8)
As demonstrated in Table 1, the mean ages at each stage are comparable among the 3 groups (p>0.05). This may be because of the availability of advanced hearing assessment tools in peripheral hospitals, rapid access for patients living in the periphery to the closest CI center, and full governmental support to patients who are following up with tertiary hospitals outside their cities (namely, through airfare for patients and caregivers).
Regarding the mean ages at each stage of the CI process, we found that our patients do not meet the 2007 recommendations of the Joint Committee on Infant Hearing (JCIH). (9) Notably, JCIH 2007 recommended that all infants are identified before the age of 3 months, and that early intervention (namely, hearing aids) should be initiated no later than 6 months of age. Therefore, initiatives are needed to increase general awareness of congenital hearing loss and the actions to take when it is suspected. Additionally, there is an unnecessary delay of approximately 5 months between confirmation of the diagnosis and fitting for hearing aids. The availability of hearing aids and facilities for fitting and servicing them is crucial to ensure early intervention for all children in both urban and rural areas.
Other factors that might have played a role in these findings are: the availability and abundance of flights from and to large cities in Saudi Arabia, the fact that familial awareness about hearing loss and its management is not affected by proximity to referral care centers (which might be secondary to the widespread of social networks), and the availability of appointments coordinators who help to make the visits of those coming from another city more convenient and productive by optimizing their schedule.
Study limitations. Mode of transportation was not taken into consideration; whether patients are coming to the CI center by car, train, or airplane. Although all patients with hearing loss have access to CI centers; other limitations are number of visits before being presented to the CI committee and how long did it take to be accepted after presentation, which were not taken into consideration as well.
In conclusion, in Saudi Arabia, the distance from residence to the nearest CI centers does not significantly impact the age of presentation to the hospital for hearing assessment. We encourage increased governmental logistic support for patients traveling to CI centers, as this may enable them to achieve comparable ages to their peers who reside near CI centers.
Acknowledgment. We would like to thank Editage for their efforts in English language editing.
Disclosure. Authors have no conflict of interests, and the work was not supported or funded by any drug company.
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Yazeed A. Al-Shawi, MD, Fahad K. Alrawaf, MD, Najd S. Al-Gazlan, MD, Munahi M. Al-Qahtani, MD, Fida A. Almuhawas, MD, SB-ORL.
Received 20th August 2019. Accepted 6th January 2020.
From the Department of Otolaryngology and Head and Neck Surgery, King Abdullah Ear Specialist Center, King Saud University, Riyadh, Kingdom of Saudi Arabia.
Address correspondence and reprints request to: Dr. Fida A. Almuhawas, Consultant, Department of Otolaryngology and Head and Neck Surgery, King Abdullah Ear Specialist Center, King Saud University, Riyadh, Kingdom of Saudi Arabia. E-mail: Fmuhawas@ksu.edu.sa ORCID ID: https://orcid.org/0000-0002-3354-8756
Caption: Figure 1--Mean ages at presentation of patients for each stage of the cochlear implant process. HA-hearing aid
Table 1--Mean ages of presentation for different location groups (based on distance from cochlear implant center). Std. Std. Mean ages of presentation N Mean Deviation Error Age at suspicion by months Residing within 200 km 99 13.19 11.014 1.107 Residing 200-500 km away 33 15.06 12.796 2.228 Residing >500 km away 89 13.93 16.848 1.786 Total 221 13.77 13.849 0.932 Residing within 200 km Residing 200-500 km away 99 16.82 12.718 1.278 Residing >500 km away 33 22.61 19.190 3.341 Total 89 19.49 19.710 2.089 Total 221 18.76 16.886 1.136 Age at diagnosis by months Residing within 200 km 99 18.29 13.692 1.376 Residing 200-500 km away 33 24.18 20.229 3.521 Residing >500 km away 89 21.12 20.137 2.135 Total 221 20.31 17.595 1.184 Age at HA fitting by months Residing within 200 km 99 23.24 14.481 1.455 Residing 200-500 km away 33 29.52 21.902 3.813 Residing >500 km away 89 27.34 21.422 2.271 Total 221 25.83 18.781 1.263 Age at cochlear implant committee by months Residing within 200 km 97 32.10 25.042 2.543 Residing 200-500 km away 31 40.16 26.431 4.747 Residing >500 km away 87 37.08 28.398 3.045 Total 215 35.28 26.696 1.821 HA--hearing aid
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|Title Annotation:||Brief Communication|
|Author:||Al-Shawi, Yazeed A.; Alrawaf, Fahad K.; Al-Gazlan, Najd S.; Al-Qahtani, Munahi M.; Almuhawas, Fida A|
|Publication:||Saudi Medical Journal|
|Date:||Mar 1, 2020|
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