What Contribution Did Economic Evidence Make to the Adoption of Universal Newborn Hearing Screening Policies in the United States?

Universal newborn hearing screening (UNHS), when accompanied by timely access to intervention services, can improve language outcomes for children born deaf or hard of hearing (D/HH) and result in economic benefits to society. Early Hearing Detection and Intervention (EHDI) programs promote UNHS and using information systems support access to follow-up diagnostic and early intervention services so that infants can be screened no later than 1 month of age, with those who do not pass their screen receiving diagnostic evaluation no later than 3 months of age, and those with diagnosed hearing loss receiving intervention services no later than 6 months of age. In this paper, we first document the rapid roll-out of UNHS/EHDI policies and programs at the national and state/territorial levels in the United States between 1997 and 2005. We then review cost analyses and economic arguments that were made in advancing those policies in the United States. Finally, we examine evidence on language and educational outcomes that pertain to the economic benefits of UNHS/EHDI. In conclusion, although formal cost-effectiveness analyses do not appear to have played a decisive role, informal economic assessments of costs and benefits appear to have contributed to the adoption of UNHS policies in the United States.

The Role of Audiologists in Assuring Follow-Up to Outpatient Screening in Early Hearing Detection and Intervention Systems.

PURPOSE: The purpose of this study was to investigate the role of audiology involvement and other factors associated with failure to follow through from the initial hearing screening to the second outpatient screen. METHOD: Linear regression, logistical regression, and descriptive analyses were used across demographic and hospital variables associated with infants who did not receive a follow-up outpatient screen. RESULTS: The results included birthing hospital outpatient rescreen rates from January 1, 2005, through December 31, 2005. Variables were collected from the birth certificate and hospital surveys. Results showed higher loss to follow-up/documentation to outpatient screen for (a) infants born in hospitals with low rates for returning for follow-up, (b) infants born in hospitals that did not have an audiologist involved, (c) infants who were Hispanic, (d) infants who were born to mothers who were not married, (e) infants with mother's with < 12 years of education, and (f) infants with Apgar scores of 7 or below. CONCLUSIONS: The findings were used to identify quality improvement strategies to decrease the loss to follow-up. Strategies included ensuring audiology support, providing information in the parent's native language, educating personnel in the newborn intensive care units, developing and disseminating information in Spanish in written form, and educating hospitals on the importance of scheduling the outpatient rescreening before hospital discharge.

Infant, Maternal, and Hospital Factors' Role in Loss to Follow-up After Failed Newborn Hearing Screening.

OBJECTIVE: Completion of newborn hearing screening (NBHS) is recommended by 1 month old. Delays and loss to follow-up and documentation (LTF/LTD) after failed NBHS are common. Committees of experts have established hospital guidelines to reduce LTF/LTD. We aimed to identify maternal and infant factors associated with LTF/LTD and determine if adherence to hospital guidelines is associated with timely completion of follow-up screening. METHODS: We conducted a retrospective study of all infants born in Colorado hospitals who failed the newborn admission hearing screening from 2007 to 2012 and a cross-sectional survey of NBHS coordinators at Colorado birthing hospitals. Neonatal intensive care unit infants were excluded. Outcomes included documented completion of the follow-up NBHS and completion by 1 month. Data sources comprised the electronic birth record, infant hearing integrated data system, and NBHS coordinator survey. Data were analyzed by logistic regression. RESULTS: A total of 13,904 newborns did not pass the newborn admission hearing screening from 2007 to 2012, and 11,422 (82%) had documentation of a completed follow-up screening. A total of 10,558 (76%) completed follow-up screening by 1 month. All 53 NBHS coordinators completed the survey. Maternal age, education, smoking, and birth country; and payer, race, birth order, and population density were associated with completion of follow-up hearing screening. Maternal education, payer, population density, birth weight, and cleft lip were associated with completion by 1 month of age. Only birth in a facility that charges a rescreening fee was associated with completion of follow-up screening. CONCLUSIONS: Low-income, rural, and minority infants are at risk for LTF. Further studies are needed to determine if adherence to guidelines can overcome barriers to follow-up.

State and territory EHDI databases: what we do and don't know about the hearing or audiological data from identified children.

PURPOSE: The purpose of this study was to define the information currently collected by state and territory Early Hearing Detection and Intervention (EHDI) coordinators and to determine whether best practice guidelines are used. METHOD: A multiple-choice electronic survey querying areas of diagnostic assessment, amplification, early intervention (EI) and medical information regarding hearing loss was sent to all state and territory EHDI coordinators. RESULTS: Seventy percent of surveys were completed. Diagnostic, amplification, and Part C services were tracked by the majority of respondents. Additionally, medical prenatal and postnatal risks were collected. CONCLUSION: Data collected on audiologic screening and diagnostic evaluations has increased. On the basis of these results, it is difficult to discern whether best practices are being used for each child. A delay in reporting a confirmed hearing loss was observed. Amplification results suggest that systems are not in place to ensure consistency and accountability for fitting amplification in infants. The results of this survey identified audiologic and EI information tracked by states to help provide a framework to monitor quality care in the future.

Evaluating the reach of universal newborn hearing screening in Colorado.

BACKGROUND: Children's language and developmental delays can result from a late diagnosis of hearing loss. To improve population-based prevention efforts to reduce such delays, Colorado's early hearing detection and intervention program examined the determinants of receiving timely newborn hearing screening to better support early identification and treatment of hearing loss. METHODS: In 2006-2007, data were examined from the state's electronic birth certificate regarding hospital, infant, and maternal characteristics. From January 2002 through December 2004, there were 204,694 hospital births; 98% of newborns were screened for hearing loss. Of those receiving a positive (failed) result, 82% then received outpatient follow-up screening. RESULTS: Newborns with normal Apgar scores were ten times more likely than infants with low Apgar scores to receive initial hearing screening; newborns with normal birth weights were four times more likely than newborns with low birth weights to receive initial hearing screening. Outpatient follow-up screening was associated with hospitals' screening performance and mothers' education. One urban safety-net hospital substantially reduced the state's follow-up screening disparities. CONCLUSIONS: While newborns with low Apgar scores and birth weights are more likely to have a higher risk of hearing loss than infants with normal Apgar scores and birth weights, they are substantially less likely to receive screening to identify it.

The work of the Village: creating a new world for children with hearing loss and their families.

Though the health and economic issues in developing countries may create situations in which the development of early hearing detection and intervention (EHDI) programs could seem insurmountable, developing countries have some resources that are not easily available to those in the developed world. Developing countries often have well-organized communities in which members work together for the benefit of the individuals within their communities as well as a willingness to learn strategies that can improve the lives of individuals in their communities. Paradoxically, there also exists societal intolerance for disabilities that can result in stigmatization and ultimate isolation of affected families. Hopefully, education within these communities can begin to overcome historical intolerance. While some might argue that sufficient financial resources are the key to the development of an EHDI system, the Colorado system, although grateful for all financial resources, is dependent, first and foremost upon the human resources. This article provides information about the history of the Colorado system in the hopes that lessons learned will provide valuable input to others facing similar challenges.

The Colorado newborn hearing screening project, 1992-1999: on the threshold of effective population-based universal newborn hearing screening.

OBJECTIVE: Although previous studies have documented the feasibility and benefits of universal newborn hearing screening in selected hospitals, none have reviewed the effectiveness of regionally mandated participation of large numbers of hospitals with variable levels of motivation to succeed. The purpose of this study was to measure hospital participation and overall screening success in a statewide program for universal newborn hearing screening and to track improvements in program establishment and outpatient follow-up over time. METHODS: Four Colorado hospitals began voluntarily performing hearing screening before hospital discharge on all newborns in 1992. By 1996, 26 Colorado hospitals were participating in universal newborn hearing screening. The publication of screening results from these early years served as a catalyst for legislation requiring increased hospital participation in establishing universal screening programs. Data systems were subsequently developed to improve statistical tracking and follow-up. Eight years' worth of cumulative study data as well as the results from calendar year 1999 (the year of greatest hospital participation) were reviewed for collective measures of successful screening and follow-up. Three hospitals did not initiate newborn hearing screening programs until after the study period ended in 1999. Of the 57 hospitals that were screening newborns in 1999, the chosen method of screening at 52 hospitals was automated auditory brainstem response testing; 3 hospitals used otoacoustic emission testing, and the remaining 2 hospitals used 2-stage screening. Hearing loss was defined as a threshold of 35 decibels or greater in 1 or both ears at the time of confirmatory testing. RESULTS: During the full 8-year study period, 1992 to 1999, 148 240 newborns were screened. A total of 291 infants who were born during the study period received a diagnosis of congenital hearing loss. In this cohort of 291 children, the cumulative frequency of bilateral hearing loss was 71% (range: 48%-94% by calendar year), the frequency of sensorineural hearing loss was 82% (range: 67%-88%), and the frequency of 1 or more risk factors was 47% (range: 37%-61%). During calendar year 1999, a total of 63 590 births were recorded at 60 birthing hospitals in Colorado. The families of 263 (0.4%) of these newborns refused newborn hearing screening. Of the remaining 63 327 newborns, 87% (55 324 infants) were screened for hearing acuity before hospital discharge, a far greater percentage than the 19% of all newborns screened during the first 5 years of voluntary hospital participation, and approaching the American Academy of Pediatrics's recommendation of 95% of newborns completing hospital-based testing in a successful screening program. As a result of this statewide hearing screening program, congenital hearing loss was diagnosed in 86 Colorado newborns during 1999, representing an occurrence rate of approximately 1 affected child in every 650 newborns. In this group of 86 infants, 59 had bilateral sensorineural hearing loss, 17 had unilateral sensorineural hearing loss, 4 had bilateral conductive hearing loss, and 6 had unilateral conductive hearing loss. Mild hearing loss was present in 6 infants, moderate hearing loss was present in 42 infants, severe hearing loss was present in 33 infants, and profound hearing loss was present in the remaining 5 infants. Only 32 of the 86 affected newborns in 1999 had 1 or more risk factors for hearing loss subsequently identified. After failing an initial hospital-based screening at 1 of the 57 participating hospitals in 1999, 2.3% of infants screened (1283 newborns) were referred for follow-up testing, easily exceeding the standard of <4% recommended by the American Academy of Pediatrics. Similarly, the false-positive rate of 2.2% during 1999 exceeded the recommended standard of <3%. Of the infants who failed their initial screening, 76% (978 infants) had documented follow-up testing to confirm or exclude congenital hearing loss, a percentage significantly improved from a follow-up rate of 48% during the first 5 years of screening, although not yet achieving the standard of 95% recommended by the American Academy of Pediatrics. Nine participating hospitals, however, were able to document appropriate follow-up for 95% or more of the infants who failed their initial screening tests. The median age of diagnosis of congenital hearing loss during 1999 was 2.1 months; 71% of affected infants were identified by 3 months of age (the recommended standard for age of diagnosis), and 92% of affected newborns were identified by 5 months of age. Measures of screening success were compared for large, mid-sized, and small hospitals. Increasing hospital size, as measured by the number of births per year, was associated with an increasing percentage of newborns who were successfully screened. It was notable that smaller hospital size was associated with increased referral rates for follow-up testing, whereas larger hospital size was associated with the highest recapture rate for follow-up testing. CONCLUSIONS: Universal screening for congenital hearing loss is demonstrated to be feasible in a large regional effort of legislatively mandated participation. The success of such an endeavor is dependent on educational efforts for community professionals, commitment on the part of program planners, and data systems that more accurately track and recall infants who fail initial hospital-based screening.

State of the States: The Status of Universal Newborn Hearing Screening, Assessment, and Intervention Systems in 16 States.

This study reports the results of a comprehensive survey of 16 states regarding the coordination and characteristics of universal newborn hearing screening, audiologic assessment, and intervention programs. The survey establishes a baseline assessment that was conducted by states as part of their first year of participation in a Maternal and Child Health Bureau grant on state systems for universal newborn hearing screening, assessment, and intervention. States are making progress toward achieving universal newborn hearing screening. However, several issues continue to impede the establishment of statewide systems for linking screening programs to diagnosis and intervention.