背景:重度至重度听力损失患者可能会从人工耳蜗植入治疗中获益。这些患者需要转诊到耳蜗植入团队进行进一步评估和可能的手术。转诊途径可能会导致各种听力保健。这项研究旨在探索转诊模式以及是否存在任何具有转诊可能性的社会经济或种族协会。主要结果是确定影响植入物评估转诊的因素。次要结果是确定影响医疗保健专业人员是否讨论过转诊选择的因素。
结果:在英国二级保健耳鼻咽喉科和听力学单位进行了一项多中心多学科观察研究。在2021年7月1日至12月31日的6个月内,确定了符合NICE(2019)植入评估听力标准的成年人。提取患者和部位特异性特征。多变量二元逻辑回归用于比较影响植入物讨论和转诊可能性的一系列因素,包括患者特异性(人口统计,既往病史,和听力损失的程度)和特定部位的因素(耳蜗植入冠军和医院是否进行了植入)。英国所有4个权力下放国家的医院都被邀请参加,英国36家城市医院提交的数据,苏格兰,威尔士。9家医院(25%)进行了人工耳蜗评估。大多数患者居住在英格兰(n=5,587,86.2%);其余患者居住在威尔士(n=419,6.5%)和苏格兰(n=233,3.6%)。患者平均年龄为72±19岁(平均值±标准差);54%为男性,75·3%的参与者是白人,6%是亚洲人,1·5%是黑色的,0·05%是混合的,4.6%的人自我定义为不同的种族。在6,482名提交的符合人工耳蜗植入纯音听力阈值的患者中,311已经植入了耳蜗。在剩下的6,171人中,有35.7%被告知他们有资格进行植入,但只有9.7%被转介评估。当针对特定地点和患者因素进行调整时,突出的发现包括,如果成年人在多重剥夺指数内生活在更贫困的地区,则不太可能被转介(第4位(优势比(OR):2·19;95%置信区间(CI):[1·31,3·66];p=0·002),第五(2·02;[1·21,3·38];p=0·05),第六(2·32;[1·41,3·83];p=0.05),和第8名(2·07;[1·25,3·42];p=0·004)),住在伦敦(0·40;[0·29,0·57];p<0·001),男性(女性1·52;[1·27,1·81];p<0·001),或年龄较大(0·97;[0·96,0·97];p<0·001)。如果他们生活在更贫困的地区,他们不太可能被告知他们的潜在资格(第四(1·99;[1·49,2·66];p<0·001),第五(1·75;[1·31,2·33],p<0·001),第六(1·85;[1·39,2·45];p<0·001),第七(1·66;[1·25,2·21];p<0·001),和第8位(1·74;[1·31,2·31];p<0·001)分位数),英格兰北部或伦敦(北0·74;[0·62,0·89];p=0·001;伦敦0·44;[0·35,0·56];p<0·001),与白人患者相比,具有亚洲或黑人种族背景(亚洲0·58;[0·43,0·79];p<0·001;黑色0·56;[0·34,0·92];p=0·021),男性(女性1·46;[1·31,1·62];p<0·001),或年龄较大(0·98;[0·98,0·98];p<0·001)。研究方法受到其观察性质的限制,依赖转介服务的准确文件,以及某些人口群体的潜在代表性不足。
结论:大多数符合人工耳蜗植入纯音听力阈值标准的成年人目前不适合进行评估。有机会针对代表性不足的患者群体,以提高转诊率。未来的研究应该让利益相关者来探索差距背后的原因。实施简单的措施,例如教育计划和用于即时识别的自动弹出工具,可以帮助简化转诊流程。
BACKGROUND: Patients with severe-to-profound hearing loss may benefit from management with cochlear implants. These patients need a referral to a cochlear implant team for further assessment and possible surgery. The referral pathway may result in varied access to hearing healthcare. This
study aimed to explore referral patterns and whether there were any socioeconomic or ethnic associations with the likelihood of referral. The primary outcome was to determine factors influencing referral for implant assessment. The secondary outcome was to identify factors impacting whether healthcare professionals had discussed the option of referral.
RESULTS: A multicentre multidisciplinary observational
study was conducted in secondary care Otolaryngology and Audiology units in Great Britain. Adults fulfilling NICE (2019) audiometric criteria for implant assessment were identified over a 6-month period between 1 July and 31 December 2021. Patient- and site-specific characteristics were extracted. Multivariable binary logistic regression was employed to compare a range of factors influencing the likelihood of implant discussion and referral including patient-specific (demographics, past medical history, and degree of hearing loss) and site-specific factors (cochlear implant champion and whether the hospital performed implants). Hospitals across all 4 devolved nations of the UK were invited to participate, with data submitted from 36 urban hospitals across England, Scotland, and Wales. Nine hospitals (25%) conducted cochlear implant assessments. The majority of patients lived in England (n = 5,587, 86.2%); the rest lived in Wales (n = 419, 6.5%) and Scotland (n = 233, 3.6%). The mean patient age was 72 ± 19 years (mean ± standard deviation); 54% were male, and 75·3% of participants were white, 6·3% were Asian, 1·5% were black, 0·05% were mixed, and 4·6% were self-defined as a different ethnicity. Of 6,482 submitted patients meeting pure tone audiometric thresholds for cochlear implantation, 311 already had a cochlear implant. Of the remaining 6,171, 35.7% were informed they were eligible for an implant, but only 9.7% were referred for assessment. When adjusted for site- and patient-specific factors, stand-out findings included that adults were less likely to be referred if they lived in more deprived area decile within Indices of Multiple Deprivation (4th (odds ratio (OR): 2·19; 95% confidence interval (CI): [1·31, 3·66]; p = 0·002), 5th (2·02; [1·21, 3·38]; p = 0·05), 6th (2·32; [1·41, 3·83]; p = 0.05), and 8th (2·07; [1·25, 3·42]; p = 0·004)), lived in London (0·40; [0·29, 0·57]; p < 0·001), were male (females 1·52; [1·27, 1·81]; p < 0·001), or were older (0·97; [0·96, 0·97]; p < 0·001). They were less likely to be informed of their potential eligibility if they lived in more deprived areas (4th (1·99; [1·49, 2·66]; p < 0·001), 5th (1·75; [1·31, 2·33], p < 0·001), 6th (1·85; [1·39, 2·45]; p < 0·001), 7th (1·66; [1·25, 2·21]; p < 0·001), and 8th (1·74; [1·31, 2·31]; p < 0·001) deciles), the North of England or London (North 0·74; [0·62, 0·89]; p = 0·001; London 0·44; [0·35, 0·56]; p < 0·001), were of Asian or black ethnic backgrounds compared to white patients (Asian 0·58; [0·43, 0·79]; p < 0·001; black 0·56; [0·34, 0·92]; p = 0·021), were male (females 1·46; [1·31, 1·62]; p < 0·001), or were older (0·98; [0·98, 0·98]; p < 0·001). The
study methodology was limited by its observational nature, reliance on accurate documentation of the referring service, and potential underrepresentation of certain demographic groups.
CONCLUSIONS: The majority of adults meeting pure tone audiometric threshold criteria for cochlear implantation are currently not appropriately referred for assessment. There is scope to target underrepresented patient groups to improve referral rates. Future research should engage stakeholders to explore the reasons behind the disparities. Implementing straightforward measures, such as educational initiatives and automated pop-up tools for immediate identification, can help streamline the referral process.