Cochlear Implant Programming: A Global Survey on the State of the Art

The programming of CIs is essential for good performance. However, no Good Clinical Practice guidelines exist. This paper reports on the results of an inventory of the current practice worldwide. A questionnaire was distributed to 47 CI centers. They follow 47600 recipients in 17 countries and 5 continents. The results were discussed during a debate. Sixty-two percent of the results were verified through individual interviews during the following months. Most centers (72%) participated in a cross-sectional study logging 5 consecutive fitting sessions in 5 different recipients. Data indicate that general practice starts with a single switch-on session, followed by three monthly sessions, three quarterly sessions, and then annual sessions, all containing one hour of programming and testing. The main focus lies on setting maximum and, to a lesser extent, minimum current levels per electrode. These levels are often determined on a few electrodes and then extrapolated. They are mainly based on subjective loudness perception by the CI user and, to a lesser extent, on pure tone and speech audiometry. Objective measures play a small role as indication of the global MAP profile. Other MAP parameters are rarely modified. Measurable targets are only defined for pure tone audiometry. Huge variation exists between centers on all aspects of the fitting practice.


Together we can improve it
Thank you for taking the time to fill out this survey. It takes no longer than 10 minutes for the first 8 pages and somewhat more time if you are so kind as to also fill out the optional pages at the end. The aim of this survey is to get a better insight into the current practice of cochlear implant fitting. We have selected you because we believe you are involved in the fitting of cochlear implants.
You can choose to fill out the forms directly on our site http://www.otoconsult.com/feedback/FittingSurvey.aspx If on paper, please return this survey to debate@otoconsult.com or to Otoconsult Drs Bart Vaerenberg Herentalsebaan 71 B-2100 Antwerp Belgium We will use the following definitions:

Service :
a relatively autonomous group of professionals with its own head or director, its own staff and its own budget. E.g. an ENT department within a hospital could be a service on its own. If the clinical audiology is organized within this ENT department, it is part of the same service. In-house : located in the same building or on the same campus.

Medical :
relating to all non-surgical medical activities, such as otoscopy, diagnostics, prescription of medication, pediatric care, etc.

Surgical :
relating to the surgical intervention of cochlear implantation Audiological : relating to clinical audiology, e.g. audiometry, speech audiometry, evoked potentials (ABR), etc. CI Fitting : the act of programming the CI processor by means of the CI fitting software. Rehabilitation : relating to speech therapy, auditory rehab, psycho-social counseling, family guidance, etc.

Audiologist :
a professional, other than a medical doctor, with a non-university or university training in audiology, spending most of his/her time at clinical audiology, hearing aid fitting or auditory rehabilitation.

Personnel
Please indicate the number of full time equivalent persons contributing to your service for each of the following categories.

Other Activities
If you've added other activities in the previous question, please specify them here.

First Implantation
In which year did your service first fit a cochlear implant? Year:

Total number of implantations
Can you give a rough estimate of the total number of implants that have been switched on in your service (since your service started doing cochlear implantation)?

Psychoacoustical / Audiological Measurements
Please indicate which of the following measurements you perform and how you use them for fitting.

Objective Measurements and Imaging
Please indicate which of the following objective measurements you perform.

We are interested in when and how often they are performed in a single patient (on what indication do you perform them), and whether they influence the fitting of the processor. If the results of the measurement have impact on the fitting, please explain which processor parameters you adjust, and how you adjust them based on the result of the measurement.
If you have any rules of thumb to adjust fitting based on test results, please explain them. We would also like to know what targets you aim at for each of these measurements. For example, you may want to aim for all electrode impedances to be below a certain value, and disable all electrodes that do not meet this requirement.

Inter-fitter and inter-patient variabilities
Could you please estimate the contribution of the following factors to fitting variability?
Suppose you change one single factor in the fitting process, what do you think will happen to the programming of the processor? Will it be more or less the same or will it be very different?

Exactly the same
More or less the same

Somewhat different
Quite different Very different If we change the audiologist performing the programming with another audiologist from within your own service, how will the resulting programs compare?
If we change the audiologist performing the programming with another audiologist from another service, how will the resulting programs compare?
If the same audiologist programs a child or an adult, how will the programs compare?
If the same audiologist programs a prelingually deaf person or a postlingually deaf person, how will the programs compare?
If the same audiologist programs an adult who has been deaf for less than a year or he/she programs an adult that has been deaf for more than 10 years, how will the programs compare?

Resources required on average for fitting and audiological measurements after implantation
Please indicate how much time is spent on the actual programming of the processor and how much is spent on audiological testing (this includes behavioral, objective and electrophysiological measurements)?

Resources required to implant a child
Please indicate how much time the following activities take on average for an individual implant recipient and by whom they are performed?
We have identified a number of tasks that are involved in the preparation of a child to the implantation and in the follow-up after implantation. The question only relates to medical, surgical and audiological issues, not to rehabilitation nor family guidance at home etc.

Medical Doctor / Surgeon
Audiologist Speech therapist Administrative worker Other personnel Medical and audiological assessment of CI candidates ("CI-selection") Adminsitrative preparation before surgery (e.g. telephone calls, reimbursement file, agenda planning, etc.)

Surgery (including intra-operative testing)
Follow-up between surgery and device switchon Device switch-on session Follow-up during 1st month after device switch-on Follow-up during 2nd and 3rd month after device switch-on Follow-up during 4th, 5th and 6th month after device switch-on Follow-up during 7th to 12th month after device switch-on

Follow-up per year afterwards
Other Resources for adult implantation If you've added other personnel in the previous question, please specify them here.