Trends in sociodemographic disparities of pediatric cochlear implantation over a 15-year period

Accepted Manuscript Trends in Sociodemographic Disparities of Pediatric Cochlear Implantation over a 15Year Period Alex J.F. Tampio, Ronald J. Schroeder, Dongliang Wang, John Boyle, Brian D. Nicholas PII:

S0165-5876(18)30506-8

DOI:

10.1016/j.ijporl.2018.10.003

Reference:

PEDOT 9205

To appear in:

International Journal of Pediatric Otorhinolaryngology

Received Date: 9 July 2018 Revised Date:

1 October 2018

Accepted Date: 1 October 2018

Please cite this article as: A.J.F. Tampio, R.J. Schroeder, D. Wang, J. Boyle, B.D. Nicholas, Trends in Sociodemographic Disparities of Pediatric Cochlear Implantation over a 15-Year Period, International Journal of Pediatric Otorhinolaryngology (2018), doi: https://doi.org/10.1016/j.ijporl.2018.10.003. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.

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Trends in Sociodemographic Disparities of Pediatric Cochlear Implantation over a 15-Year Period

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Alex J. F. Tampio, MD, Ronald J. Schroeder, MD, Dongliang Wang, PhD, John Boyle, MD, Brian D. Nicholas MD Affiliation: SUNY Upstate Medical University, Syracuse, New York

Address Correspondence to: Alex J. F. Tampio, Department of Otolaryngology, SUNY Upstate Medical University, 750 East Adams Street Campus West Building Room 241, Syracuse, NY, 13210, [email protected], Phone: 801-690-9034, Fax: 315-464-7282

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Financial disclosure: The authors have no financial disclosures to report. Funding source: None

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Conflicts of interest: The authors have no conflicts of interest to report.

Abbreviations: Cochlear Implant (CI), Sensorineural Hearing Loss (SNHL), Kids’ Inpatient Database (KID), Healthcare Cost and Utilization Project (HCUP), Socioeconomic Status (SES), Gallaudet Research Institute (GRI), National Health Interview Survey (NHIS)

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Keywords: Pediatric; cochlear Implant; socioeconomic; income; race

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Abstract

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Objective: Sociodemographic disparities of cochlear implantation in children have been reported. This study sought to determine if disparities in children receiving cochlear implants have narrowed, widened or remained constant. Methods: Children 18 years or younger who underwent cochlear implantation from 1997-2012 were selected using the Kids’ Inpatient Database. Demographic data included primary insurance payer, income quartile and race. The Cochran-Armitage test was used to determine if trends were significant. Prevalence rates of cochlear implantation by race were generated. A Poisson regression model was used to evaluate the rates of cochlear implantation within each racial group. Results: The proportion of children receiving cochlear implants with private insurance decreased from 79.3% to 42.6% (p < .0001), whereas children with Medicaid increased from 17.4% to 35.2% (p < .0001). Proportion of implanted children from the lowest two income quartiles increased from 15.5% to 24.4% (p < .0001) and 10.3% to 21.8% (p < .0035), respectively. Rates of implantation among children from income quartile four decreased from 50.9% to 35.3% (p < .0001). White children were implanted twice as often as Black or Hispanic children (p = 0.007 and p = 0.0012 respectively). Asian children were implanted more than twice as often as Black or Hispanic Children (p = .0154 and p = .0098 respectively). Conclusions: Income and insurance disparities have narrowed within the inpatient pediatric cochlear implantation cohort. Racial disparities still exist. White and Asian children are implanted at higher rates than Black or Hispanic children.

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1. Introduction: Cochlear Implants (CI) have revolutionized the treatment of severe to profound sensorineural hearing loss (SNHL), especially in children. CIs provide an opportunity for

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prelingually deaf children to acquire speech and language as well as for postlingually deaf

children to regain lost hearing. When implanted early, prelingually deafened children with CIs achieve language and reading skills similar to that of children with normal hearing [1,2].

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Unfortunately, access to CI has not been universal. Disparities in the rates of cochlear implantation in children have been reported with regard to race, socioeconomic status (SES), and

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insurance type [3-8], though few studies have been within the last decade. What remains unknown is what progress, if any, has been made in narrowing these disparities. The Kids' Inpatient Database (KID) is a nationwide sample of pediatric inpatient discharges developed for the Healthcare Cost and Utilization Project (HCUP) using billing

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data. It was developed to analyze national trends over time. Reports are generated every 3 years starting in 1997. Roughly 3 million pediatric discharges are available for analysis with each report that, when weighted, estimate about 7 million pediatric discharges [9]. The KID has been

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used previously to evaluate trends in complications, outcomes, and patient demographics, however, there are no studies that evaluate trends in demographics of cochlear implantation over

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time [7, 10-15].

Our objective is to compare the trends of sociodemographic disparities in pediatric CI

from 1997-2012 using the KID. We aim to determine if the demographic disparities of children receiving CIs have changed with regard to race, SES, and/or primary payer.

2. Methods:

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Analyses of pediatric cochlear implantation were made using the KID. Data from 19972012 were available for evaluation which represent 6 datasets since reports are generated in 3year intervals. Details such as the number of states, number of hospitals, and total population for

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each dataset are summarized in Appendix A. SPSS Version 22 was used for data analysis. This study was reviewed by The State University of New York Upstate Institutional Review Board (IRB) and was deemed this exempt from IRB review.

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Children 18 years or younger were selected using cochlear implantation ICD-9-CM codes (2096, 2097, 2098) for the principal procedure. The total number of children who received CIs within

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each dataset was cross checked with the HCUP estimate calculator (https://hcupnetarchive.ahrq.gov/) and found to be consistent. Three variables were evaluated among all datasets: race, median household income by zip code, and primary payer. The KID categorizes race as “White, Black, Hispanic, Asian/Pacific Islander, Native American and Other” which were used

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throughout the analysis. The category “Other,” which accounted for a variable number of statedependent payers (Children’s Health Insurance Plan, Indian Health Services, and County Indigent Programs, among others) was not included in the figures for the purposes of simplicity.

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The category “Native American” was also excluded from the figures for simplicity, as there were only four out of 1,322 patients who fit this demographic. The variables for each of the six

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datasets were standardized and weighted. Missing values were not included in analysis, mainly because aggregate yearly data were used for analysis instead of data from individuals. The Cochran-Armitage statistical test was used to analyze the significance of trends of subcategories. Incidence rates of pediatric cochlear implantation per 1000 children with severe to

profound SNHL were calculated using a combination of the KID data, Gallaudet Research Institute (GRI) data, United States (U.S.) Census data, and data from the literature on prevalence

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of severe profound SNHL in children. First, U.S. Census data was used to determine the total number of children in the U.S. for each year [16]. Prior studies have estimated that the rate of severe to profound SNHL in children is 4-11/10000 [17, 18]. We utilized the lower estimate of

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0.04% as this estimate was consistent across sources and calculated the absolute number of U.S. children estimated to have severe to profound SNHL. To determine the racial breakdown of hearing loss and account for population demographic changes over the study period, data from

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the GRI was utilized. The GRI collects data from public and private schools, as well as from programs that provide services for deaf/hard of hearing children. This survey collects

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information on about 40,000 deaf/hard of hearing children yearly and stratifies them by race [19]. Rates of hearing loss by race provided by the GRI were then applied to the absolute number of U.S. children with severe to profound SNHL for each study year. With the calculated numbers of U.S. children with severe to profound SNHL for each racial group, we then applied the KID

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data of CI recipients to determine the incidence of implantation per 1000 children with severe to profound SNHL. Using this method, the rates of cochlear implantation among the various racial groups were normalized to both the changing racial demographics within the U.S. over the

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studied time frame as well slight racial differences in rates of severe to profound hearing loss. A Poisson regression model was used to evaluate the overall trend of calculated incidence rates

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over time and between races. Data from 2000-2009 were compared. 1997 was excluded as there was no GRI data for this year. 2012 was excluded given the fact that 25% of patients in this year did not report race and this represented a clear outlier.

3. Results:

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The demographics of all patients within their respective dataset are summarized in Table 1. The age distribution of the total cohort demonstrated that most children were implanted within the first four years of life. The mean age was 4.69 years (median 3 years; mode 2 years).

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Standard Deviation was 4.26. The raw data for primary payer, income quartile, and race are summarized in Appendix B.

Figure 1 shows the trends of primary payer over 15 years. The proportion of children

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receiving CIs with private insurance decreased from 79.3% in 1997 to 42.6% 2012 (p < .0001), whereas children implanted with Medicaid as primary payer increased from 17.4% in 1997 to

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35.2% in 2012 (p < .0001).

To analyze the proportion of implanted children in various household income levels, the cohort was broken down by income quartiles, wherein those with the lowest incomes were represented by quartile one and those with highest incomes in quartile four. A summary of

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ranges for each income quartile within each dataset is summarized in Table 2. Figure 2 shows the trends of household income disparities among pediatric CI recipients over 15 years. Within the implanted cohort, children in the income quartiles one and two increased from 15.5% to

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24.4% (p < .0001) and 10.3% to 21.8% (p < .0035) respectively. Children from the highestincome quartile decreased from 50.9% to 35.3% (p < .0001).

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Figure 3 shows the trends of race over 15 years. Implantation of Hispanic children within

the cohort increased 10.1% to 23.6% (p < .0234) whereas implantation of White children decreased from 73.4% to 35.5% (p < .0001). There were no significant changes in the percentages of Black or Asian/Pacific Islander children. The prevalence rates of implantation by race are summarized in Figure 4. Table 3 summarizes the results from the Poisson regression model. White children were implanted about

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twice as often as Black or Hispanic children and this difference was found to be statistically different (p = 0.007 and p = 0.0012 respectively). Asian/Pacific Islander children were implanted just more than twice as often as Black or Hispanic children (p = .0154 and p = .0098). There

between Black and Hispanic children (p = 0.95). 4. Discussion:

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were no significant differences between White and Asian/Pacific Islander children (p = 0.45) or

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CIs have been essential in providing young children with severe to profound SNHL an opportunity for hearing and development of spoken language. There are, however, barriers that

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exist that may delay or prevent implantation in children who are otherwise excellent audiometric candidates. Barriers such as race, SES, insurance, parental delays, slow referrals, single parent households, and language barriers have been described in the literature [3-8.] While these studies show statistically significant barriers to CI at different points in time, no study yet has yet to

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evaluate how these disparities may have changed over time. This information may help determine whether access to this important technology is broadening or may highlight disparities that may yet be improved upon. Among the barriers to CIs in the literature, the KID provided

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three categories that were used in our analysis: insurance status, race, and income quartile using Zip code as a proxy.

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Perhaps the most widely cited barrier of CI is the discrepancy of implantation among

private insurance and Medicaid [3-6]. Our study found that the proportion of children receiving CI’s with private insurance has decreased while the children with Medicaid increased over fifteen years. Although the majority of children in 2012 who underwent cochlear implantation still had private insurance, the gap between these two groups has narrowed considerably. Importantly, these trends mirror those found in the National Health Interview Survey (NHIS)

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regarding primary payer in all children aged 0-17. That survey shows that the proportion of children with private insurance has gone from about 66% in 1997 to 56.3 in 2015 and the proportion of children with public insurance has gone from about 21% in 1997 to 40.4% in 2015

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[20].

Aside from more children being covered by public rather than private insurance, there are other factors that may be contributing to the trend in primary payer seen in this study. For

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instance, Medicaid reimbursement for CI has been shown to vary between states [8, 21-22]. Chang et al. showed that in a state with adequate reimbursement (defined as coverage that

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adequately covers the hospital costs of implant purchase and implantation), there was no statistical difference in the odds of unilateral CI between children with Medicaid and children with private insurance [23]. During our study period, the number of states included in the KID increased from 22 in 1997 to 44 in 2012. The change in proportion of children with Medicaid

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receiving CIs may be due to the inclusion of more states with better Medicaid reimbursement, states opting for more favorable Medicaid reimbursement, or both. Additionally, one must take into consideration the Affordable Care Act and associated Medicaid expansion. The Affordable

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Care Act was signed into law in 2010 and largely took effect in 2014 [24]. Only six states (CA, CT, DC, MN, NJ, WA) expanded Medicaid early from 2010-2012, all of which were included in

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the KID [25]. California, the most populous state, accounted for about 12% of the U.S. population in 2010. The expansion of Medicaid in this state may be partly responsible for the narrowed discrepancy among insurance types in the 2012 data [26]. Another known barrier to CI is SES. Literature has previously shown that children from

families of high SES are more likely to get a CI [6, 7], despite a lower prevalence of hearing loss than the prevalence among children from families of lower household income [27]. ZIP code has

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been shown to be an adequate, though not perfect, proxy for SES [28, 29]. One of the variables the KID provides is income quartile inferred by the average income of the ZIP code of the patient's home address. Our study showed that the proportion of children receiving cochlear

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implantation in the lowest-income quartiles increased while the proportion of children from the highest-income quartile decreased over fifteen years. Presumably, the reason for lower rates of implantation in children with lower SES is the inability to afford such a costly procedure, a cost

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which insurance can help offset. Other financial factors, such as cost of travel, childcare and need to miss time from work may also serve as barriers to care. Medicaid status is, in part,

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determined by income eligibility requirements. The upward trend in the lower two quartiles parallels that of the upward trend of implantation in children with Medicaid. The increasing percentage of children covered by Medicaid may be one reason for a significant increase in the proportion of children receiving CI in the lower quartiles.

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While many studies have evaluated discrepancies of cochlear implantation regarding insurance type and SES, discrepancies regarding race are limited. Stern et al. found White and Asian children were implanted at higher rates than Black and Hispanic children in 1997 [7].

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Huang et al. reported that in 2011 children there was a significant discrepancy in percent of Black and Hispanic children receiving CIs by race compared to the percent of population by race

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in Maryland and New York State [8]. Our data show that the implantation of Hispanic children increased over the fifteen-year

period. It is important to consider the fact that the Hispanic population has steadily increased within the U.S. over the study period. According to the U.S. Census Bureau in 2000 the percentage of the U.S. population that was Hispanic was 12.5% while in 2010 it was 16.3% [30]. The percentage of implanted children of Hispanic children increased from 14.5% in 2000 to

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17.3% in 2009. In this way, it appears that the rising percentage of Hispanics receiving CI in the U.S. is correlated with the rising population of Hispanics in the U.S. There were no significant changes in the percentages of Black or Asian/Pacific Islander

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children from 1997 to 2012. According to U.S. Census Bureau data, the percentage of the

population that is Black or Asian/Pacific Islander has remained roughly the same from 2000 to 2010 (12.3% to 12.6% and 3.6% to 4.8% respectively) [30].

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Looking at the KID data, it is unclear whether these racial trends in implantation are a result of changes in rate of implantation or simply a function of changing population

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demographics. Additionally, the prevalence of hearing loss is not uniform among races as studies have shown that rates of hearing loss in Black and Hispanic children in the U.S. are higher than that of White children [27, 31]. To account for these potential confounding variables, we calculated prevalence rates of cochlear implantation by race as described previously [9, 16-19].

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Prevalence rates allow direct comparison of implantation between races by taking into consideration changes in population and racial rates of hearing loss. These calculated rates are relative and intended to compare implantation between races and not to suggest absolute rate of

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implantation. Figure 4 shows a discrepancy in implantation rates that appears to have been maintained over time. White and Asian/Pacific Islander children appear to have higher

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implantation rates than that of Black or Hispanic children. Moreover, there appear to be no significant changes in the general rates of implantation overtime. In a similar study, Stern et al. also found in 1997 that the implantation rates of White and Asian children were significantly higher than that of Black or Hispanic children [7]. This suggests that the above-mentioned discrepancy of cochlear implantation among races has persisted from 1997 to 2009.

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When reviewing the KID data, the number of children who received a CI in each dataset ranged between 200 and 300. These figures were confirmed using HCUP’s online estimate calculator and are similar to values published in other studies (7, 32). This is in contrast to other

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studies which estimate a higher number of cochlear implants in a given year. For example,

Bradham et al. estimated that there were 7,048 children who received a CI between the ages of 1 and 6 years old, which assumed a profound deafness incidence of 0.06% (33). There are two

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reasons for this. First, the KID is a nationwide sample of all pediatric inpatient discharges and does not report all pediatric inpatient discharges. The number of pediatric discharges between

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1997 and 2012 is roughly the same within each dataset (6-7 million children), which shows consistency in sampling between datasets despite an increasing sample population. Second, the KID represents only the inpatient cohort of children who receive a CI. The demographics of the inpatient cohort of children who receive a CI in the U.S. is not

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entirely identical to that of the outpatient cohort. A study by Patel et al. evaluated the differences between the outpatient and inpatient cochlear implantation cohorts. They found that nearly one fifth (17.2%) of all children who received CIs were admitted after their procedure. Interestingly,

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the percentages of White, Black and Asian races were similar between groups. Within the inpatient group, 42% had no comorbidities. The other 58% had a variety of medical comorbidies

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(history of either premature birth (<32 weeks), asthma, esophageal/gastric/intestinal disease, elevated cardiac risk, seizure disorders, structural central nervous system (CNS) abnormalities, and/or a prolonged total anesthesia/operation time). A logistic regression analysis showed that strong predictors for admission were a history of asthma or structural CNS abnormalities, while younger age and longer operative time were noted to be weak predictors for admission. Taken together, while the demographics of sex and race are comparable, the inpatient group represents

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a younger cohort where roughly 60% of children have a significant past medical history and/or prolonged procedure times (31). Over the past few decades, cochlear implantation in the United States has become

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increasingly more of an outpatient procedure. This in contrast to some European countries such as Germany where the standard is to admit patients undergoing cochlear implantation with an average 4-day hospital stay (33). It is interesting to note that when comparing cochlear

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implantation in the U.S. to Germany there were no major differences in complication rates or audiometric outcomes. Despite the fact that children in the U.S. typically spent three fewer days

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in the hospital, the total cost for children receiving a CI in the U.S. was roughly $40,000 more than that of Germany (33).

Outside the U.S., there are no studies that evaluate the presence or absence of socioeconomic disparities among children who receive a CI. The disparities among income

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quartile groups within the U.S. have narrowed, which may be a result of Medicaid becoming a more prominent payer. It would be interesting to see if this effect is mirrored in countries with more universal and publicly funded healthcare. Unfortunately, there remain racial disparities in

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the U.S. among children who receive a CI. While there are no studies from other countries discussing the racial disparities of pediatric CIs, there is literature that suggests racial disparities

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exist elsewhere in the world. One study of 31 European countries showed that ethnic minorities were disadvantaged in the health care process (35). Another study that evaluated 36 European countries from 2006 to 2012 found that Black and Asian patients were less likely to receive a kidney transplant after adjusting for primary renal disease (36). It is possible and perhaps likely that racial disparities of pediatric cochlear implantation exist in other countries. An understanding of the disparities among CI recipients is necessary in order to implement changes

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that improve access to this technology. As such, this may represent an area of opportunity for future research. It is important to address the limitations of this study. The number of states from which

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each of the six datasets from the KID is not uniform. Subsequent years include a different number of states. This may under represent some groups while over representing others especially in the early datasets.

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Regarding calculation of prevalence rates of cochlear implantation, differences in rates of hearing loss between races are taken into consideration. The breakdown in severity in SNHL

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among various racial groups is less clear. For example, the rates of severe to profound SNHL may be greater in one race than that of other races accounting for a higher rate of implantation. Unfortunately, neither the GRI data nor the published population studies reports degrees of SNHL by race. Additionally, incidence of all children with severe-profound hearing loss was

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assumed to be the same each year (0.04%) although one source reports the incidence of severeprofound hearing loss in a range (4-11/10,000) [18]. Though the prevalence of severe-profound hearing loss was estimated using studies that took almost ten years of data into consideration

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[17-18], it remains possible that the prevalence could vary slightly year to year. This study also only looks at the inpatient CI cohort in which the literature has

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historically been limited. Though roughly 42% of inpatients are generally healthy without comorbidities, the majority of the inpatient CI cohort represents children with other comorbidities (32). As such, the findings of this study may not be completely generalizable to the outpatient CI cohort.

Though this study has its limitations, this study has several strengths. The KID is a powerful database offering a sample of almost 7 million pediatric discharges per dataset from all

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over the country over a fifteen-year period in ways that regional surveys could not. The use of billing data allows for more objective account of variables. Each dataset in the KID is also a randomized sample of all pediatric discharges which helps reduce bias.

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This is the first study of its kind to report pediatric cochlear implantation trends. Other studies have only reported disparities within a single year [7, 8] while this study analyzed at 15year timeframe. This study also calculates implantation rates for each race and gives an update of

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the racial disparities of cochlear implantation that still exist from what was described previously [7]. The persistence of such racial disparities well as the narrowing disparities of primary payer

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and income quartile may be helpful in directing future efforts and allocation of resources in broadening access to cochlear implantation. 5. Conclusions:

This study suggests that the socioeconomic and insurance disparities of children

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receiving CIs have narrowed since 1997. It appears, however, that racial disparities among CI recipients still exist where White and Asian children are implanted at statistically significantly

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higher rates than that of Black or Hispanic children.

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34. Teschner M, Polite C, Lenarz T, Lustig L. Cochlear implantation in different health-care systems: disparities between Germany and the United States. Otol Neurotol. 2013 Jan;34(1):66-74.

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35. Hanssens LG, Detollenaere J, Hardyns W, Willems SJ. Access, treatment and outcomes of care: a study of ethnic minorities in Europe. Int J Public Health. 2016 May;61(4):44354.

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36. Tjaden LA, Noordzij M, van Stralen KJ, Kuehni CE, Raes A, Cornelissen EA, O'Brien C, Papachristou F, Schaefer F, Groothoff JW, Jager KJ; ESPN/ERA-EDTA Registry Study

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Group. Racial Disparities in Access to and Outcomes of Kidney Transplantation in Children, Adolescents, and Young Adults: Results From the ESPN/ERA-EDTA (European Society of Pediatric Nephrology/European Renal Association-European Dialysis and Transplant Association) Registry. Am J Kidney Dis. 2016 Feb;67(2):293-

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EP

TE D

301.

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Table 1: Demographics

1997

2000

2003

2006

0 (0)

3 (0.9)

27 (8.8)

21 (5.6)

12--23

21 (8.2)

51 (16.3)

64 (20.8)

64 (17.0)

24-35

53 (20.7)

53 (17.0)

62 (20.1)

36-47

56 (22.3)

47 (15.1)

48-59

26 (10.2)

60-71

58 (22.8)

49 (28.3)

307 (18.3)

80 (21.2)

55 (21.7)

39 (22.5)

342 (20.4)

19 (6.2)

27 (7.2)

23 (9.1)

18 (10.4)

190 (11.3)

24 (7.7)

17 (5.5)

36 (9.5)

12 (4.7)

13 (7.5)

128 (7.6)

30 (11.7)

26 (8.4)

18 (5.8)

31 (8.2)

7 (2.6)

6 (3.5)

118 (7.0)

72-83

15 (5.9)

8 (2.6)

9 (2.9)

17 (4.5)

12 (4.7)

3 (1.7)

64 (3.8)

84-95

9 (3.5)

23 (7.4)

15 (4.9)

19 (5.0)

21 (8.3)

6 (3.5)

93 (5.5)

96-107

8 (3.1)

10 (3.2)

13 (4.2)

10 (2.7)

4 (1.6)

4 (2.3)

49 (2.9)

108-119

8 (3.1)

20 (6.4)

17 (5.5)

12 (3.2)

120-131

4 (1.6)

3 (0.9)

10 (3.2)

15 (4.0)

132-143

5 (2.0)

10 (3.2)

3 (1.0)

5 (1.3)

144-155

1 (0.4)

12 (3.9)

156-167

14 (5.5)

6 (1.9)

168-179

0 (0)

9 (2.9)

180-191

4 (1.6)

0 (0)

192-203

0 (0)

4 (1.3)

204-215

0 (0)

1 (0.3)

216-216

1 (0.4)

1 (0.3)

0 (0)

60 (3.6)

9 (3.5)

0 (0)

41 (2.4)

5 (2.0)

3 (1.7)

31 (1.9)

4 (1.3)

8 (2.1)

5 (2.0)

6 (4.5)

36 (2.1)

5 (1.6)

5 (1.3)

5 (2.0)

0 (0)

35 (2.1)

3 (1.0)

4 (1.1)

7 (2.8)

0 (0)

23 (1.4)

14 (4.5)

7 (1.9)

3 (1.2)

6 (3.5)

34 (2.0)

3 (1.0)

5 (1.3)

4 (1.6)

3 (1.7)

19 (1.1)

2 (0.6)

3 (0.8)

4 (1.6)

0 (0)

10 (0.6)

3 (1.0)

8 (2.1)

2 (0.8)

3 (1.7)

18 (1.1)

308

TE D

311

377

254

173

1678

157 (61.6)

176 (56.6)

114 (38.4)

168 (44.8)

147 (58.8)

99 (57.9)

861 (51.9)

Female

98 (38.4)

135 (43.4)

183 (61.6)

207 (55.2)

103 (41.2)

72 (42.1)

798 (48.1)

White

311

EP

255

297

375

250

171

1659

159 (73.3)

123 (55.7)

121 (60.2)

196 (62.0)

124 (58.2)

55 (35.7)

778 (58.9)

8 (3.7)

20 (9.1)

13 (6.5)

39 (12.3)

17 (8.0)

17 (11.0)

114 (8.6)

Hispanic Asian or Pacific Islander

19 (8.8)

29 (13.1)

40 (19.9)

43 (13.6)

37 (17.4)

37 (24.0)

205 (15.5)

16 (7.4)

18 (8.1)

7 (3.5)

11 (3.5)

20 (9.4)

11 (7.1)

83 (6.3)

Native American

0 (0)

0 (0)

0 (0)

2 (0.6)

2 (0.9)

0 (0)

4 (0.3)

Other

15 (6.9)

31 (14.0)

20 (10.0)

25 (7.9)

13 (6.1)

34 (22.1)

138 (10.4)

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Black

Total

3 (1.2)

Male

Total

Race

RI PT

80 (4.8)

255

15 (5.9)

Total

14 (8.1)

Total

Sex

2012

SC

0-11

2009

M AN U

Age (Months)

217

221

201

316

213

154

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Income Quartile Range by Year Reported by the KID in US Dollars Quartile 3

Quartile 4

1-28,999

29,000-35,999

36,000-46,999

47,000+

1-31,999

32,000-41,999

42,000-54,999

55,000+

1-35,999

36,000-44,999

45,000-59,999

60,000+

1 - 37,999

38,000 - 46,999

47,000 - 61,999

1 - 39,999

40,000 - 49,999

50,000 - 65,999

1 - 38,999

39,000 - 47,999

48,000 - 62,999

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Quartile 2

62,000+

66,000+ 63,000+

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1997 2000 2003 2006 2009 2012

Quartile 1

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Table 3: Poisson Regression Model Comparing Prevalence Rates of Cochlear Implantation between Races

p-value 0.4518 0.007 0.0012 0.0154

2.3748 0.981

1.2319-4.5780 0.5598-1.7191

0.0098 0.9467

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95% Confidence Intervals 0.6963 - 2.2545 0.3208 - 0.8352 0.3587 - 0.7761 1.1844 - 4.9472

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Asian/Pacific islander vs White Black vs White Hispanic vs White Asian/Pacific islander vs Black Asian/Pacific islander vs Hispanic Black vs Hispanic

Relative Risk 1.2529 0.5176 0.5276 2.4206

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Figure 1: Proportion of Children Who Received CI by Primary Payer from 1997 to 2012 80 70

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50 40 30

10 0 1997

2000

2003

2006

Medicaid

EP

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Medicare

2009

M AN U

Year

SC

20

AC C

Percentage

60

Private Insurance

Self-pay

2012

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Figure 2: Proportion of Children Who Received CI by Income Quartile from 1997 to 2012 60

RI PT

40 30 20

0 1997

2000

2003

2006

2009

2012

M AN U

Year

SC

10

Quartile 2

EP

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Quartile 1

AC C

Percentage

50

Quartile 3

Quartile 4

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Figure 3: Proportion of Children Who Received CI by Race from 1997 to 2012 80 70

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50 40 30 20

Year

SC

10

Hispanic

Asian or Pacific Islander

0 2000

Black

2006

EP

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White

2003

2009

M AN U

1997

AC C

Percentage

60

2012

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Figure 4 Prevalence Rates of CI for Every 1000 Children with Severe-Profound SNHL 14 12

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8 6

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4 2 0 2003

2006

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2000

2009

Year

Black

Hispanic

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White

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Prevalence Rate

10

Asian/Pacific Islander