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Objective/Hypothesis: The aim of this study was to explore the cost-utility of pediatric cochlear implantation, incorporating savings associated with ed· ucation into the analysis. Methods: The costs of pedi· atric cochlear implantation were based on the full costs levied to purchasers, inclusive of complications and maintenance, by a large pediatric cochlear im· plant program in the United Kingdom. After implantation, profoundJy hearing-impaired children have been found to develop hearing threshold levels equiv· alent to severely hearing-impaired children who wear hearing aids. An independent study calculated the educational costs for severely hearing-impaired and profoundJy hearing-impaired children. From this study, savings in ducational costs that would result from enabling the profoundly hearing-impaired to function as severely bearing-impaired were deter· mined. Cost-utility was established conservatively by applying to children the known gains in utility re· ported by adults with cochlear implants. Results: The discounted costs of creating a pediatric cochlear im· plant user and of maintaining the child over the first 12 years were £48,757 ($78,011). The discounted differ· ence in education costs associated with a profoundJy hearing-impaired child (IIL >95 dB) as compared with a sever ly hearing-impaired child over the same period was £26, 781 ($42,850). These rep· r sent the potential savings in educational costs asso· ciated with pediatric cochlear implantation. Assum· ing implantation at age 4 years, the discounted net average cost of pediatric cochlear implantation over compulsory chool years (ages 4-16) was £21,976 ($35,162). Cochlear implants have been shown to improve the quaJity of life in adults by 0.23 points per annum (where quality of life is rated on a scale from 0 to 1). Applying this weight to children r ceiving im· plantation at age 4 years, and assuming a life expectancy of 74 years, the quality-adjusted life-year (QALY) 156 gain is calculated to be 16.33. The cost per undis· counted QALY gain was estimated to b e £1,345.70 ($2153.12) and per discounted QALY gain to be £10,341 ($16,545.60). Conclusion: This study provides evidence, based on conservative assumptions, to support the view that pediatric cochlear implantation is a cost-effective health care intervention in profoundJy hearing-impaired young children.

The results suggest that speech intelligibility between 2 and 5 yr after implantation in young children with congenital and prelingual profound deafness can be predicted by measures of earlier speech perception.

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This paper assesses the expressive spoken grammar skills of young deaf children using cochlear implants who are beginning formal education, compares it with that achieved by normally hearing children and considers possible implications for educational management. Spoken language grammar was assessed, three years after implantation, in 45 children with profound deafness who were implanted between ten and 36 months of age (mean age = 27 months), using the South Tyneside Assessment of Syntactic Structures (Armstrong and Ainley, 1983) which is based on the Language Assessment and Remediation Screening Procedure (Crystal et al., 1976). Of the children in this study aged between four and six years, 58 per cent (26) were at or above the expressive spoken language grammatical level of normally hearing three year olds after three years of consistent cochlear implant use: however, 42 per cent (19) had skills below this level. Aetiology of deafness, age at implantation, educational placement, mode of communication and presence of additional disorders did not have a statistically signifi cant effect (accepted at p ≤ 0.05) on the development of expressive spoken grammar skills. While just over half of the group had acquired spoken language grammar skills equivalent to or above those of a normally hearing three year old, there Deafness and Education International Inscoe et al. 40remains a sizeable group who, after three years of cochlear implant use, had not attained this level. Spoken language grammar therefore remains an area of delay for many of the children in this group. All the children were attending school with hearing children whose language skills are likely to be in the normal range for four to six year olds. We therefore need to ensure that the ongoing educational management of these deaf children with implants addresses their spoken grammar delay in order that they can benefi t more fully from formal education.Expressive spoken language development 43 CI = Cochlear implant; TC = Total Communication; OA = oral; CMV = Cytomegalovirus.