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The Cost-Effectiveness of Bimodal Stimulation Compared to Unilateral and Bilateral Cochlear Implant Use in Adults with Bilateral Severe to Profound Deafness

Theriou, Chloi; Fielden, Claire A.; Kitterick, P�draig T.


Chloi Theriou

Claire A. Fielden

P�draig T. Kitterick


Objectives: An increasing number of severe-profoundly deaf adult unilateral cochlear implant (CI) users receive bimodal stimulation; that is, they use a conventional acoustic hearing aid (HA) in their non-implanted ear. The combination of electric and contralateral acoustic hearing provides additional benefits to hearing and also to general health-related quality of life compared to unilateral CI use. Bilateral CI is a treatment alternative to both unilateral CI and bimodal stimulation in some healthcare systems. The objective of this study was to conduct an economic evaluation of bimodal stimulation compared to other management options for adults with bilateral severe to profound deafness.

Design: The economic evaluation took the form of a cost-utility analysis and compared bimodal stimulation (CI+HA) to two treatment alternatives: unilateral and bilateral CI. The analysis used a public healthcare system perspective based on data from the United Kingdom (UK) and the United States (US). Costs and health benefits were identified for both alternatives and estimated across a patient’s lifetime using Markov state transition models. Utilities were based on Health Utilities Index (HUI3) estimates and health outcomes were expressed in Quality Adjusted Life Years (QALYs). The results were presented using the Incremental Cost-Effectiveness Ratio (ICER) and the Net Monetary Benefit approach to determine the cost-effectiveness of bimodal stimulation. Probabilistic sensitivity analyses explored the degree of overall uncertainty using Monte Carlo simulation. Deterministic sensitivity analyses and Analysis of Covariance identified parameters to which the model was most sensitive; i.e. whose values had a strong influence on the intervention that was determined to be most cost-effective. A Value Of Information analysis was performed to determine the potential value to be gained from additional research on bimodal stimulation.

Results: The base case model showed that bimodal stimulation was the most cost-effective treatment option with a decision certainty of 72% and 67% in the UK and US, respectively. Despite producing more QALYs than either unilateral CI or bimodal stimulation, bilateral CI was found not to be cost-effective because it was associated with excessive costs. Compared to unilateral CI, the increased costs of bimodal stimulation were outweighed by the gain in quality of life. Bimodal stimulation was found to cost an extra £174 per person in the UK ($937 in the US) and yielded an additional 0.114 QALYs compared to unilateral CI, resulting in an ICER of £1,521 per QALY gained in the UK ($8,192/QALY in the US). The most influential variable was the utility gained from the simultaneous use of both devices (CI+HA) compared to Unilateral CI. The value of further research was £4,383,922 at £20,000/QALY ($86,955,460 at $50,000/QALY in the US).

Conclusions: This study provides evidence of the most cost-effective treatment alternative for adults with bilateral severe to profound deafness from publicly-funded healthcare perspectives of the UK and US. Bimodal stimulation was found to be more cost-effective than unilateral and bilateral CI across a wide range of willingness-to-pay thresholds. If there is scope for future research, conducting interventional designs to obtain utilities for bimodal stimulation compared to unilateral CI would reduce decision uncertainty considerably.


Theriou, C., Fielden, C. A., & Kitterick, P. T. (2019). The Cost-Effectiveness of Bimodal Stimulation Compared to Unilateral and Bilateral Cochlear Implant Use in Adults with Bilateral Severe to Profound Deafness. Ear and Hearing, 40(6), 1425–1436.

Journal Article Type Article
Acceptance Date Feb 12, 2019
Online Publication Date Apr 10, 2019
Publication Date Nov 1, 2019
Deposit Date Jan 31, 2019
Publicly Available Date Apr 11, 2020
Journal Ear and Hearing
Print ISSN 0196-0202
Electronic ISSN 1538-4667
Publisher Lippincott, Williams & Wilkins
Peer Reviewed Peer Reviewed
Volume 40
Issue 6
Pages 1425–1436
Keywords Speech and Hearing; Otorhinolaryngology
Public URL
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