Using benefit-cost ratio to select Universal Newborn Hearing Screening test criteria

Cochlear dysfunction as an early biomarker of cognitive decline in normal hearing and mild hearing loss

INTRODUCTION

Age-related hearing loss is an important risk factor for cognitive decline. However, audiogram thresholds are not good estimators of dementia risk in subjects with normal hearing or mild hearing loss. Here we propose to use distortion product otoacoustic emissions (DPOAEs) as an objective and sensitive tool to estimate the risk of cognitive decline in older adults with normal hearing or mild hearing loss.

METHODS

We assessed neuropsychological, brain magnetic resonance imaging, and auditory analyses on 94 subjects > 64 years of age.

RESULTS

We found that cochlear dysfunction, measured by DPOAEs-and not by conventional audiometry-was associated with Clinical Dementia Rating Sum of Boxes (CDR-SoB) classification and brain atrophy in the group with mild hearing loss (25 to 40 dB) and normal hearing (<25 dB).

DISCUSSION

Our findings suggest that DPOAEs may be a non-invasive tool for detecting neurodegeneration and cognitive decline in the older adults, potentially allowing for early intervention.

Congenital Nonprofound Bilateral Sensorineural Hearing Loss in Children: Comprehensive Characterization of Auditory Function and Hearing Aid Benefit

A prospective cross-sectional design was used to characterize congenital bilateral sensorineural hearing loss (SNHL). The underlying material of >30,000 consecutively screened newborns comprised 11 subjects with nonprofound, alleged nonsyndromic, SNHL. Comprehensive audiological testing was performed at ≈11 years of age. Results showed symmetrical sigmoid-like median pure-tone thresholds (PTTs) reaching 50−60 dB HL. The congenital SNHL revealed recruitment, increased upward spread of masking, distortion product otoacoustic emission (DPOAE) dependent on PTT (≤60 dB HL), reduced auditory brainstem response (ABR) amplitude, and normal magnetic resonance imaging. Unaided recognition of speech in spatially separate competing speech (SCS) deteriorated with increasing uncomfortable loudness level (UCL), plausibly linked to reduced afferent signals. Most subjects demonstrated hearing aid (HA) benefit in a demanding laboratory listening situation. Questionnaires revealed HA benefit in real-world listening situations. This functional characterization should be important for the outline of clinical guidelines. The distinct relationship between DPOAE and PTT, up to the theoretical limit of cochlear amplification, and the low ABR amplitude remain to be elucidated. The significant relation between UCL and SCS has implications for HA-fitting. The fitting of HAs based on causes, mechanisms, and functional characterization of the SNHL may be an individualized intervention approach and deserves future research.

A Hearing Screening Pilot Study With Students With Significant Cognitive Disabilities

Purpose

Many children with severe intellectual and developmental disabilities are at a higher risk for hearing loss than their peers who are typically developing. Unfortunately, they do not consistently participate in routine school-based hearing screenings. The current study investigated the feasibility of increasing their participation using an otoacoustic emissions protocol and documented results relative to student educational profiles.

Method

A total of 43 students with significant cognitive disabilities enrolled at a public school exclusively serving this population participated in the study. All but 9, who were excluded because of known hearing loss, were screened by a licensed audiologist assisted by audiology doctoral students. The protocol included otoscopy, tympanometry, distortion product otoacoustic emissions (DPOAEs), and teacher surveys.

Results

DPOAE screening was attempted on 33 students without previously diagnosed hearing loss and successfully completed for 26 (78.8%). Two students (4.6%) with absent otoacoustic emissions and normal tympanograms were referred for further assessment due to concerns about possible sensorineural hearing loss in one or both ears, and 10 (23.3%) had abnormal tympanograms in one or both ears.

Conclusions

Considering the high risk of sensorineural hearing loss for children with significant disabilities, it is important for them to be included in school hearing screenings. The results of this study demonstrate the feasibility of using DPOAEs for school-based hearing screenings with this population with an interprofessional team of licensed audiologists, educators, and speech-language pathologists. The results further suggest that students with significant disabilities and hearing loss may be unidentified and underserved. Given the complex needs of this population, an interprofessional practice model for hearing screenings and intervention services is recommended.

Economic Evaluations of Childhood Hearing Loss Screening Programmes: A Systematic Review and Critique

BACKGROUND

Permanent childhood hearing loss is one of the most common birth conditions associated with speech and language delay. A hearing screening can result in early detection and intervention for hearing loss.

OBJECTIVES

To update and expand previous systematic reviews of economic evaluations of childhood hearing screening strategies, and explore the methodological differences.

DATA SOURCES

MEDLINE, Embase, the Cochrane database, National Health Services Economic Evaluation Database (NHS EED), the Health Technology Assessment (HTA) database, and Canadian Agency for Drugs and Technologies in Health's (CADTH) Grey matters.

STUDY ELIGIBILITY CRITERIA, PARTICIPANTS AND INTERVENTIONS

Economic evaluations reporting costs and outcomes for both the intervention and comparator arms related to childhood hearing screening strategies.

RESULTS

Thirty evaluations (from 29 articles) were included for review. Several methodological issues were identified, including: few evaluations reported outcomes in terms of quality-adjusted life years (QALYs); none estimated utilities directly from surveying children; none included disutilities and costs associated with adverse events; few included costs and outcomes that differed by severity; few included long-term estimates; none considered acquired hearing loss; some did not present incremental results; and few conducted comprehensive univariate or probabilistic sensitivity analysis. Evaluations published post-2011 were more likely to report QALYs and disability-adjusted life years (DALYs) as outcome measures, include long-term treatment and productivity costs, and present incremental results.

LIMITATIONS

We were unable to access the economic models and, although we employed an extensive search strategy, potentially not all relevant economic evaluations were identified.

CONCLUSIONS AND IMPLICATIONS

Most economic evaluations concluded that childhood hearing screening is value for money. However, there were significant methodological limitations with the evaluations.

Otoacoustic Emissions in Rural Nicaragua: Cost Analysis and Implications for Newborn Hearing Screening

Objective (1) Determine the incidence and risk factors for congenital hearing loss. (2) Perform cost analysis of screening programs. Study Design Proportionally distributed cross-sectional survey. Setting Jinotega, Nicaragua. Subjects and Methods Otoacoustic emissions (OAEs) were used to screen 640 infants <6 months of age from neonatal intensive care unit, institutional, and home birth settings. Data on 15 risk factors were analyzed. Cost of 4 implementation strategies was studied: universal screening, screening at the regional health center (RHC), targeted screening, and screening at the RHC plus targeted screening. Cost-effectiveness analysis over 10 years was based on disability-adjusted life year estimates, with the World Health Organization standard of cost-effectiveness ratio (CER) / gross domestic product (GDP) <3, with GDP set at $4884.15. Results Thirty-eight infants failed the initial OAE (5.94%). In terms of births, 325 (50.8%) were in the RHC, 69 (10.8%) in the neonatal intensive care unit, and 29 (4.5%) at home. Family history and birth defect were significant in univariate analysis; birth defect was significant in multivariate analysis. Cost-effectiveness analysis demonstrated that OAE screening is cost-effective without treatment (CER/GDP = 0.06-2.00) and with treatment (CER/GDP = 0.58-2.52). Conclusions Our rate of OAE failures was comparable to those of developed countries and lower than hearing loss rates noted among Nicaraguan schoolchildren, suggesting acquired or progressive etiology in the latter. Birth defects and familial hearing loss correlated with OAE failure. OAE screening of infants is feasible and cost-effective in rural Nicaragua, although highly influenced by estimated hearing loss severity in identified infants and the high travel costs incurred in a targeted screening strategy.

Economic evaluation of long-term impacts of universal newborn hearing screening

OBJECTIVE

Little is known about the long-term efficacious and economic impacts of universal newborn hearing screening (UNHS).

DESIGN

An analytical Markov decision model was framed with two screening strategies: UNHS with transient evoked otoacoustic emission (TEOAE) test and automatic acoustic brainstem response (aABR) test against no screening. By estimating intervention and long-term costs on treatment and productivity losses and the utility of life years determined by the status of hearing loss, we computed base-case estimates of the incremental cost-utility ratios (ICURs). The scattered plot of ICUR and acceptability curve was used to assess the economic results of aABR versus TEOAE or both versus no screening.

STUDY SAMPLE

A hypothetical cohort of 200,000 Taiwanese newborns.

RESULTS

TEOAE and aABR dominated over no screening strategy (ICUR = $-4800.89 and $-4111.23, indicating less cost and more utility). Given $20,000 of willingness to pay (WTP), the probability of being cost-effective of aABR against TEOAE was up to 90%.

CONCLUSIONS

UNHS for hearing loss with aABR is the most economic option and supported by economically evidence-based evaluation from societal perspective.

Improving newborn hearing screening: Are automated auditory brainstem response ear inserts an effective option?

OBJECTIVE

Universal newborn hearing screening is an established practice among Hong Kong public hospitals using a 2-stage automated auditory brainstem response (AABR) screening protocol. To enhance overall efficiency without sacrificing program accuracy, cost reduction in terms of replacing the initial ear coupler-based screening with a more economical ear insert-based screening procedure was considered. This study examined the utility of an insert-based AABR initial screening approach and the projected cost-effectiveness of a combined probe-based plus follow-up ear coupler AABR screening procedure.

METHODS

Following prenatal maternal consent, newborn hearing screening was conducted with 167 healthy neonates using a cross-sectional, repeated measures study design. The neonates were screened with AABR sequentially; using ear coupler and ear probe (insert) procedures, in both ears, with two different but comparable AABR instruments. Testing took place in the antenatal ward of a department of obstetrics and gynaecology, at a large public hospital.

RESULTS

With the specific combination of instruments deployed for this study insert-based AABR screening generated a five-fold higher rescreen rate and took an additional 50% screening time compared to coupler-based AABR screening. Although the cost of consumables used in a 2-stage AABR screening protocol would reduce by 9.87% if the combined procedure was implemented, the findings indicated AABR screening when conducted with an ear probe has reduced utility compared with conventional ear coupler screening.

CONCLUSIONS

Significant differences may occur in screening outcomes when changes are made to coupler method. Initiating a 2-stage AABR screening protocol with an ear insert technique may be impracticable in newborn nurseries given the greater number of false positive cases generated by this approach in the present study and the increased time required to carry out an insert-based procedure.

Otoacoustic emissions in newborn hearing screening: a systematic review of the effects of different protocols on test outcomes

BACKGROUND AND OBJECTIVES

Otoacoustic emission (OAE) tests are currently used to screen newborns for congenital hearing loss in many Universal Newborn Hearing Screening programs. However, there are concerns about high referral and false-positive rates. Various protocols have been used to address this problem. The main objective of this review is to determine the effects of different screening protocols on the referral rates and positive predictive values (PPV) of the OAE newborn screening test.

METHODS

Eligible studies published in English from January 1990 until August 2012 were identified through searches of MEDLINE, Medline In-Process, Embase, PubMed (NCBI), ISI Web of Science, and the Cochrane Central Register of clinical controlled trials. Two reviewers independently screened the data sources, using pre-defined inclusion criteria to generate a list of eligible articles. Data extracted included the number of newborns screened, age at screening, OAE pass criteria, frequencies screened, number of retests, referral rates, and the number of newborns identified with permanent congenital hearing loss.

RESULTS

Ten articles met the inclusion criteria, with a total of 119,714 newborn participants. The pooled referral rate was 5.5%. Individual referral rates ranged from 1.3% to 39%; the PPV from 2 to 40%. Increasing the age at initial screening and performing retests reduced the referral rate. Likewise, screenings involving higher frequencies had lower referral rates.

CONCLUSION

Delaying newborn hearing screening improves test results but may not be practical in all contexts. The use of higher frequencies and more sophisticated OAE devices may be useful approaches to ensure better performance of the OAE test in newborn hearing screening.

Universal newborn hearing screening

The present statement reviews the evidence for universal newborn hearing screening (UNHS). A systematic review of the literature was conducted using Medline and using search dates from 1996 to the third week of August 2009. The following search terms were used: neonatal screening AND hearing loss AND hearing disorders. The key phrase "universal newborn hearing screening" was also searched. The Cochrane Central Register of Controlled Trials and systematic reviews was searched. Three systematic reviews, one controlled non-randomized trial and multiple cohort studies were found. It was determined that there was satisfactory evidence to support UNHS. The results of the available literature are consistent and indicate clear evidence that without UNHS, delayed diagnosis leads to significant harm for children and their families; with UNHS, diagnosis and intervention occur earlier; earlier intervention translates to improved language outcomes; and in well-run programs, there is negligible harm from screening.

Triagem auditiva neonatal com emissões otoacusticas e reflexo cocleo-palpebral: estudo da sensibilidade e especificidade

OBJETIVO: analisar a especificidade e sensibilidade da TAN com emissões otoacústicas evocadas por estimulo transiente (EOAT) associadas à pesquisa do reflexo cócleo-palpebral (RCP), comparando-os aos resultados do Potencial Evocado Auditivo de Tronco Encefalico (PEATE). MÉTODO: a casuística do presente estudo foi composta por 369 RN de risco para deficiência auditiva que foram submetidos à triagem com a captação das emissões otoacústicas evocadas por estímulo transiente e pesquisa do reflexo cócleo- palpebral. Os resultados foram comparados aos resultados do Potencial Evocado Auditivo de Tronco Encefalico (PEATE). RESULTADOS: a incidência do tipo da perda auditiva na população geral foi de 4RN (1,1%) com perda coclear, 22 (5,9%) com perda condutiva, 2 (0,5%) com espectro da neuropatia auditiva (ENA), 14 (3,8%) com alteração central e 15 (4,1%) com atraso de maturação da via auditiva. A TAN mostrou 100% de sensibilidade e 94,6% de especificidade na detecção de alterações cocleares e espectro da neuropatia auditiva; 77,3% de sensibilidade e 94,6% de especificidade na detecção de alterações condutivas e 42,9% de sensibilidade e 94,6% de especificidade na detecção de alterações centrais. Todos os achados evidenciaram diferenças estatisticamente significantes em relação aos neonatos auditivamente normais. CONCLUSÃO: este protocolo de TAN mostrou-se eficaz na detecção de RN com alterações de cocleares e espectro da neuropatia auditiva com sensibilidade e especificidade elevadas.

PEATE automático em recém nascidos de risco: estudo da sensibilidade e especificidade

OBJETIVO: verificar a sensibilidade e especificidade do teste de potencial evocado auditivo de tronco encefálico em equipamento automático (PEATEa), comparando-o ao teste de potencial evocado auditivo de tronco encefálico em equipamento diagnóstico (PEATE) em um programa de triagem auditiva neonatal em neonatos de risco. MÉTODO: foram avaliados 186 neonatos, 83 nascidos a termo e 103 pré-termo, sendo 88 do sexo masculino e 98 feminino. A triagem constou de emissões otoacústicas evocadas por estímulos transientes (EOAT), PEATEa e ao PEATE na mesma semana. RESULTADOS: dos 186 neonatos avaliados, 156 (83,9%) apresentaram audição normal. A perda condutiva foi encontrada em 9 neonatos (4,8%),sendo 7 bilaterais e 2 unilaterais. A perda auditiva coclear foi observada em 5 neonatos (2,7%) sendo um unilateral. Alteração central foi obtida em 11 neonatos (5,9%) e um neonato foi diagnosticado como espectro da neuropatia auditiva -ENA(0,5%).Em 4 casos houve atraso maturacional na avaliação inicial com normalização das respostas no mês seguinte Comparando-se os resultados do PEATEa com o PEATE, observou-se alta sensibilidade ( superior a 99%) para identificação de perda coclear,condutiva, central, atraso maturacional e ENA .A especificidade do PEATEa foi de 100% para ENA, mediana para perda coclear (75% na OD e 60% na OE), e para alterações centrais (54,5%OD e 63,6% OE). Para identificação de perdas condutivas (inferior a 43%). CONCLUSÃO: o PEATEa foi eficaz na identificação das neuropatias auditivas com elevada especificidade e sensibilidade. Contudo, falsos negativos foram observados para perdas cocleares, condutivas, para alterações centrais e atraso maturacional.

Outcome of a universal newborn hearing-screening programme based on multiple transient-evoked otoacoustic emissions and clinical brainstem response audiometry

CONCLUSION

This universal newborn hearing-screening (UNHS) programme revealed high efficacy. The proportion of congenital sensorineural hearing loss was higher in left ears and in males than in right ears and females, which was in line with the systematic ear asymmetries and sex differences in transient-evoked otoacoustic emission (TEOAE) pass percentage.

OBJECTIVES

To study the long-term outcome of a UNHS programme based on multiple TEOAEs and clinical click-evoked auditory brainstem response (ABR).

METHOD

The study included all the newborns that were screened during a 6-year period (n = 31 092). TEOAE pass/fail was analysed in detail. In an assessment performed 10 years after the start of the 6-year UNHS, prevalence, degree and type of congenital hearing loss were studied.

RESULTS

The proportion of screened newborns was high, i.e. 98%. Multiple TEOAE recordings minimized the need for clinical ABR. Fifty-seven (0.18%) subjects showed bilateral hearing loss (exceeding ≈ 30 dB HL); median ABR threshold = 60 dB nHL (at 2.5 months of age). Bilateral and unilateral sensorineural hearing loss was found in 0.17% (n = 52; 56% males) and 0.06% (n = 18; 61% left ears, 56% males) of the screened newborns, respectively. Higher TEOAE pass percentages (p < 0.01) were demonstrated in right ears and in females than in left ears and males.

Universal newborn hearing screening in 2010

PURPOSE OF REVIEW

The objectives of this review are to provide the reader with a current and concise review of the data and trends in universal newborn hearing screening. Within a relatively short period of time, the concept of screening all infants for hearing loss at the time of birth has evolved from a nascent process to a truly universal system in most developed countries. As a result, the focus and challenges of universal newborn hearing screening have shifted to topics of developing even more efficient and cost-effective approaches, and potentially melding physiologic hearing screenings with ancillary screening techniques.

RECENT FINDINGS

Enhancement of the universal newborn hearing screening process is likely to be accomplished by implementation of novel tools such as wideband reflectance technologies and intelligent incorporation of screening for common genetic and viral causes of congenital hearing loss.

SUMMARY

With such a rapidly evolving process, it will be critical for clinicians to understand the benefits and limitations of various newborn hearing screening methodologies in order to determine the most appropriate management of children referred from their universal newborn hearing screening. This will entail a working knowledge of emerging audiologic tools as well as infectious and genetic causes of pediatric hearing loss.