Abstract
Objective:
To quantify progression through the hearing care pathway among US adults aged ≥65 years with bilateral sensorineural hearing loss (SNHL) and describe variation across geographic and community contexts.
Study Design:
Cross-sectional study.
Setting:
Epic Cosmos Database, January 1, 2021, through December 31, 2024.
Patients:
Adults aged ≥65 years with bilateral SNHL identified using International Classification of Diseases, Tenth Revision codes.
Main Outcome(s) and Measure(s):
Stage-specific unadjusted odds ratios with 95% confidence intervals were calculated for progression across audiology evaluation, cochlear implant evaluation, and cochlear implantation. Statistical significance was defined as P < 0.05, with P < 0.001 considered a strong signal given the large sample size.
Results:
Among 1,461,489 older adults with bilateral SNHL, 746,118 (51.1%) underwent audiology evaluation; fewer than 2% received cochlear implant candidacy evaluation, while approximately 64% of those evaluated for cochlear implantation proceeded to surgery. Marked stage-specific attrition was observed. Adults aged 85 years or older had lower odds of audiology access, higher odds of candidacy evaluation, and lower odds of cochlear implantation. Black and Asian patients had lower odds of candidacy evaluation. Women were less likely to undergo candidacy evaluation but more likely to receive implantation once evaluated for candidacy. Patients living farther from a cochlear implant center and those in rural areas had higher odds of both candidacy evaluation and cochlear implantation, a counterintuitive finding that likely reflects a selection effect among patients who overcome distance barriers rather than improved geographic access.
Conclusions:
In this national cohort, disparities along the cochlear implant care pathway were associated less with audiologic access due to distance and more with attrition at cochlear implant candidacy assessment. Candidacy referral and evaluation represent a critical, potentially modifiable bottleneck for improving equity in hearing care among older adults.
Keywords: Audiology, Cochlear implant, Sensorineural hearing loss, Social determinants of health
Hearing loss is one of the leading causes of disability, affecting approximately 1.57 billion people worldwide and an estimated 79.9 million people in the United States as of 2021 (1). Prevalence increases sharply with age; nearly 1 in 3 US adults aged 65–74 and almost half of adults aged ≥75 years experience hearing loss (2,3).
Age-related hearing loss, or progressive bilateral sensorineural hearing loss (SNHL), impacts far more than communication alone. Untreated hearing loss has been associated with increased risk of dementia, depression, falls, social isolation, and cardiovascular disease (4–9).
Cochlear implants (CIs) are the standard of care for adults with significant SNHL who receive limited benefit from hearing aids and have been shown to improve communication ability, quality of life, and long-term health outcomes while being cost-effective (10–13). CI utilization in the United States remains low, with estimates ranging from 5% to 13% of eligible adults, and disparities documented across sociodemographic and regional contexts (14–16).
Adults with SNHL typically enter the hearing care pathway through diagnostic audiology evaluation, where hearing thresholds and functional communication are assessed. American Cochlear Implant Alliance recommendations emphasize CI evaluation referral when the unaided pure-tone average is ≥60 dB, and the word recognition score is ≤60% in the better ear (17,18). Once eligibility is met, patients progress through a defined care pathway from diagnostic audiology evaluation, advancing to candidacy assessment and surgery. However, recent national claims analyses report that cochlear implantation does not consistently align with diagnostic audiology utilization (14). Cochlear implantation had a weak correlation with SNHL and audiology utilization rates in that analysis, and this misalignment could imply that under-referral and limited clinical awareness, rather than absent diagnostic access, contribute to CI underutilization even in regions where hearing evaluations are common. This gap at the transition from diagnostic audiology to candidacy referral is the specific point the present study seeks to contextualize.
Among patients who do receive a CI candidacy evaluation, progression to surgery is also uneven. Prior work has shown that older patients, those with lower socioeconomic status, and those living outside metropolitan areas are less likely to undergo cochlear implantation, even when candidacy is confirmed (19,20). This indicates that a critical bottleneck exists not solely at the point of clinical eligibility determination, but also within the transition from CI evaluation to the decision-to-surgery stage of the care pathway. However, existing studies have largely examined cochlear implantation at isolated points of care. To our knowledge, national analyses have not characterized where along the CI pathway care disparities emerge, limiting the ability to distinguish barriers to audiology entry, candidacy evaluation, and implantation.
This study investigates the CI care pathway from audiology evaluation through candidacy assessment and implantation on a national scale. By examining associations between sociodemographic and geographic factors in a stage-specific progression, the analysis aims to identify potential structural bottlenecks that limit equitable access to cochlear implantation.
MATERIALS AND METHODS
Data Source
This cross-sectional study utilized Epic Cosmos (21), a Health Insurance Portability and Accountability Act—defined limited dataset that aggregates electronic health records and includes over 300 million patients from 1884 hospitals and 42,400 clinics across the United States, Canada, Lebanon, and Saudi Arabia (22). The database includes patient demographics, diagnoses, procedures, and socioeconomic factors. In accordance with institutional policy and federal regulations (45 CFR §46.102), this research was determined to be exempt from institutional review board approval. This study follows the STROBE reporting guidelines for cross-sectional studies (23).
Study Population
A base patient was defined as a US resident aged 65 years or older who had at least 2 encounters in any 2-year timespan between January 1, 2021, and December 31, 2024, to ensure analysis of longitudinal patient charts. Within this base population, individuals with bilateral SNHL were identified using International Classification of Diseases, Tenth Revision (ICD-10) codes H91.13 (Presbycusis, bilateral) and H90.3 (SNHL, bilateral). Consistent with established CI candidacy criteria for this age group and to focus the analysis on age-related hearing loss for clarity of data, patients with conductive or mixed hearing loss, sudden or unilateral SNHL, and otologic conditions amenable to medical or non-CI surgical correction were excluded (16,24–26). These etiologies involve diagnostic work-up and management that differ from age-related bilateral SNHL and typically follow distinct, often non-CI, treatment pathways, which could confound a utilization analysis focused on the age-related hearing loss population for whom cochlear implantation is the relevant intervention. These exclusion criteria favor etiologic homogeneity over sensitivity. Detailed exclusion codes are provided in Supplemental Table 1, https://links.lww.com/ONO/A47.
CI status was defined using medical billing codes such as Current Procedural Terminology (CPT) codes and ICD-10 codes for an active CI device as outlined in Supplemental Table 2, https://links.lww.com/ONO/A48 (27–30).
Audiology evaluation was identified using CPT codes for diagnostic audiological examination or comprehensive threshold and speech recognition testing that capture completed billable services within the Epic Cosmos database (Supplemental Table 3, https://links.lww.com/ONO/A49) (14,31,32). These evaluations represent the clinical step typically preceding CI candidacy evaluation and serve as a measure of access to specialty diagnostic care rather than a measure of hearing severity.
CI candidacy evaluation, CPT code 92626 (15), captures entry into the CI evaluation pathway and formal assessment for potential implantation. As audiometric thresholds are not available in Epic Cosmos, this code represents access to evaluation rather than determination of CI eligibility.
Covariates
Care pathway progression was analyzed across each stage: audiology evaluation, CI candidacy evaluation, and cochlear implantation. The patient groups were stratified by age at visit, sex recorded using legal documentation, self-reported race and ethnicity, US Census region, insurance, rural–urban commuting area (RUCA), and social vulnerability index (SVI).
RUCA codes are based on population density and urbanization patterns at the ZIP code level. RUCA codes were categorized into a 3-tier classification: metropolitan (primary RUCA code, 1–3), micropolitan (4–6), and rural communities (7–10) (33–35).
SVI was assigned according to each patient’s most recent residential ZIP code, using Census tract-level data from the US Centers for Disease Control and Prevention. SVI reflects community-level social and structural conditions, including income, transportation access, and housing characteristics (36–38). SVI was categorized into tertiles: 0 to <33% (lowest vulnerability), ≥33 to <66%, and ≥66% (highest vulnerability).
Proximity to Cochlear Implant Surgical Centers
As the distance to the surgical center could impact the ability and decision to receive a CI (39), adult CI surgical centers were identified using publicly available center lists from Advanced Bionics and Cochlear Americas as of October 2025. This list aims to capture most US implanting institutions but may miss centers that are exclusively affiliated with other manufacturers such as MED-EL, though they are unlikely to significantly affect geographic classification.
A manual review of each location was conducted to confirm that it provided adult cochlear implantation. Locations offering audiology or programming services only, centers without a CI surgeon, and clinics serving exclusively pediatric populations were excluded. Veterans Affairs centers that provide cochlear implantation were included. The final list of CI surgical centers included is provided in Supplemental Table 4, https://links.lww.com/ONO/A50.
Geographic proximity to CI centers was represented using centroid-based geospatial distance calculations at a ZIP code level, using the geocode Python package. Distance was used as a measure of structural geographic access, not appointment availability or referral practices. Patients were categorized into 3 proximity strata: ≤25 miles (local), >25 to ≤50 miles (regional), and >50 miles (extended).
Statistical Analysis
For stage-specific analyses, odds ratios (OR) with 95% confidence intervals were calculated using stage-specific denominators that reflect progression through the CI care pathway. For CI candidacy evaluation, analyses were restricted to patients who had undergone audiology evaluation, and for cochlear implantation, they were restricted to patients who had undergone candidacy evaluation. Statistical significance was set at P < 0.05, but given the large sample size, a strong signal of association was set as P < 0.001. Odds ratios are reported with 95% confidence intervals, formatted as (OR, point estimate; lower–upper bound).
RESULTS
Among 1,461,489 US adults aged ≥65 years with bilateral SNHL in Epic Cosmos, 22,620 (1.55%) had a CI status code, and 15,415 (1.1%) received a CI candidacy evaluation during the study period. Both are cohort-wide counts, calculated against the full cohort rather than sequentially. CI status exceeds captured candidacy evaluations because implant status codes persist in the record regardless of when implantation occurred, whereas candidacy evaluation was counted only when billed during the study period. These totals are therefore distinct from the stage-specific pathway analysis as shown in Table 1, where each step is restricted to patients who completed the preceding step.
TABLE 1.
Cochlear implant care pathway
| Step in cochlear implant care pathway | N | % |
|---|---|---|
| Adults ≥65 years with bilateral SNHL | 1,461,489 | — |
| Received audiology evaluation | 746,118 | 51.05% of patients ≥65 years with bilateral SNHL |
| Cochlear implant candidacy evaluation | 9944 | 1.33% of those who received audiology evaluation |
| Cochlear implant surgery | 9804 | 63.6% of those who received candidacy evaluationa |
Cochlear implant surgery percentage is calculated among all patients with a candidacy evaluation (n = 15,415), regardless of whether a prior audiological evaluation was captured, to reflect the candidacy-to-surgery transition.
SNHL indicates sensorineural hearing loss.
In Table 1 with stage-specific pathway analysis, 51.05% of the cohort received an audiology evaluation (n = 746,118); among those patients, 1.33% underwent CI candidacy evaluation (n = 9,944). Because some candidacy evaluations were not preceded by a captured audiology visit, the candidacy-to-surgery transition was assessed across the full CI candidacy population (n = 15,415, including 9,944 with a captured audiology evaluation), of whom 63.6% proceeded to surgery (n = 9,804). Table 2 summarizes demographic characteristics in each cohort.
TABLE 2.
Cochlear implant care pathway among adults with bilateral SNHL
| Characteristic | Base patient cohort (N = 1,461,489) |
Audiology examination (N = 746,118) |
Candidacy evaluation (N = 9,944) |
Cochlear implant surgery (N = 9,804) |
|---|---|---|---|---|
| Sex | ||||
| Female | 743,259 (51) | 403,125 (54) | 4190 (42) | 4389 (45) |
| Male | 718,129 (49) | 342,954 (46) | 5753 (58) | 5415 (55) |
| None of the above | 101 (0) | 39 (0) | 1 (0) | |
| Age | ||||
| ≥65–<75 | 549,071 (38) | 324,224 (43) | 3124 (31) | 3170 (32) |
| ≥75–<85 | 565,499 (39) | 287,106 (38) | 4362 (44) | 4259 (43) |
| 85+ | 346,919 (24) | 134,788 (18) | 2458 (25) | 2375 (24) |
| Race | ||||
| White | 1,232,185 (84.31) | 614,939 (82.42) | 8756 (88.05) | 8855 (90.32) |
| Black | 111,337 (7.62) | 68,956 (9.24) | 160 (1.61) | 463 (4.72) |
| Asian | 51,589 (3.53) | 26,114 (3.50) | 244 (2.45) | 214 (2.18) |
| Native Hawaiian/other PI | 5265 (0.36) | 2665 (0.36) | 21 (0.21) | 19 (0.19) |
| American Indian/Alaska Native | 10,905 (0.75) | 5841 (0.78) | 79 (0.79) | 64 (0.65) |
| Other | 131,281 (8.98) | 72,180 (9.67) | 868 (8.73) | 791 (8.07) |
| None of the above | 45,337 (3.10) | 24,261 (3.25) | 242 (2.43) | 211 (2.15) |
| Rural–urban community | ||||
| Metropolitan | 1,223,718 (83.73) | 629,337 (84.35) | 8,010 (80.55) | 7,838 (79.95) |
| Micropolitan | 116,583 (7.98) | 55,067 (7.38) | 898 (9.03) | 940 (9.59) |
| Small town/rural | 107,021 (7.32) | 55,258 (7.41) | 939 (9.44) | 931 (9.50) |
| N/A | 14,167 (0.97) | 6,456 (0.87) | 97 (0.98) | 95 (0.97) |
| Primary payer | ||||
| Medicaid | 94,767 (6.48) | 55,966 (7.50) | 485 (4.88) | 336 (3.43) |
| Medicare | 1,254,324 (85.83) | 644,721 (86.41) | 8878 (89.28) | 8795 (89.71) |
| Commercial | 434,034 (29.70) | 251,195 (33.67) | 2760 (27.76) | 2621 (26.73) |
| Self-pay | 38,091 (2.61) | 22,695 (3.04) | 264 (2.65) | 233 (2.38) |
| Not Insured | 24,557 (1.68) | 16,702 (2.24) | 245 (2.46) | 257 (2.62) |
| Other | 79,863 (5.46) | 37,196 (4.99) | 475 (4.78) | 471 (4.80) |
| None of the Above | 53,691 (3.67) | 12,910 (1.73) | 195 (1.96) | 211 (2.15) |
| US census region | ||||
| Midwest | 449,302 (30.74) | 238,322 (31.94) | 3387 (34.06) | 2954 (30.13) |
| Northeast | 332,754 (22.77) | 170,967 (22.91) | 1700 (17.10) | 1531 (15.62) |
| South | 446,601 (30.56) | 232,596 (31.17) | 3404 (34.23) | 3531 (36.02) |
| West | 219,642 (15.03) | 97,618 (13.08) | 1369 (13.77) | 1696 (17.30) |
| None of the above | 13,190 (0.90) | 6,615 (0.89) | 84 (0.84) | 92 (0.94) |
| Distance to cochlear implant center | ||||
| Within 25 miles | 877,815 (60) | 466,927 (62.58) | 5819 (59) | 5460 (56) |
| Within 25–50 miles | 226,364 (15) | 105,826 (14.18) | 1651 (17) | 1708 (17) |
| ≥50 miles | 253,080 (17.32) | 127,679 (17.11) | 1876 (18.9) | 1957 (20) |
| None of the above | 104,230 (7.13) | 45,686 (6.12) | 598 (6.01) | 679 (6.93) |
| SVI tertile | ||||
| 0–33% (lowest vulnerability) | 605,743 (41) | 99,918 (13) | 3941 (40) | 3926 (40) |
| 33–66% | 438,101 (30) | 70,250 (9) | 3087 (31) | 3158 (32) |
| 66–100% | 400,446 (27) | 51,995 (7) | 2802 (28) | 2611 (27) |
| None of the Above | 17,199 (1.18) | 2,769 (0.37) | 114 (1.15) | 109 (1.11) |
SVI indicates Social Vulnerability Index.
Figure 1 illustrates the adjusted ORs for receiving an audiology evaluation among adults aged ≥65 years with bilateral SNHL. Figure 2 presents the adjusted ORs for undergoing CI candidacy evaluation among patients who completed an audiology evaluation. Figure 3 shows the adjusted ORs for receiving a CI among patients who underwent CI candidacy evaluation.
FIG. 1.
Odds ratios of a patient ≥65 years with bilateral sensorineural hearing loss receiving an audiology examination. OR indicates odds ratios; SVI, Social Vulnerability Index.
FIG. 2.
Odds ratios of a patient receiving a cochlear implant candidacy evaluation of those who received audiology evaluation. OR indicates odds ratios; SVI, Social Vulnerability Index.
FIG. 3.
Odds ratios of a patient receiving a cochlear implant of those who had a cochlear implant candidacy evaluation. OR indicates odds ratios; SVI, Social Vulnerability Index.
Compared with younger patients aged ≥65 to <75, older adults (age ≥85) were less likely to enter hearing care (OR, 0.44; 0.44–0.44, Fig. 1), more likely to be evaluated for CI candidacy once in care (OR, 1.91; 1.81–2.01, Fig. 2), but less likely to ultimately receive an implant (OR, 0.81; 0.75–0.87, Fig. 3). A similar but weaker association was seen when comparing adults aged ≥75 to <85 with those aged ≥65 to <75.
Women were more likely than men to undergo audiology evaluation (OR, 1.30; 1.29–1.31, Fig. 1) but were less likely to move from audiology to candidacy evaluation (OR, 0.62; 0.59–0.64, Fig. 2). Among those who did reach candidacy evaluation, this pattern reversed as women had higher odds of cochlear implantation (OR, 1.24; 1.16–1.32, Fig. 3).
Racial and ethnic disparities were most evident at the candidacy evaluation stage. Black and Asian patients cleared the first stage more readily than White patients, with higher odds of receiving an audiology evaluation (OR, 1.63; 1.61–1.65 and OR, 1.03; 1.01–1.05, respectively, in Fig. 1). Yet this early advantage reversed at every subsequent stage: both groups had significantly lower odds of CI candidacy evaluation (OR, 0.20; 0.17–0.24 and OR, 0.66; 0.58–0.75, Fig. 2) and, among those evaluated, of implantation (OR, 0.66; 0.57–0.76 and OR, 0.75; 0.61–0.92, Fig. 3).
Rurality demonstrated associations that varied in direction across the care continuum. Compared with metropolitan residents, individuals in micropolitan areas had lower odds of receiving audiological services (OR, 0.85; 0.84–0.86, Fig. 1), whereas micropolitan and rural residents had elevated odds of candidacy evaluation and cochlear implantation.
Distance to a CI surgical center showed an inverse association at the earliest stage of audiology services, with individuals living farther demonstrating reduced odds relative to those within 25 miles. In contrast, greater distance (>50 miles) was associated with elevated odds of having a CI candidacy evaluation (OR, 1.12; 1.07–1.18, Fig. 2) and CI surgery (OR, 1.24; 1.14–1.36, Fig. 3).
DISCUSSION
In this large national analysis, disparities in CI access arise in a highly stage-specific manner across the care cascade. Using prior population-based National Health and Nutrition Examination Survey modeling, Yu et al (40) estimated that approximately 3.7% of US adults aged 65 years or older (~2.08 million individuals) meet expanded Centers for Medicare and Medicaid Services audiologic criteria for cochlear implantation in bilateral hearing loss.
In comparison, 22,620 of 1.46 million older adults with bilateral SNHL in this dataset (1.55%) had CI status documented. Although Epic Cosmos does not capture individual-level candidacy determinations, the discrepancy between modeled candidacy prevalence and observed implantation suggests that many older adults who could benefit from cochlear implantation remain unimplanted.
A consistent theme across sociodemographic and geographic factors was disengagement at key transition points in the care pathway, rather than a global disconnect from care. Advanced age (≥85 years) was associated with a stage-dependent pattern: lower odds of entering audiology care, higher odds of candidacy evaluation once evaluated, and lower odds of implantation thereafter. This locates the reduced CI utilization for the oldest adults at entry into care and at the surgical step rather than at candidacy determination. Interventions to increase hearing screening in older and rural populations, utilizing primary care-driven referrals or nonaudiology private hearing aid centers not captured in this dataset, may meaningfully influence downstream care engagement.
Geographic context shaped where along the pathway disparities emerged. Individuals in micropolitan and rural areas, and those living farther from a CI center, demonstrated lower odds of accessing audiological services, yet higher odds of progressing once engaged. This paradoxical pattern is consistent with a selection effect: patients who overcome the barrier of distance may differ systematically from those who do not, in terms of clinical severity, motivation, insurance coverage, or upstream referral filtering, such that those who reach care are more likely to progress through it.
Zhan et al (14) reported wide geographic variation in the United States and proposed under-referral after the audiology stage as a key contributor to low CI utilization, even in regions with high use of audiologic services. While this analysis does not assess temporal trends, the observed patterns in this study are consistent with referral inefficiencies early in the care pathway.
Age alone should not limit CI surgery since older adults, especially those 80 years and older, experience meaningful improvement in quality of life and speech following implantation (2,41,42). Barnes et al (43) demonstrated the importance of timely referral, showing that adult CI recipients present with speech perception well below current eligibility thresholds, a pattern that disproportionately affects older adults who also showed lower audiology utilization.
Prior single-center studies have shown that younger age and non-White race had higher odds of being deemed eligible for cochlear implantation, yet White patients were more likely to proceed to surgery (20,44,45). These observations are not necessarily inconsistent with the present findings, and apparent paradoxes have plausible explanations. In a single-center study of 823 adult evaluations (20), younger age was the only independent predictor of qualifying for implantation, with each additional year of age slightly lowering the odds of qualification; this likely reflects delayed referral, as older patients may present later in their hearing-loss trajectory, when comorbidities and other factors complicate candidacy.
The pattern by race is analogous. The higher candidacy rates among non-White patients likely reflect more severe hearing loss at the time of evaluation. Critically, these earlier studies characterized candidacy determination among patients who had already reached formal evaluation, whereas the present analysis characterizes progression to evaluation. Together, the lower odds of reaching evaluation among non-White patients and their higher conditional eligibility once evaluated suggest that disparities arise predominantly upstream, at referral and entry into evaluation, rather than at the point of clinical eligibility determination. Several mechanisms may contribute to this upstream gap: limited access to non-English CI testing batteries may underlie part of the association across races, and a scoping review of barriers to CI utilization has identified additional structural, societal, organizational, and interpersonal factors that could be targeted by intervention (46).
Taken together, these findings indicate that CI underutilization stems from gaps across the care pathway, rather than from a lack of access to hearing care alone. Because attrition was stage-specific, interventions are likely to be most effective when matched to the transition they target. At the entry stage, strengthening connections between primary care physicians, audiologists, and private hearing aid centers may improve patient education and facilitate earlier entry into the hearing care pathway. Telehealth may further mitigate geographic and distance-related barriers (47,48).
At the referral-to-candidacy transition, where attrition was steep, standardizing referral practices through validated clinical audiologic measures may reduce variability and ensure timely identification of candidates (49,50).
At the final treatment stage, expanding the pool of providers trained in cochlear implantation and increasing the geographic reach of CI programs may support equitable progression for patients who would meaningfully benefit from implantation (39).
LIMITATIONS
This study draws on the scale and diversity of the Epic Cosmos dataset, providing a large and heterogeneous sample that represents hearing care patterns across US health systems, geographic regions, and patient populations (51–53). Because diagnoses and procedures are entered by treating clinicians, the data capture real-world clinical decision-making and care delivery. However, despite standardized quality controls, including Joint Commission compliance and internal auditing, variation in coding practices and incomplete or inaccurate documentation may affect the completeness and fidelity of the data and cannot be fully eliminated. In addition, the requirement of at least 2 encounters within a 2-year window, although intended to ensure longitudinal chart capture, may have preferentially excluded patients with the most limited healthcare access and could therefore lead the analysis to underestimate the magnitude of access-related disparities.
Epic Cosmos does not include audiometric threshold or speech recognition measures, which are essential for determining CI candidacy. Given that recent evidence shows CI eligibility can shift substantially depending on the speech criteria applied, candidacy cannot be accurately inferred from diagnostic coding alone; moreover, the dataset does not capture private or non-Epic hearing care systems (40). Thus, differences observed across groups could reflect both variations in candidacy qualification and access. Therefore, this study focuses on the utilization of evaluation and implantation services, rather than the determination of candidacy status.
Furthermore, Epic Cosmos provides aggregate rather than individual patient-level data, which prevents adjustment of the reported ORs. Because the aggregate structure precludes multivariable adjustment for comorbidity burden, functional status, and patient preference, observed trends (such as lower cochlear implantation rates in older populations) may be partially driven by factors that could not be accounted for, including medical comorbidities that increase surgical risk and reduce surgery rates. These findings should therefore be interpreted as population-level patterns rather than independent causal drivers, and some of the variation that appears to reflect differential access may instead stem from appropriate, individualized clinical decision-making rather than inequitable care.
ZIP codes are powerful and widely used indicators of community-level health context, but they are designed for mail delivery rather than spatial analysis and can vary in geographic size and population characteristics (54–56). As a result, distance estimates based on ZIP code centroids approximate potential geographic access, not actual travel burden. We supplemented this with RUCA codes and SVI to better capture structural and social context, though these measures also operate at the community level and may not fully reflect individual experience. Finally, the presence of a CI surgical center in proximity does not capture variation in actual access, such as appointment wait times, surgical scheduling frequency, or visiting-clinic coverage. Thus, proximity should be interpreted as potential geographic access rather than real-time availability of CI evaluation or surgery.
CONCLUSION
In this national analysis, only 1.55% of elderly patients with bilateral SNHL had a documented CI. Disparities were stage-specific and group-dependent: among the oldest adults, they emerged at audiology evaluation and CI surgery; among non-White patients, gaps emerged at the transition to CI candidacy assessment and implantation, despite comparable or greater access to initial audiology. Because no single point of intervention can address barriers distributed across the pathway, improving CI utilization will require multifaceted, pathway-specific interventions, including patient education about hearing care resources, standardized referral processes, and expansion of the range and geographic reach of CI centers to ensure equitable access to hearing care options amid the rise of age-related hearing loss.
ACKNOWLEDGMENTS
The authors would like to thank Bryan McConomy, Linda Owens, Emily Wee, Debby Vannoy, Pranav Dorbala, and Al Smith for their guidance and support throughout this work. The authors also acknowledge the Epic Cosmos team, Carle Illinois College of Medicine, and Carle Foundation Hospital for their collaboration and institutional support for student-led research.
FUNDING SOURCE
None declared.
CONFLICTS OF INTEREST STATEMENT
None declared.
DATA AVAILABILITY STATEMENT
Data used in this study were obtained from Epic Cosmos, a limited dataset created in collaboration with a community of health systems using Epic, representing more than 300 million patient records from over 1,884 hospitals and 42,400 clinics as of February 2026. The community includes patients from all 50 US states, the District of Columbia, Canada, Lebanon, and Saudi Arabia. Current counts are available at cosmos.epic.com. Anonymized data are available through the Epic Cosmos platform in accordance with institutional data use policies at cosmos.epic.com.
Supplementary Material
Footnotes
P.V.P. had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.
Acquisition, analysis, or interpretation of data: P.V.P. Supervision and critical review of the manuscript for important intellectual content: R.G.P. Statistical analysis: P.V.P. and V.G. Concept and design and drafting of the manuscript: All authors.
Supplemental digital content is available for this article.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Data Availability Statement
Data used in this study were obtained from Epic Cosmos, a limited dataset created in collaboration with a community of health systems using Epic, representing more than 300 million patient records from over 1,884 hospitals and 42,400 clinics as of February 2026. The community includes patients from all 50 US states, the District of Columbia, Canada, Lebanon, and Saudi Arabia. Current counts are available at cosmos.epic.com. Anonymized data are available through the Epic Cosmos platform in accordance with institutional data use policies at cosmos.epic.com.