Attrition Across the Adult Cochlear Implant Care Pathway: A Scoping Review of Stage-Specific Disengagement

OBJECTIVES: To synthesize evidence on attrition across the adult cochlear implant care pathway by identifying (1) stages at which adults disengage or experience delay and (2) patient-, provider-, and system-level factors associated with attrition at each stage. DATA SOURCES: PubMed/MEDLINE, Scopus, CINAHL, and the Cochrane Library. METHODS: A scoping review was conducted in accordance with PRISMA-ScR guidelines. Databases were searched from inception to August 2025, with an update in January 2026. Empirical studies reporting disengagement, delay, or nonprogression at any stage of the adult cochlear implant care pathway were included. Findings were synthesized using a pathway-based framework to map attrition across stages of care. RESULTS: Seventeen studies met the inclusion criteria. Attrition was reported across multiple stages of the adult cochlear implant care pathway, with evidence concentrated at prereferral (n=3), referral-to-assessment (n=4), and postassessment and presurgical stages (n=10). No study examined surgery-to-device activation as a discrete attrition stage, and evidence relating to postactivation follow-up was limited. Early attrition was commonly linked to under-referral, limited candidacy awareness, and socioeconomic barriers, whereas later stages reflected logistical constraints, decisional uncertainty, perceived benefit, and cumulative care burden. Attrition definitions varied substantially across studies, limiting direct cross-study comparison. CONCLUSIONS: This review reframes cochlear implant underutilization as a cumulative, pathway-based phenomenon rather than a single patient decision. Conceptualizing nonprogression across discrete stages provides a structured framework for understanding where and why disengagement occurs and may inform stage-specific strategies to improve access to and progression through cochlear implant services.