"Despite differences in the healthcare systems in the United States and England, there is strong evidence supporting the presence of socioeconomic status disparities with regard to cochlear implantation in both countries." H E A R I N G T H E CLASSES A Study of Cochlear Implantation and Socioeconomic Status r K A T H E R I N E K O N I A R E S P R O F O U N D H E A R I N G L O S S A F F E C T S T H O U S A N D S O F P E O P L E I N T H E U N I T E D S T A T E S A N D T H E U N I T E D K I N G D O M , W I T H A H I G H E R I N C I D E N C E A M O N G P E O P L E O F L O W S O C I O E C O N O M I C S T A - T U S . A C O C H L E A R I M P L A N T I S A S U R G I C A L L Y I M P L A N T E D D E V I C E T H A T H A S B E E N D E M O N S T R A T E D T O I M P R O V E C O M M U N I C A T I O N A N D Q U A L I T Y O F L I F E A M O N G P R O F O U N D L Y H E A R I N G - I M P A I R E D I N D I V I D U A L S . T H I S R E V I E W P O S T U L A T E S T H A T T H E R A T E O F C O C H L E A R I M P L A N T A T I O N A M O N G E L I G I B L E C A N D I D A T E S C A N B E U S E D T O A S S E S S Q U A L I T Y O F H E A L T H C A R E , W I T H A V I E W T O W A R D E X A M I N I N G D I S P A R I T I E S I N H E A L T H C A R E S E R V I C E S B O T H I N A M E R I C A N F R E E - M A R K E T S Y S T E M A N D I N T H E B R I T I S H N A T I O N A L H E A L T H S E R V I C E . A S Y S T E M A T I C L I T E R A T U R E S E A R C H W A S P E R F O R M E D F O R P E R T I N E N T A R T I C L E S I N V E S T I G A T I N G S O C I O E C O N O M I C S T A T U S A N D C O C H L E A R I M P L A N T A - T I O N . D A T A F R O M T W E N T Y - T W O S O U R C E S W E R E A N A L Y Z E D , A N D I T W A S S H O W N T H A T — D E S P I T E D I F F E R E N C E S I N T H E H E A L T H C A R E S Y S T E M S O F T H E U N I T E D S T A T E S A N D E N G L A N D — S I M I L A R T R E N D S A R E A P P A R E N T I N T H E T W O C O U N T R I E S W I T H R E G A R D T O A L O W E R R A T E O F P E D I A T R I C C O C H L E A R I M P L A N T A T I O N S U R G E R Y I N C H I L D R E N W I T H P R O F O U N D H E A R I N G L O S S A S F A M I L I A L S O C I O E C O N O M I C S T A T U S D E C R E A S E S . I N T R O D U C T I O N H e a r i n g loss is one o f the m o s t prevalent hea l th condi t ions i n the U n i t e d States a n d England, w i t h moderate to pro- f o u n d bi lateral hear ing loss diagnosed i n 2-3 infants per 1 ,000 b i r ths i n the U n i t e d States and 1 per 1 ,000 b i r t h s i n England. 1 Fifty to n inety percent m o r e c h i l d r e n are diag- nosed w i t h hear ing i m p a i r m e n t by 9 years o f age. 2 C h i l - d r e n f r o m lower i n c o m e famil ies are twice as l ike ly to be deaf w h e n compared to c h i l d r e n f r o m h igher i n c o m e fam- i l ies . 3 Degrees o f hear ing loss are measured i n decibels, and are def ined as moderately severe (66-74 dB) , severe (75-90 dB) , or p r o f o u n d (>90 dB) , according to the 4-frequency (500, 1000, 2 0 0 0 , a n d 4 0 0 0 H z ) pure-tone average (PTA). 4 Cochlear i m p l a n t a t i o n (CI) is an o p t i o n for i n d i - viduals w i t h severe to p r o f o u n d hear ing loss, w h o receive m i n i m a l benefit f r o m hear ing aids. 5 A C I is an electronic device surgically embedded i n the i n n e r ear, used to s t i m u - late the auditory nerve i n response to s o u n d and generate the outcome o f h e a r i n g . 6 U n l i k e hear ing aids, a C I re- quires surgery and necessitates considerable costs t h r o u g h o u t the patient's l i f e t i m e . 7 PCIs differ f r o m the i r adult equivalents because c h i l d r e n depend o n CIs to learn spoken language skills and therefore require costly and ex- tensive hab i l i t a t ion . A successful C I m a y lead to i m p r o v e d academic achievement, superior e m p l o y m e n t o p p o r t u n i - ties, and decreased dependence o n social services as an adul t . 8 Low SES, w h i c h is characterized by m i n i m a l educat ion, househo ld i n c o m e , a n d accumulated wea l th , often curtails the abi l i ty o f indiv idua ls to access crucia l healthcare, such as PCIs. W i t h i n the d o m a i n o f PCIs, there is a g r o w i n g disparity w i t h regard to the rate o f cochlear i m p l a n t a t i o n s a n d pos t - implanta t ion speech and language development for c h i l d r e n w i t h hear ing loss. 9 A P E D I A T R I C C O C H L E A R I M P L A N T W I T H A M O D E L O F T H E H U M A N EAR. To examine the effects o f SES o n cochlear i m p l a n t a t i o n i n the U n i t e d States a n d England, a l i terature search was per- f o r m e d u s i n g three databases—MEDLINE, P U B M E D , a n d Google Scholar. Art ic les were restricted to those pub- l i shed between 1999 and 2 0 0 9 . The f o l l o w i n g keywords were used i n r a n d o m combinat ions and l i n k e d u s i n g the 'and ' o p t i o n i n advanced searches: cochlear i m p l a n t , pedi- atric, SES, socioeconomic status/disparity, Medica id , US, a n d U K . Once the results were reviewed and valuable ar t i - cles ident i f ied , the i r references were combed for per t inent articles. Further cr iter ia i n the selection o f articles i n c l u d e d a pedi- atric (age less t h a n 18 years) study popula t ion . A d d i t i o n a l - ly, articles e x a m i n i n g SES w i t h regard to race/ethnicity a n d gender were excluded. Fourteen articles were i d e n t i - f ied u s i n g the established cr iter ia a n d an addi t ional e ight sources were used for statistical a n d background i n f o r m a - t i o n . RESULTS Several studies i n the U n i t e d States and the U n i t e d K ing- FICURE V. US I N C O M E C A T E G O R Y C O M P A R E D T O CI F A M I L I E S . AFTER S O R K I N ET A L . (2008) . Income Category C I Families, n (%) U.S. Families i n Category, % Less t h a n $25,000 19 (12.8) 28.7 $25,001 - $50 ,000 35 ( 2 3-6) 29 .4 $50,001 - $75,000 35 ( 2 3-6) 19.4 $75,001 - $ 100 ,000 21 (14.2) 10.2 $ 100 ,000+ 35 (23-6) 12.3 E L E M E N T S FALL 2010 Affluence Level Implanted, n (%) i (least affluent) 130 (14.9) 2 72 (8.4) 3 73 (8-4) 4 73 (8-4) 5 8 9 (10.2) 6 75 (8-6) 7 95 (10.9) 8 92 (10.5) 9 79 (9- 1 ) i o (most affluent) 93 (10.7) FIGURE 2: U K A F F L U E N C E LEVEL C O M P A R E D T O I M - P L A N T E D F A M I L I E S . AFTER F O R T N U M ET A L . ( 2 0 0 2 ) . d o m have compared household i n c o m e w i t h the rate o f pediatric cochlear i m p l a n t a t i o n . 1 0 One study i n the U n i t e d States examined the re lat ionship between household i n - come, the n u m b e r (and percentage) o f famil ies w i t h a c h i l d w h o received a C I , and the percentage o f household famil ies i n each i n c o m e category (Figure 1). I t was con- cluded t h r o u g h x2 analysis ( p < o . o o i ) that famil ies o f ch i l - d r e n w i t h a C I were m o r e l ike ly to earn over $ 100 ,000 a n d less l ike ly to earn u n d e r $25 ,000 t h a n famil ies nat ion- w i d e . 1 1 A study i n the U n i t e d K i n g d o m (Figure 2) showed that there was a s ignif icant decrease i n the percentage o f c h i l d r e n w h o received a C I as affluence decreased ( p < o . o o i ) . 1 2 Data o n cochlear i m p l a n t procedures p e r f o r m e d o n chi l - d r e n i n the U n i t e d States i n 1997 was acquired f r o m a na- t i o n a l pediatric hospi ta l discharge database, the Kids ' I n - pat ient Database (KID) f r o m the H e a l t h Care Cost a n d U t i l i z a t i o n Project ( H C U P ) , w h i c h is a col lect ion o f private and state resources and is sponsored by the Agency for H e a l t h Care Research a n d Qual i ty ( A H R Q ) . 1 3 I t was f o u n d that 4 7 % o f patients i n the K I D w h o received a PCI l ived i n households f r o m the highest K I D category (>$35,ooo), a n d m o r e t h a n 7 0 % o f patients w i t h a PCI came f r o m fam- ilies w i t h an annua l i n c o m e above the nat iona l average. C I manufacturers ' data o n PCI recipients ' household i n c o m e was s imi la r to that o f the K I D . 1 4 A study p e r f o r m e d i n the U n i t e d K i n g d o m , a i m e d at deter- m i n i n g the out-of-pocket costs for famil ies a t tending a C I p r o g r a m at N o t t i n g h a m Pediatric Cochlear I m p l a n t a t i o n P r o g r a m m e (NPCIP) , concluded that the m e a n total out- of-pocket a n d t i m e costs for a fami ly per year were £ 2 , 4 6 2 . However, these costs varied s ignif icantly depending o n the n u m b e r o f years the pat ient h a d been i n the p r o g r a m , f r o m a m e a n cost o f £ 3 , 0 9 0 d u r i n g the first 2 years to £ 2 , 1 5 9 f ° r those i m p l a n t e d 2-5 years ago, to £ 1 , 8 1 5 f ° r PC Is carr ied out over 5 years ago. The change i n average cost per year reflects the need for n u m e r o u s appointments a n d support for famil ies i n the years i m m e d i a t e l y fol low- i n g i m p l a n t a t i o n . 1 5 A study i n the U n i t e d K i n g d o m that evaluated parents ' wil l ingness-to-pay (WTP) for a PCI concluded that the m e a n monetary value parents are w i l l i n g to pay is £ 1 2 7 per m o n t h for 25 years o f t reatment . I f parents p a i d £ 1 2 7 per m o n t h for 25 years, the W T P for PCI per c h i l d w o u l d s u m to £ 3 0 , 3 4 9 . I n 2 0 0 0 / 2 0 0 1 , the annua l N H S costs for PCI were £ 9 . 2 3 m i l l i o n for a total o f 1,527 c h i l d r e n (1,290 chi l - d r e n w i t h exist ing C I and 237 newly i m p l a n t e d ) . I f the famil ies o f al l 1,527 C I patients were W T P £ 1 2 7 per m o n t h , the total W T P for 2 0 0 0 / 2 0 0 1 w o u l d have only been £ 2 . 3 m i l l i o n , l eading to a £ 6 . 9 3 m i l l i o n deficit i n supply verses d e m a n d . 1 6 P A R E N T A L C H A R A C T E R I S T I C S The results o f a study i n the U n i t e d States i n w h i c h audi- ologists were asked to describe specific causes for the poor- er outcomes o f PCI i n c h i l d r e n w i t h a l o w SES ident i f ied a lack o f parental self-efficacy i n l o w SES famil ies , w h i c h makes i t cha l lenging for parents to advocate for the i r ch i l - d r e n i n healthcare settings. Low SES parents also have dif- ficulty adher ing to schedules for appointments . I n re- sponse to a quest ion c o m p a r i n g i m p l a n t candidacy and adherence, 4 7 % (47 o f 101) o f audiologists said they w o u l d either "never" or "rarely" r e c o m m e n d p e r f o r m i n g a C I o n a c h i l d whose parents showed non-adherence d u r i n g as- sessment. 1 7 FIGURE 3: P A Y M E N T M E T H O D S O F C H I L D R E N O T O l 8 YEARS O F A G E W H O R E C E I V E D A CI I N 1997- A F T E R S T E R N ET A L . (2OO5) . Insurance Payment Type Frequency (%) Private, i n c l u d i n g H M O 74-5 Medica id 21 Self-pay 1 • Other 3-5 H E A R I N G T H E C L A S S E S A S E V E N - Y E A R - O L D BOY H A V I N G H I S C O C H L E A R I M - P L A N T S T U N E D I N A N A N E C H O I C C H A M B E R . One U.S. study p e r f o r m e d an analysis concern ing whether or not a referral for a C I was made. Mult ivar iab le logistic regression was u t i l i z e d to observe a re lat ionship between socio-demographics and referrals. O f the 105 patients i n - c luded i n the study, 73 ( 6 9 % ) received a referral . C h i l d r e n w h o were referred for a C I were m o r e l ike ly to have mar- r ied parents ( 9 1 % verses 7 0 % ) . 1 8 P A Y M E N T M E T H O D S Several studies have explored the re lat ionship between payment methods used to cover the costs o f a C I i n the U n i t e d States and U n i t e d K i n g d o m , a n d r e i m b u r s e m e n t rates for hospitals. Figure 3 shows that m o r e t h a n 7 0 % o f the PCI recipients used private hea l th insurance i n the U n i t e d States as the i r p r i n c i p a l means o f payment i n 1997, w h i l e 21% used M e d i c a i d . 1 9 I n one study i t was f o u n d that i n at least 18 states Medica id r e i m b u r s e m e n t policies d i d n o t cover hospitals ' costs o f b u y i n g C I devices. These 18 states comprise 4 4 % o f Med- icaid e n r o l l m e n t . I n at least 8 other states, Medica id r e i m - bursements usual ly compensated hospitals for the cost o f the C I device, b u t these states comprise only 8 % o f Medic- aid e n r o l l m e n t . The average purchase price for a C I pros- thetic system is $19,745 (n=46 hospitals) . A l t h o u g h Medic- aid policies for r e i m b u r s i n g hospitals for CIs vary wide ly f r o m state to state, the m e d i a n r e i m b u r s e m e n t rate for Medica id is $13,800 (n=9 hospitals) , w h i l e the m e a n r e i m - b u r s e m e n t rate for private insurers is $15,757 (n=27 hospi- ta l s ) . 2 0 V I t has already been established that CIs are cost effective, independent o f the patients ' age at the t i m e o f implanta - t i o n , b u t a study was p e r f o r m e d i n the U n i t e d K i n g d o m to determine the direct cost o f i m p l a n t a t i o n per c h i l d charged to hea l th authorit ies by the N P C I P i n 1997-1998. 2 1 The cost for assessment and i m p l a n t a t i o n was est imated to be £ 2 7 , 5 0 0 ( $ 4 4 , 0 0 0 , a s suming £ 1 = $1.60). Rehabi l i tat ion a n d maintenance for the first two years f o l l o w i n g i m p l a n - t a t i o n cost , £ 4 , 0 0 0 ($6 ,400) per year. Maintenance for the t h i r d year after i m p l a n t a t i o n and each consecutive year was expected to cost £ 2 , 3 0 0 ($3,680) per year. Therefore, the total cost i n c u r r e d by the government for the first 4 years i n c l u d i n g the i m p l a n t a t i o n was est imated to be £ 3 7 , 8 0 0 ( $ 6 o , 4 8 o ) . 2 2 D I S C U S S I O N Despite differences i n the healthcare systems i n the U n i t - ed States a n d the U n i t e d K i n g d o m , there is s t rong evi- dence s u p p o r t i n g the presence o f SES disparities w i t h re- gard to cochlear i m p l a n t a t i o n i n b o t h countries . There are s imi la r patterns o f affluence and PCI prevalence i n the U n i t e d States, where the m a j o r i t y o f patients have private insurance, and the U n i t e d K i n g d o m , where the N H S pays for the complete medica l cost o f CIs. Th i s impl i e s that variables besides household i n c o m e a n d educat ion level affect rates o f P C I . 2 3 There are several possible factors l i m - i t i n g access to CIs, i n c l u d i n g a lack o f knowledge about CIs a m o n g famil ies o f hear ing i m p a i r e d c h i l d r e n , n o t hav- i n g insurance, and financial incentives for providers or ig i - n a t i n g i n payment policies for pub l i c and private insur- ers . 2 4 I t has been extensively d o c u m e n t e d that m o r e c h i l d r e n w i t h PCIs are f r o m famil ies w i t h annua l incomes h igher t h a n the nat iona l average. 2 5 One explanation for this is that affluent indiv iduals are m o r e l ike ly to employ healthcare service's i n genera l . 2 6 This may be because famil ies w i t h a h igher SES are m o r e concerned w i t h heal th and are less discouraged by personal expenses, such as t i m e and travel, i n c u r r e d for u t i l i z i n g healthcare facilities. Th i s is part icu- lar ly per t inent to PCI centers i n the U n i t e d K i n g d o m be- cause there are only 16 facilities that provide the proce- dure , and therefore, famil ies m u s t f requently travel extensive distances, especially d u r i n g the first few years f o l l o w i n g i m p l a n t a t i o n . 2 7 C h i l d r e n o f lower SES famil ies often have parents w i t h l o w levels o f educat ion and subsequent low-paying employ- m e n t , w h o m u s t w o r k l o n g hours i n order to earn an ade- E LE M E N T S F A L L 2010 quate i n c o m e . Long w o r k i n g hours lead to an inf lexible schedule a n d i m p a i r the i r abi l i ty to attend appointments . Low SES famil ies have a shortage o f resources such as t i m e a n d t ransportat ion , and are confronted w i t h such challenges as f ami ly size, childcare, and single parent- hood , w h i c h only exacerbate the inab i l i t y to attend appoint- ments and thus det r imenta l ly affect the l i k e l i h o o d o f b e i n g considered as a PCI candidate . 2 8 Financial incentives for audiologists may impede l o w SES patients ' access to PCIs because o f l o w r e i m b u r s e m e n t rates for patients u s i n g Medica id , as compared to private insurance companies . 2 9 CIs do n o t replace alternative ex- pensive medica l t reatments because m o s t C I candidates have hear ing i m p a i r m e n t s that are too severe to be recti- fied by hear ing aids. Rather, savings are encountered out- side the healthcare f ie ld i n such areas as educat ion, com- m u n i c a t i o n , and employabi l i ty , i n add i t ion to the psychological a n d social aspects o f the chi ld 's we l l -be ing . 3 0 I n England, PCI is capacity-constrained, m e a n i n g that on ly a l i m i t e d n u m b e r o f facilities receive f u n d i n g each year; therefore, PCI programs are not heavily advertised. Instead, referral to the p r o g r a m is requ i red f r o m the pa- t ient 's doctor. Not only are famil ies w i t h a h igher SES m o r e l ike ly to vis i t the doctor, b u t they are consequently m o r e i n f o r m e d about PCIs and m o r e articulate i n advocat- i n g for the i r c h i l d . 3 1 POSSIBLE STEPS TO ALLEVIATE DISPARITIES A l t h o u g h rect i fy ing the root cause o f u n e q u a l access to PCI services w o u l d require e l i m i n a t i o n o f global poverty, some less ambi t ious objectives may be i m p l e m e n t e d i n order to i m p r o v e access to care for patients i n l o w SES famil ies i n the U n i t e d States and U n i t e d K i n g d o m . One such goal is to a u g m e n t the workforce o f C I providers , es- pecially those t ra ined to w o r k i n underserved and m o r e cul tura l ly diverse c o m m u n i t i e s . Th i s w o u l d reduce the t ransportat ion and t i m e costs i n c u r r e d by famil ies w h o have to travel l o n g distances to attend PCI appointments , and w o u l d increase the access l o w SES c h i l d r e n have to PCIs. Addit ional ly , i m p l e m e n t i n g educat ion and counsel- i n g programs w o u l d i m p r o v e parents ' abi l i ty to advocate for the i r chi ldren's healthcare. 3 2 The U.S. Medica id system, w h i c h insures 37.5 m i l l i o n peo- ple or 12 .9% o f the popu la t ion , should be restructured to a l low for universa l hospita l r e i m b u r s e m e n t standards i n every state and r e i m b u r s e m e n t policies comparable to A F A T H E R A N D H I S S I X Y E A R - O L D S O N REACT T O T H E S O N H E A R I N G H I S F I R S T S O U N D S T H A N K S T O A C I . those o f private insurance companies . 3 3 Th i s w o u l d e l i m i - nate any propensi ty for physicians a n d audiologists to preferential ly p e r f o r m PCIs o n privately i n s u r e d candi- dates. Rather t h a n pay hospitals and doctors o n a proce- d u r a l basis, payment s h o u l d be d i s t r ibuted based o n the qual i ty o f care. U n d e r such circumstances, a patient's i n - surance status w o u l d have n o bear ing o n the i r level o f healthcare. President Barack O b a m a is t a k i n g steps to i m - p l e m e n t a publ ic heal th insurance o p t i o n for those i n d i - viduals w i t h o u t insurance. This w o u l d p u t pressure o n private insurance companies to keep the i r p r e m i u m s d o w n and increase l o w SES patients ' access to healthcare. 3 4 The N H S has taken steps to aid l o w SES famil ies ' access to healthcare t h r o u g h such programs as the Healthcare Trav- el Costs Scheme, w h i c h provides a r e f u n d for travel ex- penses i n c u r r e d w h i l e t ravel ing to a hospita l or other N H S locat ion for N H S funded t rea tment . 3 5 Despite efforts to e l iminate financial inequal i t ies , the SES disparity remains . The establ ishment o f a self-help support group for l o w SES parents w o u l d i m p r o v e self-efficacy and adherence to ) H E A R I N G T H E C L A S S E S scheduled appointments . The ideal p r o g r a m w o u l d pro- vide medica l care for the c h i l d i n c o n j u n c t i o n w i t h educa- t i o n a n d support for the parents . 3 6 L I M I T A T I O N S SES is di f f icult to define and is measured by a variety o f di f ferent scales. 3 7 A l t h o u g h studies have been conducted i n the U n i t e d States and the U n i t e d K i n g d o m to explore disparities between SES and the rate o f PCIs, di f ferent SES proxies were used i n each country. Therefore, trends i n SES disparities can be analyzed i n each i n d i v i d u a l country, b u t i t is n o t current ly possible to quantitat ively compare the extent o f disparity i n the U n i t e d States to that i n the U n i t e d K i n g d o m . Addit ional ly , the populat ions o f the U n i t e d States and U n i t e d K i n g d o m are n o t u n i f o r m . T h u s , even t h o u g h studies e x a m i n i n g disparities between race/ ethnic i ty a n d gender were n o t i n c l u d e d i n th is l i terature review, part icular SES categories m a y be m o r e represented by certain social groups. Also , studies i n the U n i t e d King- d o m d i d n o t always have corresponding data for the U n i t - ed K i n g d o m , and vice versa. Therefore, some aspects o f SES disparit ies were m o r e t h o r o u g h l y investigated i n one country t h a n the other. F U R T H E R R E S E A R C H After analyzing the current l i terature o n SES disparities and the rate o f PCIs, i t is essential to suggest topics for fur ther research. A study should be under taken to com- pare the SES o f famil ies w i t h c h i l d r e n w i t h a C I u s i n g the same standard o f measurement i n the U n i t e d States and U n i t e d K i n g d o m , such as the Jarman Score or H o l l i n g s - head's Four-Factor Score. Future research s h o u l d also ex- plore the wa i t t i m e for PCI i n the U n i t e d States and U n i t e d K i n g d o m , a n d investigate whether or n o t there is a rela- t i o n s h i p between SES a n d wa i t t i m e . Th i s w o u l d a l low for a concrete compar i son o f SES disparities i n the t w o coun- tries. Addi t ional ly , research s h o u l d explore the speech de- ve lopment and l o n g - t e r m educational outcomes o f ch i l - d r e n w h o received a C I at a y o u n g age versus those w h o were older at the t i m e o f i m p l a n t a t i o n . C O N C L U S I O N The free-market healthcare system i n the U n i t e d States differs f r o m the N H S i n the U n i t e d K i n g d o m , b u t b o t h systems exhibi t SES disparities w i t h regard to PCIs. A l - t h o u g h the N H S pays for al l costs o f PCIs, these disparities are s t i l l present i n the U n i t e d K i n g d o m . Thi s should be taken i n t o account by U.S. legislatures w h e n f o r m u l a t i n g new healthcare plans for the U n i t e d States. I n l i g h t o f the current healthcare re forms u n d e r the Obama adminis t ra- t i o n , w h i c h a i m to provide healthcare for al l Amer icans , i t should be noted that a universa l healthcare system does not necessarily e l iminate disparities. I n a d d i t i o n to prov id- i n g healthcare payment for al l Amer icans , the U.S. govern- m e n t s h o u l d focus o n educat ing Amer icans about the i r healthcare options t h r o u g h nat iona l m e d i a campaigns a n d local workshops specialized for part icular medica l fields, w h i c h w o u l d enable ind iv idua l s to advocate for t h e m - selves. Further research is needed to m o r e t h o r o u g h l y i n - vestigate the issues involved i n healthcare disparit ies, b u t the results o f this l i terature review indicate that ne i ther a free-market nor a universa l healthcare system is the ideal m e t h o d for p r o v i d i n g equal healthcare to al l . A P P E N D I X SES I N D I C E S Townsend Material Deprivation Score: The Townsend Score com- bines the individual scores of four variables to form an overall score that can then be used to rank particular geographical areas relative to others. The average score is zero, and the higher the score, the more deprived the area. The four variables are: 3 8 1) Unemployment - Percentage of residents actively seeking em- ployment 2) Car Ownership - Percentage of households that do not possess a car 3) Owner Occupation - Percentage of households that do not own their accommodations 4) Overcrowding - Percentage of households wi th more than one person per room Jarman Score: The Jarman Score is used to determine deprivation payments to General Practitioners and consists of the following variables:3 9 1) People over the age of 65 who are living alone 2) Children under the age of 5 3) Single parent households 4) Unskilled workers 5) Unemployment E L E M E N T S : : F A L L 2010 6) Overcrowded households 7) Address change i n the past year 8) Ethnic group Hollingshead's Four-Factor Score: The Hollingshead Score is de- rived from education and occupation characteristics of each par- ent. Individual education and occupation scores are weighted to obtain a single score for each parent that represents 1 of 5 social strata (1 represents unskilled laborers and 5 represents higher pro- fessionals). The scores for each parent are then averaged to deter- mine a single score for the household. The education and occupa- tion scores are calculated as follows: 4 0 1) Education - Score ranges from 1-7, wi th 1 equal to less than 7* grade education and 7 equal to graduate level education 2) Occupation - Score ranges from 1-9, with 1 equal to farm labor- ers/menial service workers and 9 equal to higher executives, own- ers of large businesses, and major professionals Medicaid: Medicaid is a government program that provides health insurance for low-income individuals. Eligibility is based on a combination of income and population "category." The popula- tions generally eligible are children, parents of dependent chil- dren, pregnant women, the disabled, and the elderly. The income levels at which these groups qualify for Medicaid differ f rom state to state.41 Q U O R U M F L O W C H A R T Articles identified as poten- tially relevant to pediatric cochlear implants, n= 415 Articles identified as poten- tially relevant to pediatric cochlear implants, n= 415 Articles excluded due to lack of relevance to SES dispari- ties i n the United States or United Kingdom, n= 383 Articles excluded due to lack of relevance to SES dispari- ties i n the United States or United Kingdom, n= 383 Articles excluded due to lack of relevance to SES dispari- ties i n the United States or United Kingdom, n= 383 Articles identified as relevant to SES disparities i n the United States or United King- dom and pediatric cochlear implants, n= 32 Articles excluded due to lack of relevance to SES dispari- ties i n the United States or United Kingdom, n= 383 Articles identified as relevant to SES disparities i n the United States or United King- dom and pediatric cochlear implants, n= 32 Articles identified as relevant to SES disparities i n the United States or United King- dom and pediatric cochlear implants, n= 32 Articles excluded due to lack of relevance to rates of cochle- ar implantation, n= 10 Articles excluded due to lack of relevance to rates of cochle- ar implantation, n= 10 Articles excluded due to lack of relevance to rates of cochle- ar implantation, n= 10 Articles with useful and rel- evant information, n= 22 Articles excluded due to lack of relevance to rates of cochle- ar implantation, n= 10 Articles with useful and rel- evant information, n= 22 T H E K I D The KID provides data for analysis of national pediatric hospital discharges (for inpatient stays lasting longer than 24 hours) and consists of a random sample of 80% (n=i,905,797) of non-new- born pediatric discharge records from 22 states i n 1997. The vari- ables recorded i n the KID include age, race, procedure codes, di- agnostic codes, length of stay, total charges, and insurance coverage. Children receiving cochlear implants have one of three primary diagnoses—sensorineural hearing loss, sensorineural loss combined type, or hearing loss—and one of three primary procedure codes—electromagnetic hearing device implant, i m - planted cochlear prosthetic device, or implanted mechanical co- chlear prosthetic device. Once the patients were identified, demo- graphic information including age and median household income i n the geographic region of the patient's home zip code (catego- rized as: $o-$25,ooo; $25,ooi-$30,ooo; $30,ooi-$35,ooo; and >$35,ooo) was collected. The average household income i n 1997 was $35,145. Demographic information concerning SES and household educational level was provided by the Advanced Bion- ics and Cochlear Corporations and was then compared with the KID. O U T - O F - P O C K E T EXPENSES Out-of-pocket costs include transportation, overnight accommo- dation, child-care, and time costs of the children and parents not being able to work while attending appointments. Time costs were calculated as 65% of the parents'/children's weekly wage rate. E N D N O T E S 1. National Institute for Deafness and Communication Disorders 2008 2. Fortnum et al. (2001) 3. National Health Interview Survey 4. Wiley et al. (2009) 5. NHS National Institute for Health and Clinical Experience; Shiomi et al. (1999) 6. O'Neill et al. (2009); Sach et al. (2005) 7. National Institute for Deafness and Communication Disorders (2008) 8. O'Neill et al. (2009) 9. Kirkham et al. (2009) 10. Sorkin et al. (2008); Fortnum et al. (2002) 11. Sorkin et al. (2008) 12. Fortnum et al. (2002) 13. Steiner et al. (2002) 14. Stern et al. (2005) 15. Sach et al. (2005) 16. Sach et al. (2004) 17. Kirkham et al. (2009) ) H E A R I N G T H E C L A S S E S 18. Wiley et al. (2009) 19. 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