RESUMO
PURPOSE OF REVIEW: Effective hearing rehabilitation with cochlear implantation is challenging in developing countries, and this review focuses on strategies for childhood profound sensorineural hearing loss care in South America. RECENT FINDINGS: Most global hearing loss exists in developing countries; optimal cost-effective management strategies are essential in these environments. This review aims to assess and discuss the challenges of cochlear implantation effectiveness in South America. The authors searched electronic databases, bibliographies, and references for published and unpublished studies. Sensitivity analysis was performed to evaluate the effect of device cost, professional salaries, annual number of implants, and failure rate. Costs were obtained from experts in South America using known costs and estimations whenever necessary. Recent studies reported several challenges in unilateral or bilateral cochlear implants: cochlear implant costs, deaf education costs, increasing need for cochlear implant capacity, and training and increasing longevity. SUMMARY: Cochlear implantation was very cost-effective in all South American countries. Despite inconsistencies in the quality of available evidence, the robustness of systematic review methods substantiates the positive findings of the included studies, demonstrating that unilateral cochlear implantation is clinically effective and likely to be cost-effective in developing countries.
Assuntos
Implante Coclear/economia , Implantes Cocleares/economia , Surdez/cirurgia , Países em Desenvolvimento , Perda Auditiva Neurossensorial/cirurgia , Surdez/economia , Surdez/reabilitação , Perda Auditiva Neurossensorial/economia , Perda Auditiva Neurossensorial/reabilitação , Humanos , América do SulRESUMO
HYPOTHESIS: Cochlear implantation (CI) and deaf education are cost effective management strategies of childhood profound sensorineural hearing loss in Latin America. BACKGROUND: CI has been widely established as cost effective in North America and Europe and is considered standard of care in those regions, yet cost effectiveness in other economic environments has not been explored. With 80% of the global hearing loss burden existing in low- and middle-income countries, developing cost effective management strategies in these settings is essential. This analysis represents the continuation of a global assessment of CI and deaf education cost effectiveness. METHODS: Brazil, Colombia, Ecuador, Guatemala, Paraguay, Trinidad and Tobago, and Venezuela participated in the study. A Disability Adjusted Life Years model was applied with 3% discounting and 10-year length of analysis. Experts from each country supplied cost estimates from known costs and published data. Sensitivity analysis was performed to evaluate the effect of device cost, professional salaries, annual number of implants, and probability of device failure. Cost effectiveness was determined using the World Health Organization standard of cost effectiveness ratio/gross domestic product per capita (CER/GDP)<3. RESULTS: Deaf education was very cost effective in all countries (CER/GDP 0.07-0.93). CI was cost effective in all countries (CER/GDP 0.69-2.96), with borderline cost effectiveness in the Guatemalan sensitivity analysis (Max CER/GDP 3.21). CONCLUSION: Both cochlear implantation and deaf education are widely cost effective in Latin America. In the lower-middle income economy of Guatemala, implant cost may have a larger impact. GDP is less influential in the middle- and high-income economies included in this study.
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Implante Coclear/economia , Surdez/economia , Surdez/reabilitação , Surdez/cirurgia , Análise Custo-Benefício , Produto Interno Bruto , Humanos , América Latina , Anos de Vida Ajustados por Qualidade de VidaRESUMO
INTRODUCTION: Cochlear implantation (CI) is a common intervention for severe-to-profound hearing loss in high-income countries, but is not commonly available to children in low resource environments. Owing in part to the device costs, CI has been assumed to be less economical than deaf education for low resource countries. The purpose of this study is to compare the cost effectiveness of the two interventions for children with severe-to-profound sensorineural hearing loss (SNHL) in a model using disability adjusted life years (DALYs). METHODS: Cost estimates were derived from published data, expert opinion, and known costs of services in Nicaragua. Individual costs and lifetime DALY estimates with a 3% discounting rate were applied to both two interventions. Sensitivity analysis was implemented to evaluate the effect on the discounted cost of five key components: implant cost, audiology salary, speech therapy salary, number of children implanted per year, and device failure probability. RESULTS: The costs per DALY averted are $5,898 and $5,529 for CI and deaf education, respectively. Using standards set by the WHO, both interventions are cost effective. Sensitivity analysis shows that when all costs set to maximum estimates, CI is still cost effective. CONCLUSION: Using a conservative DALY analysis, both CI and deaf education are cost-effective treatment alternatives for severe-to-profound SNHL. CI intervention costs are not only influenced by the initial surgery and device costs but also by rehabilitation costs and the lifetime maintenance, device replacement, and battery costs. The major CI cost differences in this low resource setting were increased initial training and infrastructure costs, but lower medical personnel and surgery costs.
Assuntos
Implante Coclear/economia , Implantes Cocleares/economia , Surdez/economia , Surdez/terapia , Educação/economia , Audiologia/economia , Pré-Escolar , Análise Custo-Benefício , Surdez/reabilitação , Falha de Equipamento/economia , Custos de Cuidados de Saúde , Perda Auditiva Neurossensorial/economia , Perda Auditiva Neurossensorial/terapia , Humanos , Lactente , Nicarágua/epidemiologia , Anos de Vida Ajustados por Qualidade de Vida , Fonoterapia/economia , Resultado do TratamentoRESUMO
American organizations bringing assistance to deaf people in developing countries unintentionally create relationships of dependency or oppression rather than relationships of support. Using qualitative methods, the author examined the effectiveness of development assistance provided to the Jamaican Deaf community by two American churches, one American nongovernmental organization, and one U.S. federal agency. Documents were reviewed and observations were made. Interviews were conducted with more than 60 deaf and hearing people involved with the American organizations, the Jamaican organizations, and deaf Jamaican beneficiaries. The author concludes that the Jamaican Deaf community was often excluded in planning, designing, or evaluating programs, and was unsatisfied with the American assistance it received. Results also indicate that the American organizations were poorly prepared to work with the Deaf community. Suggestions for American organizations wishing to strengthen and empower deaf people through development assistance in developing countries are proposed.