The Laryngoscope V C 2011 The American Laryngological, Rhinological and Otological Society, Inc. Contemporary Review The Cost-Utility of Bilateral Cochlear Implantation: A Systematic Review Marc J. W. Lammers, MD; Wilko Grolman, MD, PhD; Yvette E. Smulders, MD; Maroeska M. Rovers, PhD Objectives/Hypothesis: The (cost-)effectiveness and the subsequent reimbursement of bilateral cochlear im- plantation has been vigorously debated. Throughout the world healthcare commissioners are still struggling with the decision to reimburse bilateral implantation. Given this debate, this study’s objective was to review the litera- ture on the cost-utility of bilateral cochlear implantation in both children and adults, and study the impact of the used cost and quality-of-life estimates. Study Design: Systematic review. Methods: Electronic databases were systematically searched for relevant studies published up to December 2010. All studies reporting on cost-utility and bilateral cochlear implantation were included. Results: Five studies fulfilled the inclusion criteria. The methodological quality of the studies, assessed with Drummond’s checklist of cost-effectiveness studies, varied from poor to good. The assumptions regarding gain in quality-adjusted life years (QALYs) and direct costs varied among studies, resulting in a varying gain in QALY (0.38–1.93). The incremental cost-effectiveness ratios for bilateral cochlear implantation differed widely across stud- ies for both children and adults (children: $30,973–$94,340; adults: $38,189–$132,160) and were inversely related to the gain in QALY, cost reductions due to simultaneous implantation, and discounts offered on the second implant. Conclusions: The incremental cost-effectiveness ratios for bilateral cochlear implantation vary widely and appear to depend on the gain in QALY due to the second implant. The results of this review confirm that more em- pirical data are required to estimate the cost-effectiveness of bilateral implantation. Key Words: Cochlear implantation, cost-benefit analysis, cost-effectiveness analysis, quality-adjusted life years, quality of life. Level of Evidence: 2a. Laryngoscope, 121:2604–2609, 2011 INTRODUCTION Over the last few years the (cost-)effectiveness of bilateral versus unilateral cochlear implantation has been vigorously debated. In some countries, healthcare commis- sioners have decided to reimburse bilateral implantation, whereas in other countries the commissioners were not convinced by the current evidence and subsequently decided not to reimburse a second cochlear implant. To reimburse a particular intervention, healthcare policy makers require evidence on the safety, clinical effec- tiveness, and cost-effectiveness of the intervention. The effectiveness of cochlear implantation is frequently demon- strated with clinical outcome measures, such as speech in noise tests and electrophysiologic testing. From a patient’s point of view, the quality of life and health utility are more important parameters. The health utility of a patient, also referred to as health-related quality of life, is the corner- stone in cost-utility analyses. Many clinical studies use questionnaires, such as the Health Utilities Index Mark 3 (HUI 3), which expresses a patient’s health utility on a scale ranging from zero to one, where one corresponds to perfect health and zero to death. 1 Other methods for esti- mating health utility are the time trade-off (TTO) and the visual analogue scale (VAS). 2 The cumulative improvement in quality of life measured with these methods can be con- verted to generic units of health gain, such as quality- adjusted life years (QALYs), which form the basis of cost- utility analyses. Whether or not an intervention is cost- effective depends on the costs of gaining 1 QALY. In view of the ongoing debate about the (cost)- effectiveness of bilateral cochlear implantation, it is From the Department of Otorhinolaryngology–Head and Neck Surgery (M.J.W.L., W.G., Y.E.S., M.M.R.), Rudolf Magnus Institute of Neuroscience (M.J.W.L., Y.E.S.), and Julius Center for Health Sciences and Primary Care (M.M.R.), University Medical Center Utrecht, Utrecht, The Netherlands. Editor’s Note: This Manuscript was accepted for publication June 15, 2011. Wilko Grolman, MD, received unrestrictive research grants from Cochlear Ltd., Med-El GmbH, and Advanced Bionics. The authors have no other funding, financial relationships, or conflicts of interest to disclose. Send correspondence to Marc J. W. Lammers, MD, Department of Otolaryngology–Head and Neck Surgery, University Medical Center Utrecht, G02.531, PO Box 85500, 3508 GA Utrecht, The Netherlands. E-mail: ent-research@umcutrecht.nl DOI: 10.1002/lary.22387 Laryngoscope 121: December 2011 Lammers et al.: Bilateral Cochlear Implantation 2604