Loss to Follow-Up After Newborn Hearing Screening: Analysis of Risk Factors at a Massachusetts Urban Safety-Net Hospital

Examining Barriers to Early Hearing Diagnosis

PURPOSE

Many factors create barriers for early hearing detection and intervention (EHDI), especially those related to unfavorable social determinants of health (SDOH). The primary aim of this study was to evaluate diagnostic timing of infants at risk for congenital hearing loss in consideration of known barriers. Understanding the specific barriers to early diagnosis can inform interventions to improve timeliness of diagnosis and subsequent habilitation.

METHOD

A retrospective chart review was completed for infants referred for diagnostic audiologic testing at a tertiary urban-setting Children's Hospital from 2018 to 2021. After exclusion criteria were applied, 1,488 infants were included in the analysis. Various factors were recorded from electronic medical records including those specific to SDOH. Time to diagnosis was derived and compared across five factors of interest that have previously been shown to impact diagnostic timeline, including (a) insurance type, (b) race/ethnicity, (c) presence of middle ear dysfunction at first auditory brainstem response (ABR), (d) proximity to diagnostic center, and (e) diagnostic timing before and during/after the COVID-19 pandemic.

RESULTS

Across the study time period, 77% of infants referred for diagnostic testing had confirmed diagnosis by the EHDI benchmark of 3 months. Analysis of time to diagnosis across factors of interest revealed no clinically significant differences for insurance type, race/ethnicity, proximity to diagnostic center, or timing in reference to the COVID-19 pandemic. Presence of middle ear dysfunction on first ABR was found to significantly protract final diagnostic timing.

CONCLUSIONS

Although some known barriers for EHDI can be universal, other factors may have a differential impact on an infant's timeline to diagnosis based on their specific location, which can interact differently with additional known barriers. Understanding local challenges will serve to better guide programs in implementing facilitators that will address their specific needs for improved outcomes.

Factors that influence health service access in deaf and hard-of-hearing children: a narrative review

OBJECTIVES

Early diagnosis and intervention of deaf and hard-of-hearing (DHH) children leads to improved language and psychosocial outcomes. However, many child, parent and provider related factors can influence access to early intervention services, including hearing devices. This narrative review aims to explore factors that influence health service access in DHH children.

DESIGN

A systematic search was conducted to identify articles that explored factors that influenced health service access in DHH children in countries with Universal Newborn Hearing Screening, published between 2010 and 2022.

STUDY SAMPLES

Fifty-nine articles met the inclusion criteria for data extraction. This included 4 systematic reviews, 2 reviews, 39 quantitative and 5 mixed methods studies and 9 qualitative studies.

RESULTS

The identified factors were grouped into the following themes: (a) demographic factors, (b) family related factors, (c) child related factors, (d) factors specific to hearing devices, (e) service delivery, f) telehealth and (g) COVID-19.

CONCLUSION

This review provided a comprehensive summary of multiple factors that affect access to health services in DHH children. Psychosocial support, consistent clinical advice, allocation of resources to rural communities and use of telehealth are possible ways to address barriers and improve health service access.

Maternal and child predictors associated with loss to follow-up in the newborn hearing screening program: a cohort study in maternity hospitals in northeastern Brazil

PURPOSE

Analyze maternal and child predictors associated with loss to follow-up in the newborn hearing screening program at maternity hospitals in northeastern Brazil.

METHODS

Retrospective cohort study, including secondary data from infants (n=604) referred to the newborn hearing screening program in two maternity hospitals for monitoring and/or diagnosis. The predictors evaluated included socioeconomic factors, such as maternal age, marital status, income, schooling, place of residence, number of children and number of prenatal visits. In addition, maternal and child health factors, such as smoking and drug intake during pregnancy, consanguinity, congenital infections, craniofacial malformations, use of ototoxic drugs, syndromes and a history of hearing loss in the family. Statistical analysis was performed based on binary logistic regression models, using the stepwise method.

RESULTS

The logistic regression model containing the number of prenatal visits and the history of hearing loss in the family was significant [χ2(2) =34.271; p<0.001]. The number of prenatal visits (OR = 2.343; 95% CI = 1.626 - 3.376) and family history of hearing loss (OR = 2.167; 95% CI = 1.507 - 3.115) were significant predictors. The other predictors were not significant.

CONCLUSION

The results reveal that newborns whose mothers had ≤ 5 prenatal visits and those with a family history of hearing loss increased their likelihood of loss to follow-up by 2.3 and 2.1 times, respectively. It is important to provide subsidies for public health improvements in order to help advise, guide and educate mothers, especially during prenatal care.

Modeling Lost to Intervention in Early Hearing Detection and Intervention: A Modified eDelphi Study

PURPOSE

The purpose of this study was to develop a functional model of the drivers behind why families may decline early intervention services following the identification of a child as D/deaf or hard of hearing.

METHOD

This model was developed using a modified eDelphi method. Invited experts (N = 155) were provided proposed models of why families may decline early intervention services in accordance with current literature. In the first phase of feedback, participants (n = 23) provided changes they would make to the model to be more in line with their perceptions of lost to intervention. These changes were implemented, and a second phase of feedback with participants (n = 25) moved to accept the model as presented.

RESULTS

Agreement was reached on five main barriers to early intervention access for children who have been identified as D/deaf or hard of hearing (family experience, family culture, perceived vulnerability, perceived benefits, and perceived barriers). Each of these main barriers has associated examples of how they may manifest across different early intervention programs and situations.

CONCLUSIONS

This is the first theoretical model of why loss to intervention happens within early hearing detection and intervention. Having a model provides the opportunity for future work to implement novel approaches to support families during the early intervention enrollment process.

Sociodemographic Factors Affecting Loss to Follow-Up After Newborn Hearing Screening: A Systematic Review and Meta-Analysis

OBJECTIVE

Universal newborn hearing screening (NBHS) has been widely implemented as a part of early hearing detection and intervention (EHDI) programs worldwide. Even with excellent provider knowledge and screening rates, many infants do not receive definitive hearing testing or intervention after initial screening. The objective of this study was to identify sociodemographic factors contributing to loss of follow-up.

DATA SOURCES

PubMed, Scopus, and CINAHL.

REVIEW METHODS

Per Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, the databases were searched from the date of inception through December 28, 2021. Studies containing sociodemographic information on patients who were referred to NBHS were included. Meta-analysis of odds ratios (ORs) was performed comparing rates of sociodemographic variables between patients adherent and nonadherent to follow-up.

RESULTS

A total of 169,238 infants from 19 studies were included. Low birth weight (OR 1.6 [95% confidence interval, CI 1.2-2.2, p < .001), racial minority (OR 1.4 [95% CI 1.2-1.6], p < .001), rural residence (OR 1.5 [95% CI 1.1-1.9], p = .005), lack of insurance (OR 1 [95% CI 1.4-2.5], p < .001), and public or state insurance (OR 1.7 [95% CI 1.2-4.2], p = .008) were associated with missed follow-up after referred NBHS. Associated maternal factors included low maternal education (OR 1.8 [95% CI 1.6-2.0], p < .001), young maternal age (OR 1.5 [95% CI 1.5-1.6], p < .001), unmarried maternal status (OR 1.5 [95% CI 1.1-1.9], p = .003), and current or former maternal smoking status (OR 1.8 [95% CI 1.4-2.2], p < .001).

CONCLUSION

Both infant and maternal sociodemographic factors influence follow-up compliance after referred NBHS. Focused efforts should be made by medical providers and policymakers to address these factors to ensure appropriate newborn hearing care and interventions are achieved.

Barriers to and Facilitators of Early Hearing Detection and Intervention in the United States: A Systematic Review

OBJECTIVES

Early hearing detection and intervention (EHDI) is guided by the 1-3-6 approach: screening by one month, diagnosis by 3 mo, and early intervention (EI) enrollment by 6 mo. Although screening rates remain high, successful diagnosis and EI-enrollment lag in comparison. The aim of this systematic review is to critically examine and synthesize the barriers to and facilitators of EHDI that exist for families, as they navigate the journey of congenital hearing loss diagnosis and management in the United States. Understanding barriers across each and all stages is necessary for EHDI stakeholders to develop and test novel approaches which will effectively reduce barriers to early hearing healthcare.

DESIGN

A systematic literature search was completed in May and August 2021 for empirical articles focusing on screening, diagnosis, and EI of children with hearing loss. Two independent reviewers completed title and abstract screening, full-text review, data extraction, and quality assessments with a third independent reviewer establishing consensus at each stage. Data synthesis was completed using the Framework Analysis approach to categorize articles into EHDI journey timepoints and individual/family-level factors versus system-level factors.

RESULTS

Sixty-two studies were included in the narrative synthesis. Results revealed that both individual/family-level (e.g., economic stability, medical status of the infant including middle ear involvement) and system-level barriers (e.g., system-service capacity, provider knowledge, and program quality) hinder timely diagnosis and EI for congenital hearing loss. Specific social determinants of health were noted as barriers to effective EHDI; however, system-level facilitators such as care coordination, colocation of services, and family support programs have been shown to mitigate the negative impact of those sociodemographic factors.

CONCLUSIONS

Many barriers exist for families to obtain appropriate and timely EHDI for their children, but system-level changes could facilitate the process and contribute to long-term outcomes improvement. Limitations of this study include limited generalizability due to the heterogeneity of EHDI programs and an inability to ascertain factor interactions.

Protocol and programme factors associated with referral and loss to follow-up from newborn hearing screening: a systematic review

BACKGROUND

An effective newborn hearing screening programme has low referral rate and low loss to follow-up (LTFU) rate after referral from initial screening. This systematic review identified studies evaluating the effect of protocol and programme factors on these two outcomes, including the screening method used and the infant group.

METHODS

Five databases were searched (latest: April 2021). Included studies reported original data from newborn hearing screening and described the target outcomes against a protocol or programme level factor. Studies were excluded if results were only available for one risk condition, for each ear, or for < 100 infants, or if methodological bias was observed. Included studies were evaluated for quality across three domains: sample, screening and outcome, using modified criteria from the Ottawa-Newcastle and QUADAS-2 scales. Findings from the included studies were synthesised in tables, figures and text.

RESULTS

Fifty-eight studies reported on referral rate, 8 on LTFU rate, and 35 on both. Only 15 studies defined LTFU. Substantial diversity in referral and LTFU rate was observed across studies. Twelve of fourteen studies that evaluated screening method showed lower referral rates with aABR compared to TEOAE for well babies (WB). Rescreening before hospital discharge and screening after 3 days of age reduced referral rates. Studies investigating LTFU reported lower rates for programmes that had audiologist involvement, did not require fees for step 2, were embedded in a larger regional or national programme, and scheduled follow-up in a location accessible to the families. In programmes with low overall LTFU, higher LTFU was observed for infants from the NICU compared to WB.

CONCLUSION

Although poor reporting and exclusion of non-English articles may limit the generalisability from this review, key influential factors for referral and LTFU rates were identified. Including aABR in WB screening can effectively reduce referral rates, but it is not the only solution. The reported referral and LTFU rates vary largely across studies, implying the contribution of several parameters identified in this review and the context in which the programme is performed. Extra attention should be paid to infants with higher risk for hearing impairment to ensure their return to follow-up.

Cochlear Implantation in Infants: Why and How

In children with congenital deafness, cochlear implantation (CI) prior to 12 months of age offers the opportunity to foster more typical auditory development during late infancy and early childhood. Recent studies have found a positive association between early implantation and expressive and receptive language outcomes, with some children able to achieve normal language skills by the time of school entry. Universal newborn hearing screening improved early detection and diagnosis of congenital hearing loss, allowing for earlier intervention, including decision-making regarding cochlear implant (CI) candidacy. It can be more challenging to confirm CI candidacy in infants; therefore, a multidisciplinary approach, including objective audiometric testing, is recommended to not only confirm the diagnosis but also to counsel families regarding expectations and long-term management. Surgeons performing CI surgery in young children should consider both the anesthetic risks of surgery in infancy and the ways in which mastoid anatomy may differ between infants and older children or adults. Multiple studies have found CI surgery in infants can be performed safely and effectively. This article reviews current evidence regarding indications for implantation in children younger than 12 months of age and discusses perioperative considerations and surgical technique.