Expensive today but cheaper tomorrow: lifetime costs of an active middle ear implant compared to alternative treatment options

K ohn, Ma kus e al.
A icle — Published Ve sion
Expensi e oday bu cheape omo ow: li e ime cos s
o an ac i e middle ea implan compa ed o al e na i e
ea men op ions
The Eu opean Jou nal o Heal h Economics
P o ided in Coope a ion wi h:
Sp inge Na u e
Sugges ed Ci a ion: K ohn, Ma kus e al. (2024) : Expensi e oday bu cheape omo ow: li e ime
cos s o an ac i e middle ea implan compa ed o al e na i e ea men op ions, The Eu opean
Jou nal o Heal h Economics, ISSN 1618-7601, Sp inge , Be lin, Heidelbe g, Vol. 26, Iss. 5, pp.
797-816,
h ps://doi.o g/10.1007/s10198-024-01743-6
This Ve sion is a ailable a :
h ps://hdl.handle.ne /10419/323291
S anda d-Nu zungsbedingungen:
Die Dokumen e au EconS o dü en zu eigenen wissenscha lichen
Zwecken und zum P i a geb auch gespeiche und kopie we den.
Sie dü en die Dokumen e nich ü ö en liche ode komme zielle
Zwecke e iel äl igen, ö en lich auss ellen, ö en lich zugänglich
machen, e eiben ode ande wei ig nu zen.
So e n die Ve asse die Dokumen e un e Open-Con en -Lizenzen
(insbesonde e CC-Lizenzen) zu Ve ügung ges ell haben soll en,
gel en abweichend on diesen Nu zungsbedingungen die in de do
genann en Lizenz gewäh en Nu zungs ech e.
Te ms o use:
Documen s in EconS o may be sa ed and copied o you pe sonal
and schola ly pu poses.
You a e no o copy documen s o public o comme cial pu poses, o
exhibi he documen s publicly, o make hem publicly a ailable on he
in e ne , o o dis ibu e o o he wise use he documen s in public.
I he documen s ha e been made a ailable unde an Open Con en
Licence (especially C ea i e Commons Licences), you may exe cise
u he usage igh s as speci ied in he indica ed licence.
h p://c ea i ecommons.o g/licenses/by/4.0/
Vol.:(0123456789)
The Eu opean Jou nal o Heal h Economics (2025) 26:797–816
h ps://doi.o g/10.1007/s10198-024-01743-6
ORIGINAL PAPER
Expensi e oday bu cheape omo ow: li e ime cos s o anac i e
middle ea implan compa ed oal e na i e ea men op ions
Ma kusK ohn1 · KlaasKiesewe e 2· AnnikaBuchholz3· Be inaSchlick2· SusanBusch3· ThomasLena z3·
AnkeLesinski‑Schieda 3· HannesMaie 4· Co neliaBa soulis5· MichaelU ban2· S e enFlessa1
Recei ed: 30 July 2024 / Accep ed: 14 No embe 2024 / Published online: 6 Decembe 2024
© The Au ho (s) 2024
Abs ac
Backg ound When choosing be ween di e en ea men op ions, implan s o en appea oo cos ly. Howe e , his pe spec-
i e does no ake u u e cos s in o accoun . This a icle e alua es li e ime cos s o di e en su gical in e en ions o ea
hea ing loss.
Me hods The analysis ocused on h ee g oups om he pe spec i e o heal h insu e s. G oup 1 comp ises pa ien s who ha e
only been implan ed wi h a middle ea implan . Pa ien s in G oup 2 had al eady unde gone middle ea su ge y o imp o e
hea ing p io o he implan a ion o a middle ea implan . G oup 3 consis s o pa ien s who we e ea ed exclusi ely wi h
hea ing-imp o emen su ge ies (no implan ). The li e ime cos s we e calcula ed using he Mon e Ca lo simula ion. The inpu s
we e based on medical da a om a maximum-ca e hospi al and da a om he Ge man heal hca e sys em.
Resul s Based on an a e age obse a ion pe iod o 26.73yea s, he li e ime cos s amoun ed o 28,325€ o g oup 1, 32,187€
o g oup 2 and 28,381€ o g oup 3. While he mean alues be ween g oups 1 and 3 appea compa able, g oup 1 has a
signi ican ly lowe s anda d de ia ion (G1 s. G3: 6120€ s. 10,327€).
Discussion/conclusion Choosing a ea men op ion can be a complex medical decision and impose a subs an ial economic
bu den o he s a u o y heal h insu ance. Hence, ea men decisions should be pa ien -cen ed a i s bu also including
a sha ed-decision making on economic easibili y, whe he p oposed ea men al e na i es a e likely o be success ul and
economically easonable.
Keywo ds Middle ea implan · Cos analysis· Li e ime cos · Mon e-Ca lo-Simula ion· Hea ing-imp o emen su ge ies
JEL Classi ica ion I10· I11· I13· C15
In oduc ion
Se e al ea men op ions a e usually conside ed as pa o
any medical decision-making p ocess. Fo example, ea -
men op ions o p og essi e hea ing loss may include hea -
ing-imp o emen su ge ies ( ympanoplas ies) o middle ea
implan s. While ypical su ge y o hea ing loss cos s a ound
3700 € (example DRG D30A) [1], he cos s o a middle
ea implan a e highe a a ound 13,000 € [2]. A i s , he
implan appea s o be disad an ageous om an economic
pe spec i e. Howe e , he e a e o he possible e ec s ha
may a ise in he u he cou se o ea men ; he e o e, cos s
should be calcula ed o e he en i e li espan based on medi-
cal da a.
Acco ding o he Wo ld Repo on Hea ing by he Wo ld
Heal h O ganiza ion (WHO), hea ing loss is he ou h
* Ma kus K ohn
ma kus.k ohn@uni-g ei swald.de
1 Chai o Gene al Business Adminis a ion andHeal h
Ca e Managemen , Uni e si y o G ei swald, G ei swald,
Ge many
2 MED-EL Medical Elec onics, Innsb uck, Aus ia
3 Depa men o O ola yngology, Hanno e Medical School,
Hanno e , Ge many
4 Clinic o La yngology, Rhinology andO ology, Hanno e
Medical School, Hanno e , Ge many
5 MED-EL Medical Elec onics, MED-EL Resea ch Cen e ,
Hanno e , Ge many
798 M.K ohn e al.
highes cause o disabili y globally, wi h an es ima ed annual
cos o mo e han 980 billion dolla s [3]. In Ge many, he
annual cos o heal h diso de s caused by hea ing impai -
men s we e es ima ed o be € 2.65 billion in 2011 [4]. Cu -
en da a sugges ha app oxima ely 5% o he wo ld’s popu-
la ion o 430 million people equi e audi o y ehabili a ion
o add ess hei disabling hea ing loss. I is es ima ed ha by
2050 mo e han 700 million people – o 1 in e e y 10 people
– will su e a disabling hea ing loss (hea ing loss g ea e
han 35 decibels (dB) in he be e -hea ing ea ). Acco d-
ing o he me a s udy “Hea ing Loss – Numbe s and Cos s”
published by hea -i AISBL, he e a e app oxima ely 34.4
million people in he Eu opean Union li ing wi h a disabling
hea ing loss, wi h 22.6 million people emaining un ea ed.
This esul s in an annual o e all cos o 185 billion Eu os o
8200 Eu os pe a ec ed pe son [5]. Fu he mo e, app oxi-
ma ely 10 million people in he EU su e a hea ing loss
o 50dB o g ea e , wi h a ound 5.5 million o hese s ill
un ea ed.
In 2021 in Ge many alone, app oxima ely 4.5 million
people (5.35%) had a disabling hea ing loss, acco ding o
he mos ecen da a om he Ins i u e o Heal h Me ics
and E alua ion (IHME) [6]. In 2019, Löhle e al. in es i-
ga ed six s udies in ol ing hea ing diso de s in Ge many,
showing a b oad ange o hea ing loss p e alence (be ween
16 and 25%) wi h no s anda dized de ini ion o hea ing loss
[7]. Also in 2019, Schmucke e al. conduc ed a sys ema ic
e iew o complemen he esul s o Löhle e al. epo ing
a p e alence o hea ing loss in he child and adolescen Ge -
man popula ion anging om 0.1 o 128 pe 1000 child en
and adolescen s [8]. Sel - epo ed hea ing loss a a highe
h eshold (> 30dB HL) anged be ween 2.4 and 5.2% [8].
Ano he epidemiological s udy on hea ing s a us in no h-
wes Ge many (HÖRSTAT) es ima ed he p e alence o
hea ing loss, as de ined by he Wo ld Heal h O ganiza ion,
o be 16%, which is in line wi h he numbe o pa icipan s
who had a hea ing le el g ea e han 40dB in he “hea -
i AISBL” a icle [9]. I is ob ious ha disabling hea ing
loss nega i ely a ec s mul iple aspec s o an indi idual’s
li e when le unadd essed o when he indi idual’s com-
munica ion needs a e unsuppo ed.
Fo many yea s, s anda d ea men o conduc i e and/
o mixed hea ing loss has consis ed o middle ea su ge -
ies wi h o wi hou he eplacemen o de ec i e ossicles
( ympanoplas y) and i possible, he applica ion o a hea ing
aid. Middle ea su ge ies, such as a ympanoplas ies and/o
mas oidec omies (su ge ies o he mas oid bone o in ec ion
and he ympanic memb ane), a e equen ly pe o med wi h
excellen esul s o he ea men o in ec ious middle ea
diseases wi h o wi hou implan ing passi e ossicula p os-
heses o es o e hea ing. Middle ea su ge ies a e p ima ily
conce ned wi h esol ing he discha ging pa hology, as in
he case o pa ien s wi h ch onic o i is media (COM), o
wi h he comple e e adica ion in case o choles ea omas. As
he pa hologies ha e a high chance o eoccu ence, hese
p ocedu es may usually equi e epea ed su ge ies. Success
o middle ea su ge ies can be linked o he unc ional es o-
a ion o he ympanic memb ane, wi h high ecu ence a es
be ween 50 and 100%, including a a ie y o di e en and
equen ly in e ela ed causes o ailu es, making su gical
p ognosis e y di icul , o en esul ing in a se e e mixed
hea ing impai men in pa ien s wi h COM o en no able
o wea hei hea ing-aids. In addi ion, hea ing aid usage in
such pa ien s may lead o adical ca i y in ec ions o ecu -
en my ingi is i sealed oo igh ly [10]. E en when pa ien s
unde go mul iple app op ia e middle ea su ge ies, hea ing
imp o emen some imes emains inadequa e.
These pa ien s wi h unsuccess ul con en ional hea ing
ehabili a ion and a a ie y o middle ea condi ions can be
ea ed e ec i ely using an elec omagne ically ac i e mid-
dle ea implan such as he Vib an Soundb idge (VSB), as
he ana omical condi ions in such cases o en impede an
adequa e acous ic coupling. Ac i e middle ea implan s
(AMEIs) a e medical de ices in ended o ea hea ing loss
by s imula ion o he middle and inne ea s uc u es. This
s udy in es iga ed he use o he Vib an Soundb idge (VSB)
(MED-EL Aus ia), he wo ld’s, up o now, mos u ilized
AMEI. Wi h mo e han 25yea s o expe ience in es o -
ing hea ing o housands o people a ound he wo ld, he
VSB is sui able o di e en ypes o hea ing loss and is also
app o ed o child en. I is implan ed in cases o senso ineu-
al hea ing loss when he i ing o con en ional hea ing aids
is no possible because o ch onic o i is ex e na, as well as in
cases o conduc i e o combined hea ing impai men when
con en ional ympanoplas ies and passi e ossiculoplas ies
canno su icien ly imp o e hea ing.
Al hough su ge ies o imp o e hea ing and ac i e middle
ea implan s a e bo h highly ele an in his pa ien popula-
ion and bo h may be used o audi o y ehabili a ion in he
same pa ien . The e exis e y ew s udies ha compa e he
li e ime cos s o hese ea men op ions. Such s udies a e
necessa y o policymake s and su geons o in o m hem-
sel es abou he cos e icacy o di e en in e en ions. In
his pape we in end o ill his esea ch gap.
Me hodology
The analysis compa ed he cos s o h ee ca e al e na i es
om he pe spec i e o heal h insu e s. In he ollowing
model, he e a e speci ic du a ions be ween he in e en ions.
These a e de i ed om he medical da a. Wi hin hese ime
pe iods, he ea men success, e.g. hea ing imp o emen ,
is de ined as compa able be ween he op ions. The analysis
does no include he esul s o hea ing measu emen s (e.g.
799
Expensi e oday bu cheape omo ow: li e ime cos s o anac i e middle ea implan compa ed…
in dB) o heal h- ela ed quali y o li e. This assump ion is
essen ial o a meaning ul compa ison o li e ime cos s:
The ollowing h ee g oups o pa ien s we e de ined:
G oup 1: Pa ien s who ecei ed a middle ea implan
di ec ly, wi hou p io hea ing-imp o emen su ge y.
G oup 2: Pa ien s who unde wen one o mo e hea -
ing-imp o emen su ge ies be o e ecei ing a middle ea
implan .
G oup 3: Pa ien s who had mo e han one hea ing-
imp o emen su ge ies bu no middle ea implan .
The o e all li e ime cos s will be in es iga ed conside ing
se e al inpu pa ame e s. A Mon e Ca lo simula ion will be
used as he me hodological ool. In addi ion o he a e age
cos pe in e en ion, s a emen s can be made abou he ben-
e i o he in e en ion based on he unce ain y o he indi-
idual inpu alues. In pa icula , he pa ame e s “implan a-
ion age/ emaining li e ime” and he in luence o he numbe
o in e en ions will be looked a .
T ea men da a
The ea men da a in his e ospec i e s udy o igina ed
om he hospi al in o ma ion sys em o a maximum ca e
hospi al. Only he da a o pa ien s ha ga e hei consen
du ing ea men was analysed. G oups 1 and 2 consis ed
o all pa ien s implan ed wi h a VSB a he Hanno e Medi-
cal School, Hanno e , Ge many, be ween 1997 and 2021,
selec ed om he in e nal da abase o middle ea implan s.
O he ypes o middle ea implan s we e no included in his
s udy. This esul ed in 389 pa ien s. Pa ien s we e excluded
i hei las appoin men was ea lie han 2019, as well as o
ha ing mul imo bidi y’s o p i a e insu ance.
Subjec s we e selec ed and g ouped based on: AMEI
wi hou p io co ec i e hea ing-imp o emen su ge y
(g oup 1: n = 100) o co ec i e hea ing-imp o emen su -
ge y be o e AMEI implan a ion (g oup 2: n = 51).
The pa ien s we e hen sc eened so ha each pa ien
had an indi idual inciden lis wi h speci ic da es o hei
inpa ien and ou pa ien isi s ela ed o hei AMEI. The
inpa ien s ays included appoin men s such as implan a ion,
e ision, o e-implan a ion. Fo g oup 2, he p e ious hea -
ing-imp o emen ope a ions we e added. Ou pa ien isi s
included egula annual check-ups and p ocesso i ings,
isi s o complica ions and/o hea ing p oblems. These spe-
ci ic inpa ien and ou pa ien e en s we e hen egis e ed in
SAP o con i m ha he appoin men in he in e nal da abase
had indeed aken place and o speci y which OPS and DRG
codes o hese appoin men s we e used o billing pu poses.
Fo g oup 3, an SAP que y was gene a ed a he cen al
depa men o MHH IT Se ices Applica ions, En e p ise
Documen s and Con en , MHH In o ma ion Technology
o pa ien s wi h he OPS codes 5–195.90, .91, .92, .93 and
5–197.2. This de e mina ion o ele an pa ien s in g oup 3
is done acco ding o OPS codes (Ge man p ocedu e clas-
si ica ion “Ope a ions- und P ozedu enschlüssel-OPS”).
In his s ep, g oup 2 se es as he basis o he selec ion o
p ocedu es. Based on he da a in g oup 2, i was de e mined
which hea ing-imp o ing su ge ies a e o be conside ed
common be o e a VSB implan . The i e OPS codes men-
ioned esul ed om his analysis. Pa ien s who ecei ed a
leas one o he p ocedu es men ioned and we e su gically
ea ed be ween 2018 and 2021 and had s a u o y heal h
insu ance we e included. Exclusion c i e ia we e bila e al
ca e and mul imo bidi y, since in hese cases he da a o
he indi idual isi in SAP (especially o ou pa ien isi s)
could no longe be comp ehensibly assigned o one speci ic
pa hology. This esul ed in 211 pa ien s, ou o which 100
we e andomly selec ed. Like he pa ien s in g oups 1 and
2, hei isi s we e also egis e ed in SAP so ha an inciden
lis wi h co esponding ICD codes, OPS codes and DRG
codes could be c ea ed o each pa ien .
Cos da a
Rele an cos da a o he indi idual se ices we e aken om
he Ge man heal h ca e sys em. Fo inpa ien ea men s,
he hea ing-imp o emen su ge y cos s we e aken om he
obse ed se o pe -case la a es (aG-DRG), including addi-
ional nu sing e enues om he pe -case la a e ca alogue
[11]. Fo non- a ed aG-DRGs, e enue alues we e used ha
we e indi idually nego ia ed be ween heal h insu e s and
hospi als [2, 12–19]. These alues also include he cos s o
he implan . Fo ou pa ien s ays, he uni e si y’s ou pa ien
la a e o he hospi al he da a o igina ed om was used.
Consequen ly, all cos da a a e eal da a and no assump ions
o es ima es.
Simula ion
The expo ed medical da a was hen alida ed, and he g oup
classi ica ion was checked, as well as he age dis ibu ion
be ween he g oups. F om he medical da a, dis ibu ion
iden i ica ion was used o de e mine he heo e ic dis i-
bu ions o he inpu pa ame e s o indi idual model inpu
pa ame e s [20]. No mal dis ibu ion, unca ed no mal
dis ibu ion, log-no mal, exponen ial and uni o m dis ibu-
ion we e all es ed. The pa ien ’s age a i s in e en ion,
du a ion be ween hea ing-imp o emen su ge ies, du a ion
be ween p ocesso upg ades, and du a ion o ca e wi h hea -
ing-imp o emen su ge ies be o e VSB implan a ion we e
all conside ed. Fu he mo e, based on he obse ed p ob-
abili ies o e ision o e-implan a ion (depending on he
du a ion o use) in VSB pa ien s, a iangula dis ibu ion
was calcula ed.
800 M.K ohn e al.
We hen pe o med a Mon e Ca lo simula ion wi h he
indings o he da a p epa a ion. The Mon e Ca lo simu-
la ion includes ea men da a and cos da a. Based on he
indi idual inpu alues and he iden i ied dis ibu ions, he
cos s o all h ee pa ien g oups we e de e mined. Fo each
g oup, 10,000 simula ion uns we e pe o med. The esul
o he simula ion is hus no only a ixed indi idual esul ,
bu a he a p obabili y dis ibu ion o he a ge alues [21].
The aim is o ensu e ha he simula ion model ep esen s
eali y in he bes possible way. The quali y o he model is
checked by compa ing he model esul s wi h he ea men
da a om he hospi al o o igin.
The indi idual s eps o he simula ion a e explained
below. The calcula ion is desc ibed in ex o m. The desc ip-
ion co e s he key aspec s o he calcula ion. The ac o s
desc ibed in ex o m a e highligh ed in bold in Tables1,
2, 3. The o mal implemen a ion is shown in Tables1, 2, 3.
In addi ion o he aspec s desc ibed, hese ables con ain all
he calcula ion s eps, including all he necessa y in e medi-
a e s eps and auxilia y calcula ions. Table4 shows he inpu
pa ame e s.
G oup 1: Pa ien s who we e di ec ly i ed wi h a middle
ea implan wi hou i s unde going a hea ing-imp o emen
su gical in e en ion.
Based on he dis ibu ion o age a ini ial in e en ion
(“AFI”) and he li e expec ancy (“LEX”), which is de ined
as ixed, he ea men pe iod (“TOP” = o al obse a ion
pe iod) was calcula ed. Fo his pe iod, he cos s o he i s
in e en ion (in his case, implan a ion o VSB) (“G1_CFI
(g oup 1 - cos i s in e en ion)”), he cos s o e-implan a-
ions (“G1_CRI (g oup 1 - cos e-implan a ion)”), he cos s
o e isions (“G1_CRE (g oup 1 - cos e ision)”), he cos s
o audio p ocesso upg ades (“G1_APU (g oup 1 - audio
p ocesso upg ade)”) and he cos s o an annual check-up
we e included o each simula ion un. These add up o he
li e ime cos o g oup 1 (“G1_LTC”).
The cos s o he i s in e en ion include he cos s o
implan a ion (“ISB (Implan a ion Vib an Soundb idge)”)
based on he de e mined dis ibu ion and h ee ou pa-
ien ollow-up appoin men s (“FOA ( la - a e ou pa ien
appoin men s)”).
The cos s o e-implan a ions we e simila ly composed.
The cos s o “ISB” and “FOA” we e also used he e. The
only di e ence is ha he numbe o “FOA” appoin men s
was educed o wo, since he hi d appoin men was co e ed
by he annual check-up appoin men in he model. Fu he -
mo e, he ime o a i s o second e-implan a ion esul s
om he li e imes o he implan s (“LTS (Li e ime Vib an
Soundb idge) o LTS1, LTS2 and LTS3”). The model was
limi ed o a maximum o wo e-implan a ions. Possible
esul ing model e o s due o a possible inc eased numbe
o equi ed e-implan a ions was indica ed by (“EP_LTS_G1
(e o p obabili y li e ime Vib an Soundb idge g oup 1)”).
This alue hus pa ially desc ibes he model quali y. Fu -
he mo e, a discoun a e (“DIR”) o 5% was applied o all
cos s a ising in he u u e. This co esponds o he Hano e -
ian consensus and is aken in o accoun in all pa s o he
model [22]. The numbe o implan a ions esul s om he
ini ial implan a ion plus he numbe o necessa y e-implan-
a ions and is de ined as "NOI_G1 (numbe o implan a ions
g oup 1)”.
The cos s o e isions include he cos s o an inpa ien
e ision s ay (“REV”) acco ding o he de e mined dis ibu-
ion plus an addi ional “FOA” appoin men . The in e al
be ween necessa y e isions is de i ed om he de e mined
dis ibu ion. These dis ibu ions a e de ined as “TTR ( ime
o e ision) o TTR1, TTR2, TTR3, TTR4”. The model
allows o a maximum o h ee e isions. The model e o ,
which desc ibes he need o addi ional e isions, is de ined
as “EP_TTR_G1 (e o p obabili y ime o e ision g oup
1)”. The numbe o e isions is de ined as “NOR_G1 (num-
be o e isions g oup 1)”.
The cos o he audio p ocesso upg ades was calcula ed
om he cos o one audio p ocesso (“APU”), aking in o
accoun he pe iod be ween upda es (“TAP”) and he o al
du a ion o ca e (“TOP”). The minimum ime o upg ade is
six yea s, as billing o heal h insu ance is mainly possible
a e six yea s [23]. The ime be ween he comple ed six h
yea o use and he change o a new p ocesso was de i ed
om he obse ed da a. This ollows an exponen ial dis-
ibu ion.The numbe o p ocesso upg ades is de ined as
“NOP_G1” (numbe o p ocesso upg ades).
The o al cos o annual inspec ions (FOA) was calcula ed
as he p esen alue o e he “TOP” pe iod. Fu he mo e,
he ou pu s “DR_LTS” and “DR_TTR” we e gene a ed.
These desc ibe he de aul a es o he implan s (LTS) a e
1, 10 and 25yea s o use and he e ision p obabili y (TTR)
a e 1, 5 and 10yea s. The alues we e used o de e mine
he model quali y. He e, he da a om he hospi al in o ma-
ion sys em a e compa ed wi h he esul s o he simula ion
uns. The ou pu s including all co ec ion s eps a e shown
in Table1. The ou pu s explici ly p esen ed in he me hod
desc ip ion a e p in ed in bold.
G oup 2: Pa ien s who ecei ed a middle ea implan a e
one o mo e hea ing-imp o emen middle ea su ge ies.
G oup 2 pa ien s unde wen hea ing-imp o emen su ge -
ies p io o VSB implan a ion. Consequen ly, he i s in e -
en ion consis ed o a hea ing-imp o emen su ge y (“G2_
CFI (g oup 2-cos i s in e en ion)”). Possible u he
hea ing-imp o emen su ge ies (“G2_CFS (g oup 2-cos
u he su ge y) as well as he subsequen ea men wi h
VSB ha e o be aken in o accoun . This includes he cos s
o he i s implan a ion (“G2_VSB (g oup 2-cos implan a-
ion VSB)”), he cos s o e-implan a ions (“G2_CRI (g oup
2-cos e-implan a ion)”), he cos s o e isions (“G2_CRE
(g oup 2-cos e ision)”) and he cos s o audio p ocesso

801
Expensi e oday bu cheape omo ow: li e ime cos s o anac i e middle ea implan compa ed…
Table 1 Simula ion model – g oup 1
Ou pu Equa ion
TOPuB1 i ( ound(LEX-AFIa) > (LEX-MIA), ound(LEX-AFIb), ound(LEX-AFIa))
TOPuB2 i (TOPuB1 > 77; ound(LEX-AFIc);TOPuB1)
TOPlB1 i (TOPuB2 < 1; ound(LEX-AFIb);TOPuB2)
TOPlB2 i (TOPlB1 < 1; ound(LEX-AFIc);TOPlB1)
TOPlB3 i (TOPlB2 < 1;1;TOPlB2)
TOPuB3 i (TOPlB3 > (LEX-MIA);(LEX-MIA);TOPlB3)
TOP TOPuB3
AFI LEX-TOP
LTS1lB i (LTS1 < 0;0;LTS1)
LTS2lB i (LTS2 < 0;0;LTS2)
LTS3lB i (LTS3 < 0;0;LTS3)
EP_LTS_G1 TOP-LTS1lB-LTS2lB-LTS3lB [uppe spec limi = 0]
DR_LTS1 ound(LTS1lB-0,5) [lowe spec limi = 1]
DR_LTS10 ound(LTS1lB-0,5) [lowe spec limi = 10]
DR_LTS25 ound(LTS1lB-0,5) lowe spec limi = 25]
NOI_G1 1 + i (LTS1lB > = TOP;0;1) + i ((LTS1lB + LTS2lB) > = TOP;0;1)
TTR1lB i (TTR1 < 0;0;TTR1)
TTR2lB i (TTR2 < 0;0;TTR2)
TTR3lB i (TTR3 < 0;0;TTR3)
TTR4lB i (TTR4 < 0;0;TTR4)
TTR1uB TTR1lB
TTR2uB TTR2lB
TTR3uB TTR3lB
TTR4uB TTR4lB
EP_TTR_G1 TOP-TTR1uB-TTR2uB-TTR3uB-TTR4uB [uppe spec limi = 0]
DR_TTR1 ound(TTR1uB-0.5) [lowe spec limi = 1]
DR_TTR5 ound(TTR1uB-0.5) [lowe spec limi = 5]
DR_TTR10 ound(TTR1uB-0.5) [lowe spec limi = 10]
NOR_G1 i (TTR1uB > = TOP;0;1) + i ((TTR1uB + TTR2uB) > = TOP;0;1) + i ((TTR1uB + TTR2uB + TTR3uB) > = TOP;0;1)
TTU TTUa + TTUb
TAP ound(TTU)
NOP_G1 i (TOP > = TAP;1;0) + i (TOP > = (2*TAP);1;0) + i (TOP > = (3*TAP);1;0) + i (TOP > = (4*TAP);1;0) + i (TOP > = (5*TAP);1
;0) + i (TOP > = (6*TAP);1;0) + i (TOP > = (7*TAP);1;0) + i (TOP > = (8*TAP);1;0) + i (TOP > = (9*TAP);1;0) + i (TOP > =
(10*TAP);1;0) + i (TOP > = (11*TAP);1;0) + i (TOP > = (12*TAP);1;0)
G1_CFI (ISB + 3*FOA)/((1 + DIR)^0)
G1_CRI i (LTS1lB < TOP;1;0)*((ISB + 2*FOA)/((1 + DIR)^( ound(LTS1lB-0.5)))) + i ((LTS1lB + LTS2lB) < TOP;1;0)*((ISB + 2*FOA)/
((1 + DIR)^(( ound(LTS1lB + LTS2lB-0.5)))))
G1_CRE i (TTR1uB < TOP;1;0)*((REV + FOA)/((1 + DIR)^( ound(TTR1uB-0.5)))) + i ((TTR1uB + TTR2uB) < TOP;1;0)*((REV + FO
A)/((1 + DIR)^(( ound(TTR1uB + TTR2uB-0.5))))) + i ((TTR1uB + TTR2uB + TTR3uB) < TOP;1;0)*((REV + FOA)/((1 + DIR
)^(( ound(TTR1uB + TTR2uB + TTR3uB-0.5)))))
G1_APU i (TOP > = TAP;1;0)*(APU/((1 + DIR)^TAP)) + i (TOP > = (2*TAP);1;0)*(APU/((1 + DIR)^(2*TAP))) + i (TOP > = (3*TAP);
1;0)*(APU/((1 + DIR)^(3*TAP))) + i (TOP > = (4*TAP);1;0)*(APU/((1 + DIR)^(4*TAP))) + i (TOP > = (5*TAP);1;0)*(APU/
((1 + DIR)^(5*TAP))) + i (TOP > = (6*TAP);1;0)*(APU/((1 + DIR)^(6*TAP))) + i (TOP > = (7*TAP);1;0)*(APU/((1 + DIR)^(
7*TAP))) + i (TOP > = (8*TAP);1;0)*(APU/((1 + DIR)^(8*TAP))) + i (TOP > = (9*TAP);1;0)*(APU/((1 + DIR)^(9*TAP))) +
i (TOP > = (10*TAP);1;0)*(APU/((1 + DIR)^(10*TAP))) + i (TOP > = (11*TAP);1;0)*(APU/((1 + DIR)^(11*TAP))) + i (TOP
> = (12*TAP);1;0)*(APU/((1 + DIR)^(12*TAP)))
G1_TSC FOA*((((1 + DIR)^(TOP-1))-1)/(((1 + DIR)^(TOP-1))*DIR))
G1_LTC G1_CFI + G1_CRI + G1_CRE + G1_APU + G1_TSC
802 M.K ohn e al.
upg ades (“G2_APU (g oup 2 – audio p ocesso upg ade)”).
In addi ion, he e a e cos s o an annual se ice appoin men
(“G2_TSC”) o he en i e ime. Toge he his esul s in he
li e ime cos s o g oup 2 (“G2_LTC”). Du ing he pe iod o
ea men wi h hea ing-imp o ing su ge ies, cos s o pos-
sible hea ing aids a e no included. This poin is add essed
in he discussion.
The con en o G2_LTC is iden ical o G1_LTC. Fu he -
mo e, he con en s o G2_VSB a e also iden ical o G1_CRI,
G2_CRI o G1_CRI, G2_APU o G1_APU and G2_CRE
o G1_CRE. The e a e only wo changes o be conside ed.
The ime o use o he VSB needs o be sho ened because
hea ing-imp o emen ope a ions we e pe o med be o e
he VSB. Fu he mo e, he numbe o FOA appoin men s
is educed o wo o G2_VSB because he hi d appoin -
men is included by G2_LTC. The p e ious obse a ion ime
(“TOP”) is now spli in o “THI ( ime o hea ing-imp o ing
in e en ions)” and “TSB ( ime o Vib an Soundb idge)”.
THI esul s om he de e mined dis ibu ion wi h a maxi-
mum alue o 25yea s. This maximum de ini ion is neces-
sa y because g oup 2 pa ien s change o a VSB. I no maxi-
mum alue we e de ined, ea men sequences could a ise
ha co espond o g oup 3. The numbe o ope a ions esul s
om he de e mined success du a ion be ween hea ing-
imp o emen ope a ions and THI. The du a ion o success
o su ge y was de ined as “DSH1, DSH2, … (du a ion suc-
cess hea ing-imp o ing su ge y)”. The numbe o hea ing-
imp o emen su ge ies was limi ed o six including ini ial
in e en ion and is de ined as NHI_G2. The p obabili y o
needing mo e su ge ies is desc ibed as EP_NHI_G2 (e o
p obabili y numbe o hea ing-imp o emen su ge ies g oup
2). The cos o hea ing-imp o emen su ge y was aken om
he dis ibu ion o he obse ed aG-DRG se . Fu he mo e,
wo FOA appoin men s we e included a e each su ge y.
Table 2 Simula ion model (addi ions) – g oup 2
Ou pu Equa ion
THIlB i ( ound(THI ) < TOP, ound(THI ),TOP)
THI i (THIlB < 25,THIlB,25)
TSB TOP-THI
NHI_G2 1 + i (DSH1 < THI,1,0) + i ((DSH1 + DSH2) < THI,1,0) + i ((DSH1 + DSH2 + DSH3) < THI,1,0) + i ((DSH1 + DSH2 + DSH3 +
DSH4) < THI,1,0) + i ((DSH1 + DSH2 + DSH3 + DSH4 + DSH5) < THI,1,0)
EP_NHI_G2 THI-DSH1-DSH2-DSH3-DSH4-DSH5-DSH6
G2_CFI (HIS1 + 2*FOA)/((1 + DIR)^0)
G2_CFS i (DSH1 < THI,1,0)*((HIS2 + FOA)/((1 + DIR)^ ound(DSH1-0,5))) + i (( ound(DSH1 + DSH2)) < THI,1,0)*((HIS3
+ FOA)/((1 + DIR)^ ound(DSH1 + DSH2-0,5))) + i (( ound(DSH1 + DSH2 + DSH3)) < THI,1,0)*((HIS4 + FOA)/
((1 + DIR)^ ound(DSH1 + DSH2 + DSH3-0,5))) + i (( ound(DSH1 + DSH2 + DSH3 + DSH4)) < THI,1,0)*((HIS5 + FOA)/
((1 + DIR)^ ound(DSH1 + DSH2 + DSH3 + DSH4-
0,5))) + i (( ound(DSH1 + DSH2 + DSH3 + DSH4 + DSH5)) < THI,1,0)*((HIS6 + FOA)/
((1 + DIR)^ ound(DSH1 + DSH2 + DSH3 + DSH4 + DSH5-0,5)))
G2_VSB (ISB + 2*FOA)/((1 + DIR)^THI)
G2_CRI i (LTS1lB < TSB;1;0)*((ISB + 2*FOA)/((1 + DIR)^ ound(THI + LTS1lB-0,5))) + i ((LTS1lB + LTS2lB) < TSB;1;0)*((ISB + 2*F
OA)/((1 + DIR)^ ound(THI + LTS1lB + LTS2lB-0,5)))
NOI_G2 1 + i (LTS1lB > = TSB,0,1) + i ((LTS1lB + LTS2lB) > = TSB,0,1)
G2_CRE i (TTR1uB < TSB,1,0)*((REV + FOA)/((1 + DIR)^ ound(THI + TTR1uB-0,5))) + i ((TTR1uB + TTR2uB) < TSB,1,0)*((REV + F
OA)/((1 + DIR)^ ound(THI + TTR1uB + TTR2uB-0,5))) + i ((TTR1uB + TTR2uB + TTR3uB) < TSB,1,0)*((REV + FOA)/((1 +
DIR)^ ound(THI + TTR1uB + TTR2uB + TTR3uB-0,5)))
NOR_G2 i (TTR1uB > = TSB,0,1) + i ((TTR1uB + TTR2uB) > = TSB,0,1) + i ((TTR1uB + TTR2uB + TTR3uB) > = TSB,0,1)
G2_TSC G1_TSC
G2_APU i (TSB > = TAP;1;0)*(APU/((1 + DIR)^(TAP + THI))) + i (TSB > = (2*TAP);1;0)*(APU/((1 + DIR)^(2*TAP + THI))) + i (TSB
> = (3*TAP);1;0)*(APU/((1 + DIR)^(3*TAP + THI))) + i (TSB > = (4*TAP);1;0)*(APU/((1 + DIR)^(4*TAP + THI))) + i (TSB
> = (5*TAP);1;0)*(APU/((1 + DIR)^(5*TAP + THI))) + i (TSB > = (6*TAP);1;0)*(APU/((1 + DIR)^(6*TAP + THI))) + i (TSB
> = (7*TAP);1;0)*(APU/((1 + DIR)^(7*TAP + THI))) + i (TSB > = (8*TAP);1;0)*(APU/((1 + DIR)^(8*TAP + THI))) + i (TSB
> = (9*TAP);1;0)*(APU/((1 + DIR)^(9*TAP + THI))) + i (TSB > = (10*TAP);1;0)*(APU/((1 + DIR)^(10*TAP + THI))) + i (T
SB > = (11*TAP);1;0)*(APU/((1 + DIR)^(11*TAP + THI))) + i (TSB > = (12*TAP);1;0)*(APU/((1 + DIR)^(12*TAP + THI)))
NOP_G2 i (TSB > = TAP;1;0) + i (TSB > = (2*TAP);1;0) + i (TSB > = (3*TAP);1;0) + i (TSB > = (4*TAP);1;0) + i (TSB > = (5*TAP);1;
0) + i (TSB > = (6*TAP);1;0) + i (TSB > = (7*TAP);1;0) + i (TSB > = (8*TAP);1;0) + i (TSB > = (9*TAP);1;0) + i (TSB > = (
10*TAP);1;0) + i (TSB > = (11*TAP);1;0) + i (TSB > = (12*TAP);1;0)
G2_LTC G2_CFI + G2_CFS + G2_VSB + G2_CRI + G2_CRE + G2_APU + G2_TSC
EP_LTS_G2 TSB-LTS1lB-LTS2lB-LTS3lB
EP_TTR_G2 TSB-TTR1uB-TTR2uB-TTR3uB-TTR4uB
803
Expensi e oday bu cheape omo ow: li e ime cos s o anac i e middle ea implan compa ed…
The ou pu s and equa ions including all co ec ion s eps
a e shown in Table2. The ou pu s explici ly p esen ed in he
me hod desc ip ion a e p in ed in bold.
G oup 3: Pa ien s who ecei ed mo e han one hea ing-
imp o emen su ge y bu no middle ea implan .
Pa ien s in g oup 3 ecei ed hea ing-imp o emen su -
ge y h oughou he obse a ion pe iod. The cos s o his
g oup consis o he cos s o he i s in e en ion (“G3_
CFI”) plus he cos s o u he hea ing-imp o emen su ge -
ies (“G3_CFS”), as well as an assumed annual con ol isi
whose o al cos s a e ep esen ed by “G3_TSC”. G3_TSC
co esponds o G1_TSC in e ms o con en . Toge he his
esul s in he li e ime cos s o g oup 3 (“G3_LTC”). The
ime be ween hea ing-imp o emen ope a ions co esponds
o he alue “DSH1, DSH2, …” al eady p esen ed in g oup
2. The numbe o in e en ions, whose cos s pe in e en ion
ollow he same dis ibu ion as in g oup 2 (“HIS”), is limi ed
in he model o 15 in e en ions (ini ial in e en ion plus a
maximum o 14 ollow-up in e en ions). The p obabili y
o highe need is desc ibed by EP_NHI_G3 (e o p ob-
abili y numbe o hea ing-imp o emen su ge ies g oup 3).
Consequen ly, g oup 3 co esponds o g oup 2 in e ms o
con en , bu he p o ision o hea ing-imp o emen su ge y
akes place o e he en i e du a ion (“TOP”), no only du ing
a sho pe iod (“THI”) be o e a subsequen VSB implan a-
ion. The ou pu s including all co ec ion s eps a e shown
in Table3. The ou pu s explici ly p esen ed in he me hod
desc ip ion a e p in ed in bold. In addi ion, i should be
no ed o g oup 3 ha no cos s a e included o he p o ision
o hea ing aids. This poin is add essed in he discussion.
Model pa ame e s
The ollowing Table4 shows he inpu pa ame e s o he
simula ion model. The sou ce o he da a o igin is desc ibed
in he las column.
Table 3 Simula ion model (addi ions) – g oup 3
Ou pu Equa ion
G3_CFI (HIS1 + 2*FOA)/((1 + DIR)^0)
G3_CFS i (DSH1 < TOP;1;0)*((HIS2 + FOA)/((1 + DIR)^ ound(DSH1-0.5))) + i (( ound(DSH1 + DSH2)) < TOP;1;0)*((HIS3
+ FOA)/((1 + DIR)^ ound(DSH1 + DSH2-0.5))) + i (( ound(DSH1 + DSH2 + DSH3)) < TOP;1;0)*((HIS4 + FOA)/
((1 + DIR)^ ound(DSH1 + DSH2 + DSH3-0.5))) + i (( ound(DSH1 + DSH2 + DSH3 + DSH4)) < TOP;1;0)*((HIS5 + FOA)/
((1 + DIR)^ ound(DSH1 + DSH2 + DSH3 + DSH4-0.5))) + i (( ound(DSH1 + DSH2 + DSH3 + DSH4 + DSH5)) < TOP;1;0)*((HIS6 + FOA)/
((1 + DIR)^ ound(DSH1 + DSH2 + DSH3 + DSH4 + DSH5-0.5))) + i (( ound(DSH1 + DSH2 + DSH3 + DSH4 + DSH5 + DSH6)) < TOP;1;0)*((HIS7 + FOA)/
((1 + DIR)^ ound(DSH1 + DSH2 + DSH3 + DSH4 + DSH5 + DSH6-
0.5))) + i (( ound(DSH1 + DSH2 + DSH3 + DSH4 + DSH5 + DSH6 + DSH7)) < TOP;1;0)*((HIS8 +
FOA)/((1 + DIR)^ ound(DSH1 + DSH2 + DSH3 + DSH4 + DSH5 + DSH6 + DSH7-
0.5))) + i (( ound(DSH1 + DSH2 + DSH3 + DSH4 + DSH5 + DSH6 + DSH7 + DSH8)) < TOP;1;0)*((HIS9 + FOA)/
((1 + DIR)^ ound(DSH1 + DSH2 + DSH3 + DSH4 + DSH5 + DSH6 + DSH7 + DSH8-
0.5))) + i (( ound(DSH1 + DSH2 + DSH3 + DSH4 + DSH5 + DSH6 + DSH7 + DSH8 + DSH9)) < TOP;1;0)*((
HIS10 + FOA)/((1 + DIR)^ ound(DSH1 + DSH2 + DSH3 + DSH4 + DSH5 + DSH6 + DSH7 + DSH8 + DSH9-
0.5))) + i (( ound(DSH1 + DSH2 + DSH3 + DSH4 + DSH5 + DSH6 + DSH7 + DSH8 + DSH9 + DSH10)) < TOP;1;0)*((
HIS11 + FOA)/((1 + DIR)^ ound(DSH1 + DSH2 + DSH3 + DSH4 + DSH5 + DSH6 + DSH7 + DSH8 + DSH9 + DSH10-
0.5))) + i (( ound(DSH1 + DSH2 + DSH3 + DSH4 + DSH5 + DSH6 + DSH7 + DSH8 + DSH9 + DSH10 + DSH11)) < TOP;1;0)*((
HIS12 + FOA)/((1 + DIR)^ ound(DSH1 + DSH2 + DSH3 + DSH4 + DSH5 + DSH6 + DSH7 + DSH8 + DSH9 + DSH10 + DSH11-
0.5))) + i (( ound(DSH1 + DSH2 + DSH3 + DSH4 + DSH5 + DSH6 + DSH7 + DSH8 + DSH9 + DSH10 + DSH11 + DSH12)) < TOP;1;0)*((
HIS13 + FOA)/((1 + DIR)^ ound(DSH1 + DSH2 + DSH3 + DSH4 + DSH5 + DSH6 + DSH7 + DSH8 + DSH9 + DSH10 + DSH11 + DSH12-
0.5))) + i (( ound(DSH1 + DSH2 + DSH3 + DSH4 + DSH5 + DSH6 + DSH7 + DSH8 + DSH9 + DSH10 + DSH11 + DSH12 + DSH13)) < TOP;1;0)*((
HIS14 + FOA)/((1 + DIR)^ ound(DSH1 + DSH2 + DSH3 + DSH4 + DSH5 + DSH6 + DSH7 + DSH8 + DSH9 + DSH10 + DSH11 + DSH12 + DSH13-
0.5))) + i (( ound(DSH1 + DSH2 + DSH3 + DSH4 + DSH5 + DSH6 + DSH7 + DSH8 +
DSH9 + DSH10 + DSH11 + DSH12 + DSH13 + DSH14)) < TOP;1;0)*((HIS15 + FOA)/
((1 + DIR)^ ound(DSH1 + DSH2 + DSH3 + DSH4 + DSH5 + DSH6 + DSH7 + DSH8 + DSH9 + DSH10 + DSH11 + DSH12 + DSH13 + DSH14-0.5)))
G3_TSC G1_TSC
EP_NHI_G3 TOP-DSH1-DSH2-DSH3-DSH4-DSH5-DSH6-DSH7-DSH8-DSH9-DSH10-DSH11-DSH12-DSH13-DSH14-DSH15
G3_LTC G3_CFI + G3_CFS + G3_TSC
NHI_G3 1 + i (DSH1 < TOP;1;0) + i ((DSH1 + DSH2) < TOP;1;0) + i ((DSH1 + DSH2 + DSH3) < TOP;1;0) + i ((DSH1 + DSH2 + DSH3 + DSH4) < TOP;1;0) + i ((DSH
1 + DSH2 + DSH3 + DSH4 + DSH5) < TOP;1;0) + i ((DSH1 + DSH2 + DSH3 + DSH4 + DSH5 + DSH6) < TOP;1;0) + i ((DSH1 + DSH2 + DSH3 + DSH4 + D
SH5 + DSH6 + DSH7) < TOP;1;0) + i ((DSH1 + DSH2 + DSH3 + DSH4 + DSH5 + DSH6 + DSH7 + DSH8) < TOP;1;0) + i ((DSH1 + DSH2 + DSH3 + DSH4
+ DSH5 + DSH6 + DSH7 + DSH8 + DSH9) < TOP;1;0) + i ((DSH1 + DSH2 + DSH3 + DSH4 + DSH5 + DSH6 + DSH7 + DSH8 + DSH9 + DSH10) < TOP;1;
0) + i ((DSH1 + DSH2 + DSH3 + DSH4 + DSH5 + DSH6 + DSH7 + DSH8 + DSH9 + DSH10 + DSH11) < TOP;1;0) + i ((DSH1 + DSH2 + DSH3 + DSH4 + D
SH5 + DSH6 + DSH7 + DSH8 + DSH9 + DSH10 + DSH11 + DSH12) < TOP;1;0) + i ((DSH1 + DSH2 + DSH3 + DSH4 + DSH5 + DSH6 + DSH7 + DSH8 + D
SH9 + DSH10 + DSH11 + DSH12 + DSH13) < TOP;1;0) + i ((DSH1 + DSH2 + DSH3 + DSH4 + DSH5 + DSH6 + DSH7 + DSH8 + DSH9 + DSH10 + DSH11
+ DSH12 + DSH13 + DSH14) < TOP;1;0)
804 M.K ohn e al.
Resul s
T ea men du a ion (“TOP”)
In he model, he du a ion o ca e was calcula ed om
he di e ence be ween a ixed li e expec ancy o 81yea s
and he age a i s in e en ion acco ding o dis ibu ion
iden i ica ion.
This esul ed in a “TOP” du a ion o 26.73yea s, wi h a
s anda d de ia ion o 13.94yea s. This du a ion desc ibes
he pe iod o li e ime cos s. In g oup 1 i includes he ca e
wi h VSB, and in g oup 3 he ca e by means o hea ing-
imp o emen ope a ions. Fo g oup 2, his pe iod was
di ided in o he ca e by means o hea ing-imp o emen
ope a ions (“THI”) and he ea men ime wi h VSB
(“TSB”). Figu e1 shows he dis ibu ion o “TOP”. In
g oup 2, he du a ion o ca e wi h hea ing-imp o emen
su ge y was 4.01yea s (± 5.18), and o ca e wi h VSB
22.72yea s (± 14.60). The sum o he du a ions again co -
esponds o TOP. Time in yea s is plo ed on he x-axis, and
he numbe o obse a ions in he model is plo ed on he
y-axis.
Model esul s o g oup 1
In g oup 1, ca e was p o ided exclusi ely wi h a VSB. Du -
ing he 26.73 [± 13.94]-yea ea men pe iod, a mean o
1.15 [± 0.39] implan a ions we e pe o med. The numbe
o e-implan a ions o e he en i e li e ime is he e o e 0.15,
wi h 86.6% o pa ien s equi ing no e-implan a ion and
12.2% equi ing only one e-implan a ion. The numbe o
e ision su ge ies necessa y o e he en i e pe iod o ca e
a e aged 0.45 (± 0.70), wi h 65.6% o pa ien s equi ing no
e ision and 26.0% equi ing only one e ision. The a e age
numbe o p ocesso upg ades was 3.64 (± 2.19). The alues
shown ela e o he o e all model. Due o he dis ibu ion o
“TOP”, 50% o pa ien s in he model will ha e a VSB ea -
men du a ion o mo e han 25yea s. The ollowing igu es
show he numbe o implan a ions (Fig.2) and e isions
(Fig.3).
The ques ion a ises as o whe he he model can ep e-
sen eali y. To answe his, he compa ison be ween model
esul s and eal da a mus be used. The model shows he
ollowing alues o he ailu e p obabili ies o he implan s
(DR_LTS).
Table 4 Inpu alues
Inpu name Dis ibu ion Pa ame e s Sou ce
LEX – li e expec ancy Fixed Value: 81 [24] (mean alue man and woman)
MIA – minimum implan a ion age Fixed Value: 5 [25]
AFIa, AFIb, AFIc – age a i s in e en ion ( o lowe /
uppe bound co ec ion)
Weibull Shape: 244.32323
Scale: 2866.73542
Th eshold: -2806.08613
own, based on medical da a
FOA – la - a e ou pa ien appoin men s Fixed Value: 145 own, based on MHH cos da a
DIR – discoun a e Fixed Value: 0.05 [22]
ISB – cos o implan a ion o Vib an Soundb idge Logno mal Loca ion: 9.57283
Scale: 0.07429
own, based on medical da a and cos da a
men ioned be o e
LTS1, LTS2, LTS3 – li e ime Vib an Soundb idge T iangula Lowe : -3
Mode: 0
Uppe : 400
own, based on medical da a
TTR1, TTR2, TTR3 – ime o e ision T iangula Lowe : -3
Mode: 0
Uppe : 140
own, based on medical da a
REV – cos e ision Logno mal Loca ion:
8.29047
Scale: 0.20121
own, based on medical da a and cos da a se
APU – cos audio p ocesso Fixed Value: 5719.9 [26]
TTUa – ime o upg ade APU minimum Fixed Value: 6 [23]
TTUb – addi ional ime o upg ade APU Exponen ial Ra e: 1.41988 own, based on medical da a
THI – Time o hea ing-imp o ing in e en ion o al ( o
lowe /uppe bound co ec ion)
Logno mal Loca ion: 0.70939
Scale: 1.3453
own, based on medical da a
DSH1, DSH2, … DSH15 – du a ion o success o
hea ing-imp o ing su ge y
Weibull Shape: 0.68361
Scale: 1.74601
Th eshold: 0.28273
own, based on medical da a
HIS1, HIS2, … HIS15 – cos o hea ing-imp o ing
su ge y
Logno mal Loca ion: 8.2339
Scale: 0.25662
own, based on medical da a and cos da a se
811
Expensi e oday bu cheape omo ow: li e ime cos s o anac i e middle ea implan compa ed…
canno be ea ed o he emaining ime. Thus, om a
cos pe spec i e, al e na i e ea men op ions mus be
conside ed. The VSB seems o be a easonable choice
due o i s lowe li e ime cos s.
Homogenei y o cos s
Wi h espec o cos homogenei y, he esul s om he en i e
simula ion as well as he cos s o emaining li e imes o
10, 20 and 30 yea s will be examined as examples. Table5
shows he mean cos s as well as he homogenei ies o he
cos s. A - es was used o check whe he he mean alues a e
di e en and i signi ican di e ences exis ed in he s anda d
de ia ion. A p- alue o less han 0.05 indica es signi ican
di e ence.
The cos s o g oup 1 and 3 did no di e h oughou he
en i e simula ion. This is due o he ac ha o sho ea -
men du a ions G1 domina es, bu o long du a ions g oup
3 is p e e able, as was p e iously s a ed. Ne e heless, he
di e ences in he s anda d de ia ions we e always signi i-
can -and hus signi ican ly highe in g oups 2 and 3 due
o he in luence o he hea ing-imp o emen ope a ions.
Consequen ly, ea men wi h he VSB had signi ican ly
highe homogenei y coe icien s, a ibu able o e y low
mid- and long- e m cos s, due o small numbe s o e i-
sion su ge ies and e-implan a ions o e he en i e pe iod o
ca e. The e o e, he use o he middle ea implan he e o e
educes he isk o cos ou lie s, e en hough he implan a-
ion o an ac i e middle ea implan is o en associa ed wi h
inc eased complexi y and highe cos s [27]. The ad an age
o he lowe s anda d de ia ion is e iden in Fig.11. Cos s in
g oup 3 sca e signi ican ly mo e han in he o he g oups.
Fu he mo e, i should be no ed ha he analysis p esen ed
he e excludes he cos s o hea ing aid i ing, which is o en
necessa y a e hea ing-imp o emen su ge ies. Hence, li e-
ime cos s o hea ing aid i ing, which can sum up o 4518€,
as de e mined by Thum e al. should ha e been aken in o
accoun ei he in o de o comp ehensi ely epo o al li e ime
cos s o g oup 3 [28]. Also, addi ional ea men cos s o he
mo e han 25% o pa ien s in g oup 3 who couldn’ be success-
ully ea ed (e.g. due o ea in ec ions) un il he end o li e,
would ha e been needed o be conside ed, oo. These 25% o
pa ien s could po en ially be desc ibed as a subse o pa ien s
wi h insu icien bene i om his combina ion he apy, as e en
s a e-o he-a powe hea ing aids would no be able o p o-
ide su icien gain and/o ou pu equi ed by hese pa ien s
[29]. Fo hese 25% o pa ien s who couldn’ be success ully
ea ed in g oup 3, bypassing he middle ea and ai –bone gap
(ABG) wi h a powe ul ac i e middle ea implan o a di ec
acous ic s imula ion o he cochlea, migh ha e been he mo e
p omising hea ing solu ion [29].
F om an economic poin o iew, he ollowing aspec
can be added:
Fig. 10 Dis ibu ion o success ully ea ed yea s in he simula ion model. (sou ce: own simula ion)

812 M.K ohn e al.
– The use o a middle ea implan makes u u e cos s
signi ican ly easie o plan, since he e is a highe deg ee
o cos homogenei y.
In luence o  henumbe o hea ing‑imp o emen
su ge ies
Ano he ques ion o be add essed ega ds he in luence
o he numbe o hea ing-imp o emen su ge ies admin-
is e ed. We aimed o ind ou whe he he a e age cos s
depend on he numbe o hea ing-imp o emen ope a ions.
Table6 shows he mean cos s and s anda d de ia ions. A
- es was used o de e mine signi icance. A p alue o
less han 0.05 indica es ha he cos s we e signi ican ly
inc eased compa ed o “one su ge y less”.
The cos s inc ease signi ican ly as he numbe inc eases.
In he simula ion, he di e ence be ween wo and h ee
hea ing-imp o emen ope a ions is he smalles . This
is due o he age dis ibu ion in he simula ion. He e i
becomes clea ha wi h a ela i ely low emaining li e
expec ancy, an addi ional hi d su ge y can pos pone VSB
implan a ion so long ha no p ocesso upg ade will be
necessa y sho ly be o e dea h. Howe e , i has al eady
been shown in he p e ious discussion poin s ha g oup 3
seems o be ad an ageous a low li e expec ancies.
F om an economic pe spec i e, he ollowing can be
s a ed: swi ching o VSB implan a ion seems o be ea-
sonable e en a e hea ing-imp o emen su ge ies ha e
al eady been pe o med, because each subsequen hea ing-
imp o emen su ge y signi ican ly inc eases he li e ime
cos s.
Figu e12 shows he dis ibu ion unc ions, which is help-
ul o discussion o mo e han jus he mean alues. These
dis ibu ion unc ions we e de e mined by dis ibu ion iden-
i ica ion om he simula ion esul s.
“0” – G1_LTC – Gen. Logis ick=0.06296s=3351.4
m=27,976.0
“1” – Gen. Logis ick=0.04093s=3582.5m=30,364.0
“2” – Bu k=2.0806a=7.2139b=36,652.0
“3” – Bu k=3.1797a=6.2471b=41,144.0
“4” – Weibull (3P)a=2.9827b=23,244.0g=13,307.0
“5” – Johnson SBg=2.3776d=3.3915l=1.1399E+5
x=−2760.1
In abou 80% o cases, ewe hea ing-imp o emen ope a-
ions incu less cos s. Pa ien s wi h i e hea ing-imp o e-
men ope a ions always esul in he highes cos s. In app ox-
ima ely 25% o cases, he di e ence be ween wo, h ee o
ou hea ing-imp o emen ope a ions is unclea . This e ec
again mainly esul s in pa ien s wi h a low emaining li e
expec ancy, whe e a change o he VSB is no cos -e ec-
i e. Howe e , one hea ing-imp o emen ope a ion always
appea s o be be e han wo o mo e. This op ion is domi-
na ed only by he di ec VSB op ion.
F om an economic poin o iew, i can be concluded ha
i he emaining li e expec ancy is su icien , a swi ch o VSB
ea men a e he i s hea ing-imp o emen su ge y seems
o be easonable.
Based on he p e ious aspec s o he discussion, i can
be concluded:
1) When he li e expec ancy is less han 14yea s, he mos
a o able is a hea ing-imp o ing su ge y.
2) In pa ien s wi h esidual li e imes o mo e han 35yea s,
he success o exclusi e ea men wi h hea ing-
imp o emen su ge y is unlikely. Since i is shown ha
a low numbe o hea ing-imp o emen ope a ions esul s
in lowe li e ime cos s, di ec VSB implan a ion appea s
o be a good choice.
3) I he emaining li espan is be ween 14 and 36yea s,
a de ini i e s a emen abou he ad an ageousness is
di icul , bu esul s show ha downscaling hea ing-
imp o ing ope a ions makes sense.
The ollowing is an example o a possible economic
ecommenda ion.
Table 5 Cos s and cos homogenei ies depending on he du a ion o
ea men . (sou ce: own simula ion)
To al simula-
ion se
(TOP)
10yea s 20yea s 30yea s
n in simula ion 10,000 196 323 258
G oup 1
A e age cos in € 28,325 21,123 27,037 30,842
S anda d de ia ion
in €
6121 3249 4258 4652
Cos homogenei y 0.82 0.87 0.86 0.87
G oup 2
A e age cos in € 32,187 25,321 31,096 34,232
S anda d de ia ion
in €
6902 4496 5662 5975
Cos homogenei y 0.82 0.85 0.85 0.85
G oup 3
A e age cos in € 28,381 18,471 27,409 32,552
S anda d de ia ion
in €
10327 8018 9690 8037
Cos homogenei y 0.73 0.70 0.74 0.80
- es –mean cos
G1 s. G2 < 0.001 < 0.001 < 0.001 < 0.001
G1 s. G3 0.637 < 0.001 0.528 0.003
G2 s. G3 < 0.001 < 0.001 < 0.001 0.007
Bonne - es -s anda d de ia ion
G1 s. G2 < 0.001 0.013 0.002 0.031
G1 s. G3 < 0.001 < 0.001 < 0.001 < 0.001
G2 s. G3 < 0.001 < 0.001 < 0.001 < 0.001
813
Expensi e oday bu cheape omo ow: li e ime cos s o anac i e middle ea implan compa ed…
1. I TOP < 14 (age a i s in e en ion > 67), hen G3 (only
hea ing-imp o emen su ge y)
2. I TOP > 35 (age a i s in e en ion < 46), hen di ec
G1 (VSB implan a ion)
3. I 13 < TOP < 36, hen hea ing-imp o emen su ge y
(age a i s in e en ion 46 o 67). Change o VSB a e
one su ge y i emaining li e ime a da e o new in e -
en ion > 13yea s (co esponds o maximum age o
67) (= G2 wi h hea ing-imp o ing su ge y), o he wise
emain a G3 (only hea ing-imp o emen su ge y).
Based on he age dis ibu ion o TOP, we ha e ou di -
e en pa ien g oups. 16.46% o pa ien s can be exclusi ely
ea ed wi h hea ing-imp o emen su ge ies due o hei age
a i s in e en ion (> 67). 5.93% o pa ien s also ecei e only
hea ing-imp o emen su ge ies due o hei age a second
in en ion being 68 o olde . 23.76% o pa ien s can unde go
di ec VSB implan a ion because hei age a i s in e en-
ion is less han 46yea s. 53.85% o pa ien s can i s ecei e
hea ing-imp o emen su ge y, ollowed by a VSB.
Such a s a egy leads o a mean cos o 29,099.50€ wi h a
s anda d de ia ion o 8384.29€. This is s ill signi ican ly abo e
he cos o di ec VSB implan a ion, bu below he cos o
hea ing-imp o emen su ge y ollowed by VSB implan a ion
(each p < 0.001).
The main e ec esul s in he numbe o yea s he pa ien
is success ully ea ed. The cos s pe success ully ea ed yea
o li e a e 1088.61€. This is s ill highe han he cos o VSB
(1059.61€) pe yea , bu he model also only conside s cases in
Fig. 11 O e iew o simula ion esul s (he e: G1 g een; G2 ed; G3 blue) (sou ce: own simula ion)
Table 6 In luence o he numbe o hea ing-imp o emen ope a ions
on li e ime cos s (sou ce: own simula ion)
NHI (G1 o G2 da a) Mean in € S anda d
de ia ion
Cos inc eased?
“0” = G1_LTC 28,325 6121 –
“1” 30,606 6499 < 0.001
“2” 32,347 6493 < 0.001
“3” 32,796 6953 0.030
“4” 34,067 7567 < 0.001
“5” 35,394 7361 < 0.001
814 M.K ohn e al.
which a hea ing-imp o emen su ge y is ollowed by a second
in e en ion. Howe e , he cos s a e educed by mo e han 10%
compa ed o he o he s a egies.
Conclusion
Choosing a ea men op ion is a complex medical decision.
T ea men success and ou come o he pa ien is di icul o
assess om he “economis s’ desk”. Cos da a, p obabili ies
om medical da a se s and knowledge o ea men p o-
cesses enable us o es ima e u u e cos s. This can suppo
medical decision-making, which is also o en in luenced by
sho - e m cos aspec s.
Ou s udy has shown ha ime plays a decisi e ole. We
ound ha di e en ia ed decision making can educe li e ime
cos s, and ea men al e na i es pe cei ed as cos ly oday
may be bene icial in he long un. Di ec , i s -line VSB
implan a ion o implan a ion a e a low numbe o hea -
ing-imp o emen su ge ies is a easonable ea men op ion.
This opens up he possibili y o a s onge pa ien -cen e ed
app oach in decision-making. When ocusing on he cu -
en cos s o a single in e en ion, o en only he op ion o a
( u he ) hea ing-imp o ing su ge y emained open due o
he e usal o co e age by heal h insu ance. Howe e , i he
o al li e ime cos s a e conside ed, a b oade se o ea men
al e na i es (di ec implan a ion o i s hea ing-imp o ing
su ge y) may esul o he pa ien ( aking in o accoun his
o he age), which can also be conside ed economically
ad an ageous.
F om an economic poin o iew – in pa icula om
he poin o iew o heal h insu ance companies – ou
analysis shows ha he de e mina ion o li e ime cos s is
an impo an basis o economic decision-making ha goes
beyond he indi idual inancial yea o he heal h insu -
ance company. Based on pa ien da a, i was clea ly shown
ha i is economically easible o conside he op ion o
VSB implan a ion ea lie .
Wi h ega d o he me hodology o ou analysis, i
should be no ed ha cos analyses a e always subjec o
he limi a ion ha he inpu pa ame e s can change o ha
di e en heal h ca e sys ems may ha e di e en cos s uc-
u es. Fu he mo e, da a on e en s in he dis an u u e,
whe he medical o economic, is o en subjec o unce -
ain ies. Fu u e e en s a e he e o e di icul o calcula e.
Howe e , he unce ain y can be educed by using simula-
ion models ha ake dis ibu ion unc ions in o accoun .
I should also be no ed ha a conse a i e app oach in he
inclusion o unclea e en s such as complica ions educes
unce ain y.
The ocus o his analysis was on he cos o ea men .
Al hough “success ully ea ed yea s” we e add essed based
on he imes be ween su ge ies, he quali y o ca e in hese
yea s was no conside ed. O he me hods o heal h economic
Fig. 12 Cumula i e dis ibu ion unc ions o he cos s o he ea men al e na i es “0 o 5 hea ing-imp o emen ope a ions p io o VSB
implan a ion” (sou ce: own simula ion)
815
Expensi e oday bu cheape omo ow: li e ime cos s o anac i e middle ea implan compa ed…
e alua ion ela e ea men ou comes o cos s. Concei able
ou comes include ac o s such as decibels (dB) o gains in
quali y o li e (e.g., QALYs). Wha hese analyses ha e in
common is ha knowledge abou cos s is necessa y. Thus,
he p esen esul s can be ega ded as a s a ing poin o
u he analyses, me hodologically as well as o he cu en
objec o in es iga ion, VSB implan a ion.
Au ho con ibu ions MK de eloped he me hodology and w o e he
i s d a o he manusc ip . His ocus was on he me hodology, he
esul s and he discussion. KK had he p ojec lead, w o e he back-
g ound and suppo ed he de elopmen o he me hodology and dis-
cussion. KK was suppo ed in his by BS and CB. AB coo dina ed
he p ojec , expo ed he medical da a and assis ed wi h he analysis
and backg ound. SB, TL, ALS and HM ensu ed he main enance and
expansion o he medical da abase and he c ea ion o expo op ions
as well as he possibili y o medical discussion app oaches. SF, ALS,
CB and MU had he esea ch idea and led he p ojec in he di e en
dimensions o expe ise equi ed. All au ho s ead and app o ed he
inal manusc ip .
Funding Open Access unding enabled and o ganized by P ojek
DEAL. Funding in o ma ion can be ound in he ‘Con lic o in e es ’
sec ion.
A ailabili y o da a and ma e ials The da a ha suppo he indings o
his s udy a e a ailable om he co esponding au ho , upon eason-
able eques .
Decla a ions
Con lic o in e es This s udy was pa ly inanced by MED-EL. The
au ho s con i m ha he esul s o his analysis we e no in luenced a
all by his sponso ship.
Open Access This a icle is licensed unde a C ea i e Commons A i-
bu ion 4.0 In e na ional License, which pe mi s use, sha ing, adap a-
ion, dis ibu ion and ep oduc ion in any medium o o ma , as long
as you gi e app op ia e c edi o he o iginal au ho (s) and he sou ce,
p o ide a link o he C ea i e Commons licence, and indica e i changes
we e made. The images o o he hi d pa y ma e ial in his a icle a e
included in he a icle’s C ea i e Commons licence, unless indica ed
o he wise in a c edi line o he ma e ial. I ma e ial is no included in
he a icle’s C ea i e Commons licence and you in ended use is no
pe mi ed by s a u o y egula ion o exceeds he pe mi ed use, you will
need o ob ain pe mission di ec ly om he copy igh holde . To iew a
copy o his licence, isi h p://c ea i ecommons.o g/licenses/by/4.0/.
Re e ences
1. RI Inno a ion GmbH: DRG D30B. h ps:// app. eimb u sem en . in o/
d gs/ D06B?s= D06B (2023)
2. Cha i é: En gel a i ü K ankenhäuse im Anwendungsbe eich des
K ankenhausen gel gese zes (KHEn gG) und de Bundesp lege-
sa z e o dnung (BP lV) sowie Un e ich ung de Pa ien innen und
Pa ien en gemäß § 8 KHEn gG / § 8 BP lV. h ps:// www. cha i e.
de/ ilea dmin/ use _ upload/ po al/ klini kum/ behan dlung_ s a i onae /
En ge l a i . pd (2023)
3. Chadha, S., Kameno , K., Cieza, A.: The wo ld epo on hea ing,
2021. Bull Wo ld Heal h O gan (2021). h ps:// doi. o g/ 10. 2471/ BLT.
21. 285643
4. Neubaue , G., Gmeine , A.: Volkswi scha liche Bedeu ung on
Hö schäden und Möglichkei en zu Reduk ion de en Folgekos en.
h ps:// www. kb . de/ media/ sp/ 120811_ s udie_ i g_ absch lussb e ich .
pd (2011)
5. Schield, B.: Hea ing Loss – Numbe s and Cos s. EVALUATION
OF THE SOCIAL AND ECONOMIC COSTS OF HEARING
IMPAIRMENT A epo o Hea -I AISBL. h ps:// www. ehima.
com/ wp- con e n / uploa ds/ 2021/ 01/ Hea - i - Repo - Hea i ng- Loss-
Numbe s- and- Cos s- 2019. pd (2019)
6. Ins i u e o Heal h Me ics and E alua ion (IHME): GBD Compa e.
h p:// izhub. heal hda a. o g/ gbd- compa e (2015). Accessed 15 Jun
2024
7. Löhle , J., Wal he , L.E., Hansen, F., Kapp, P.C., Mee pohl, J.J.,
Wollenbe g, B., Schönweile , R., Schmucke , C.: The p e alence
o hea ing loss and use o hea ing aids among adul s in Ge many.
A sys ema ic e iew. Eu A ch O o hinola yngol Head Neck 276,
945–956 (2019)
8. Schmucke , C., Kapp, P.C., Mo schall, E., Löhle , J., Mee pohl,
J.J.: P e alence o hea ing loss and use o hea ing aids among chil-
d en and adolescen s in Ge many: a sys ema ic e iew. Uni e si ä ,
F eibu g (2019)
9. on Gablenz, P., Holube, I.: P ä alenz on Schwe hö igkei im No -
dwes en Deu schlands: E gebnisse eine epidemiologischen Un e -
suchung zum Hö s a us (HÖRSTAT). HNO (2015). h ps:// doi. o g/
10. 1007/ s00106- 014- 2949-7
10. Dispenza, F., Ba aglia, A.-M., Sal ago, P., Ma ines, F.: De e mi-
nan s o ailu e in he econs uc ion o he ympanic memb ane: a
case-con ol s udy. I an J O o hinola yngol 30, 341–346 (2018)
11. InEK: Ins i u ü das En gel sys em im K ankenhaus - Fallpauscha-
len-Ka alog 2023. h ps:// www.g- d g. de/ ag- d g- sys em- 2023/ allp
ausch alen- ka al og/ allp ausch alen- ka al og- 20232 (2022)
12. Uni e si ä sklinikum E langen: Fd-91–01 DRG-En gel a i und
P legekos en a i 2023. e langen.de/ ileadmin/da eien/pa ien en/
pa ien en_a-z/P legekos en a i _DRG.pd (2022)
13. Ka holisches Klinikum Bochum: DRG-En gel a i im Anwend-
ungsbe eich des KHEn gG Un e ich ung des Pa ein en gemäß §8
KHEn gG. h ps:// www. klini k um- bochum. de/ a b. h ml? ile= iles/
klini kum- bochum/ dokum en e/ AVB/ 2023- 09% 20DRG- En ge l a
i % 20inkl. MLK. pd (2023)
14. Klinikum Nü nbe g: En gel a i des Klinikum Nü nbe g und Un e -
ich ung de Pa ien en gemäß § 8 Abs. 9 KHEn gG bzw. § 8 Abs. 5
BP lV. h ps:// www. klini kum- nue n be g. de/ ilea dmin/ use _ upload/
Fl ye _ Dokum en e_ Ve w a l ung/ P a ie n ena u nah me_ und_ Leis ungsa
b ech nung/ En ge l a i _ 01. 11. 2023_ Ve si on_1. 0_ eu_ 25102 023. pd
(2023)
15. Klinikum S u ga : DRG-En gel a i (gemäß K ankenhausen gel -
gese z (KHEn gG)) und PEPP-En gel a i (gemäß Bundesp lege-
sa z e o dnung (BP lV)). h ps:// www. klini kum- s u ga . de/ ilea
dmin/ media pool/ do wnl oads/ 230220_ En ge l Ta i _ Klini kumS u g a
_m_ Anlag en. pd (2023)
16. Medizinische Hochschule Hanno e : DRG und PEPP En gel - und
Behandlungskos en a i Un e ich ung des Pa ien en gemäß § 8 Abs.
8 KHEn gG und § 8 Abs. 5 BP lV. h ps:// www. mhh. de/ ilea dmin/
mhh/ gb- klini kmana g eme n / downl oads/ 210105_ DR G- En g e l -_ und_
Behan dlung skos en a i _ ohne_ Fussz eile. pd (2021)
816 M.K ohn e al.
17. Uni e si ä sklinikum Bonn: En gel a i 2021 Un e ich ung des
Pa ien en gemäß § 8 KHEn gG. h ps:// www. ukbonn. de/ si e/ asse s/
iles/ 18552/ d g_ en ge l a i _ 01072 021. pd (2021)
18. Uni e si ä sklinikum Ulm: aDRG En gel a i ü das Uni e si ä -
sklinikum Ulm Un e ich ung des Pa ien en gemäß § 8 KHEn gG
Abs.8 (K ankenhausen gel gese z). h p:// www. uni e si a e skl inik-
ulm. de/ ilea dmin/ de au l / 05_ Ube - uns/ DR G_ En ge l a i _ ue _ das_
Uni e si a e skl inikum_ 01_ 2020_ Ve si on_2. pd (2020)
19. Uni e si ä smedizin Gö ingen: K ankenhausen gel a i gül ig ab
01.01.2022 ü s a ionä e und eils a ionä e Behandlung in de Uni-
e si ä smedizin Gö ingen (2022)
20. Ha ell, C., Ghosh, B.K., Bowden, R.: Simula ion using P oModel.
McG aw-Hill se ies in indus ial enginee ing and managemen sci-
ence. McG aw-Hill, Bos on, Mass. (2000)
21. Fleßa, S.: Sys emisches K ankenhausmanagemen , 2nd edn. De
G uy e S udium, Be lin (2022)
22. on de G a , S.J.M., G eine , W., Jos , F., Klusen, N., Kubin, M.,
Leidl, R., Mi endo , T., Rebsche , H., Schö ski, O., Vau h, C., Vol-
me , T., Wahle , S., Wasem, J., Webe , C.: Deu sche Emp ehlungen
zu gesundhei sökonomischen E alua ion - d i e und ak ualisie e
Fassung des Hanno e ane Konsens. Gesundhei sökonomie Qual-
i ä smanagemen (2007). h ps:// doi. o g/ 10. 1055/s- 2007- 963505
23. GKV-Spi zen e band: Appa a i e Ve so gung bei Schwe hö igkei .
Begu ach ungsanlei ung (2020)
24. S a is isches Bundesam : S e be älle und Lebense wa ung. h ps://
www. des a is. de/ DE/ Themen/ Gesel lscha - Umwel / Be oe lke u ng/
S e b e ael le- Leben se wa ung/_ inhal . h ml (2023)
25. MED-EL Medical Elec onics: VIBRANT SOUNDBRIDGE Mid-
dle Ea Implan . h ps:// www. medel. com/ hea i ng- solu ions/ ib a
n - sound b idge (2023)
26. Donau Vienna Insu ance G oup: Ve siche ung ausschließlich ü
Hö sys eme de Fi ma MED-EL. h ps:// www. bk. co. a / wp- con e
n / uploa ds/ 2023/ 04/ MED- EL- An ag- 04- 2023. pd (2022)
27. Wa denga, N., Died ich, V., Waldmann, B., Lena z, T., Maie , H.:
Hea ing aid ea men in pa ien s wi h mixed hea ing loss. Pa I:
expec ed bene i and limi a ions a e s apes su ge y. Audiol Neu-
o ol (2020). h ps:// doi. o g/ 10. 1159/ 00050 2994
28. Thum, C., Langen eld, R., Flessa, S.: Lebenszei kos en de Hö ge -
ä e e so gung in Deu schland (li e ime cos o hea ing aids in
Ge many). La yngo hinoo ologie (2021). h ps:// doi. o g/ 10.
1055/a- 1253- 8325
29. Wa denga, N., Snik, A.F.M., Klud , E., Waldmann, B., Lena z, T.,
Maie , H.: Hea ing aid ea men o pa ien s wi h mixed hea ing
loss. Pa II: speech ecogni ion in compa ison o di ec acous ic
cochlea s imula ion. Audiol Neu o ol (2020). h ps:// doi. o g/ 10.
1159/ 00050 4285
Publishe 's No e Sp inge Na u e emains neu al wi h ega d o
ju isdic ional claims in published maps and ins i u ional a ilia ions.