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Original Investigation
August 1, 2019

Geographic Disparities in US Veterans’ Access to Cochlear Implant Care Within the Veterans Health Administration System

Author Affiliations
  • 1Department of Otolaryngology–Head and Neck Surgery, Oregon Health & Science University, Portland
  • 2Operative Care Division, Veterans Health Administration Portland Health Care System, Portland, Oregon
  • 3Department of Neurology, Oregon Health & Science University, Portland
JAMA Otolaryngol Head Neck Surg. Published online August 1, 2019. doi:10.1001/jamaoto.2019.1918
Key Points

Question  What are the geographic limitations faced by US veterans in accessing cochlear implant care within the Veterans Health Administration system?

Findings  In this analysis of census tract–level data on 19.9 million US veterans, more than 80% of veterans in 7 states resided more than 180 miles from the nearest Veterans Health Administration facility providing cochlear implant services, including sites that offer only audiologic services. Veterans living in both rural and large urban population centers face several geographic limitations in accessing cochlear implant care.

Meaning  This study suggests that additional avenues to provide cochlear implant services within the Veterans Health Administration system may help provide adequate and accessible care to veterans with hearing loss.


Importance  Veterans are at high risk for developing sensorineural hearing loss leading to cochlear implant (CI) candidacy; however, the ability to care for these patients is limited by the number and location of Veterans Health Administration (VHA) facilities that provide specialized CI services.

Objective  To investigate geographic disparities in access to CI care within the VHA system for US veterans.

Design, Setting, and Participants  An analysis of census tract–level data including US veterans was conducted using the nationwide American Community Survey data collected by the US Census Bureau from January to December 2016, which were accessed in 2017.

Main Outcomes and Measures  Maps showing the geographic variability in need for specialized CI services, estimated as a function of the number of veterans and the distance to the nearest established VHA-based CI surgical or audiologic facilities.

Results  A total of 19.9 million veterans within the continental United States resided at a median distance of 80 miles (interquartile range [IQR], 30.1-140.9; mean [SD], 1002 [465.8] miles) from the nearest VHA facility offering CI care; of these, 3.98 million (20.0%) resided more than 160.7 miles from the nearest VHA facility. When considering only comprehensive facilities offering both surgical and audiologic care, the median distance was 101.3 miles (IQR, 39.4-178.7; mean [SD], 126.0 [448.4] miles), but 20.0% of veterans had to travel more than 201.0 miles to a VHA facility. Veterans residing in urban areas (74.0%) lived a median distance of 61.2 miles (IQR, 23.7-121.3; mean [SD], 83.8 [477.1] miles) from the nearest VHA facility, with 2.9 million (20.0%) living the farthest at 140.7 miles. Veterans residing in rural areas (26.0%) lived a median distance of 119.8 miles (IQR, 79.0-182.4; mean [SD], 146.9 [431.0] miles) from their nearest VHA facility, with 1.04 million (20.0%) living more than 206.2 miles from the nearest VHA facility.

Conclusions and Relevance  This study’s findings suggest that large disparities exist in the distance to the nearest VHA-based CI facilities. Veterans face considerable geographic barriers to obtaining VHA-based CI care in many parts of the country, including some large metropolitan areas. Those requiring only audiologic services face similar geographic barriers as those requiring surgery. Thoughtful placement of new facilities, along with upcoming advances in remote programming of implants, may help ensure appropriate care for this high-risk population.