title: Improving adult CI referral in the UK
Creators: name: Cullington, Helen
Publisher: name: University of Southampton
Year: 2022

description: Aim<br>The uptake of cochlear implants (CI) among adults in the UK is low[1, 2], despite well-documented social and economic benefits[1, 3]. Why is this? Where is the block?<br><br>The transition from hearing aids to CI represents a continuum of care for adults with severe to profound hearing loss[1, 4]. This relies on an appropriate referral - usually from Audiologists -who may have only limited training, knowledge and confidence in CI as a rehabilitation option[5]. CI referral patterns across services in the UK are unknown but the literature suggests referral is limited by a number of patient and professional factors[5].<br><br>We aim to use a joined-up approach to understand, improve and increase adult CI referral: enabling local Audiologists to audit their clinic's referral rate, and encouraging cochlear implant teams to analyse and share their incoming referral data.<br><br>Method<br>Audiology sites:<br><br>An AuditBase Crystal Report (BCIG CI Referral Report) developed by Auditdata and CochlearÂ®, with input from the pilot sites, was run between 1 July 2019 and 1 January 2020 at four audiology sites, and between 1 September and 30 November 2019 at one site. Three sites also had a cochlear implant centre in their hospital; two did not. The report identified all adults who were audiometrically suitable for a cochlear implant. These cases were then retrospectively categorised by the clinic staff. Our main measure was whether there was documentation to show that cochlear implant referral had been discussed.<br><br>Cochlear implant centre:<br><br>We analysed one year of referral data (2021) at one cochlear implant centre â examining referral trends, location of referral clinic and outcome of referral.<br><br>Results<br>Audiology sites:<br><br>790 adults who had done an audiogram in the time period met the NICE audiometric criteria. There was much variation in referral between sites. In 50 to 78% of cases, there was documentation to show that CI referral was considered. CI referral was declined by the patient in 16 to 45% of cases, depending on site. Older patients were less likely to be considered for CI referral, but were equally likely to accept referral after discussion.<br><br>Cochlear implant centre:<br><br>Adult referral patterns are beginning to reach pre-Covid levels; 210 adult referrals were received in 2021. Excluding those awaiting assessment completion, the conversion rate (those that continued to cochlear implant surgery) was 29%. 18% of referrals were unsuitable and a further quarter (26%) of patients declined a full CI assessment.<br><br>Conclusion<br>There are variable patterns of CI referral between services. Up to half the adults with severe to profound hearing loss did not have a documented discussion about CI referral with their local Audiologist. Less than a quarter of the adults referred to the CI centre had CI surgery. The audit enabled the audiology sites to take significant steps to improve their CI referral rates.<br><br>We will continue with a joined-up referral improvement approach. The BCIG CI Referral Report is freely available. The BAA/BCIG CI Champions scheme and the manufacturer engagement teams continue to help empower Audiologists to feel confident to talk about CI. Sharing learning from CI centre referral data enables education to improve referral quality.<br><br>Despite extensive post-Covid waiting lists for adults in some clinics, we need to continue to encourage equitable access, informed choice and shared decision making to all adults who meet criteria.<br><br>References<br>1. Buchman, C.A., et al., Unilateral Cochlear Implants for Severe, Profound, or Moderate Sloping to Profound Bilateral Sensorineural Hearing Loss: A Systematic Review and Consensus Statements. JAMA Otolaryngol Head Neck Surg, 2020.<br><br>2. Raine, C., et al., Access to cochlear implants: Time to reflect. Cochlear Implants Int, 2016. 17 Suppl 1: p. 42-6.<br><br>3. The Ear Foundation, The Real Cost of Adult Hearing Loss: reducing its impact by increasing access to the latest hearing technologies. 2014, The Ear Foundation,.<br><br>4. Turton, L., et al., Guidelines for Best Practice in the Audiological Management of Adults with Severe and Profound Hearing Loss. Semin Hear, 2020. 41(3): p. 141-246.<br><br>5. Bierbaum, M., et al., Barriers and Facilitators to Cochlear Implant Uptake in Australia and the United Kingdom. Ear Hear, 2020. 41(2): p. 374-385.