Access and Attrition Across Audiology and Cochlear Implant Care Among Older Adults with Bilateral Sensorineural Hearing Loss
TL;DR
In this national cohort, disparities along the cochlear implant care pathway were associated less with audiologic access due to distance and more with attrition at cochlear implant candidacy assessment.
Abstract
Objective: To quantify progression through the hearing care pathway among US adults aged ≥65 years with bilateral sensorineural hearing loss (SNHL) and describe variation across geographic and community contexts. Study Design: Cross-sectional study. Setting: Epic Cosmos Database, January 1, 2021, through December 31, 2024. Patients: Adults aged ≥65 years with bilateral SNHL identified using International Classification of Diseases, Tenth Revision codes. Main Outcome(s) and Measure(s): Stage-specific unadjusted odds ratios with 95% confidence intervals were calculated for progression across audiology evaluation, cochlear implant evaluation, and cochlear implantation. Statistical significance was defined as P < 0.05, with P < 0.001 considered a strong signal given the large sample size. Results: Among 1,461,489 older adults with bilateral SNHL, 746,118 (51.1%) underwent audiology evaluation; fewer than 2% received cochlear implant candidacy evaluation, while approximately 64% of those evaluated for cochlear implantation proceeded to surgery. Marked stage-specific attrition was observed. Adults aged 85 years or older had lower odds of audiology access, higher odds of candidacy evaluation, and lower odds of cochlear implantation. Black and Asian patients had lower odds of candidacy evaluation. Women were less likely to undergo candidacy evaluation but more likely to receive implantation once evaluated for candidacy. Patients living farther from a cochlear implant center and those in rural areas had higher odds of both candidacy evaluation and cochlear implantation, a counterintuitive finding that likely reflects a selection effect among patients who overcome distance barriers rather than improved geographic access. Conclusions: In this national cohort, disparities along the cochlear implant care pathway were associated less with audiologic access due to distance and more with attrition at cochlear implant candidacy assessment. Candidacy referral and evaluation represent a critical, potentially modifiable bottleneck for improving equity in hearing care among older adults.