Identifying quality improvement opportunities in a universal newborn hearing screening program

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.

Expanding the Role of Educational Audiologists After a Failed Newborn Hearing Screening: A Quality Improvement Study

Purpose Lack of timely and proximal access to diagnostic hearing evaluation using auditory brainstem response (ABR) testing hampers the effectiveness of Early Hearing Detection and Intervention (EHDI) programs in the United States. This study measured the impact of a state-based quality-improvement (QI) project that provided diagnostic ABR equipment and training to educational audiologists distributed throughout Iowa in regional special education centers. Method We used de-identified administrative data generated by the state EHDI program to analyze markers of access to early hearing health care for infants in a preproject condition ("Baseline") compared to the implementation of diagnostic ABRs at the regional special education centers ("QI Project"). Results Our findings revealed that the QI Project was associated with improvements in timeliness of first hearing evaluation, distance traveled for first hearing evaluation, and likelihood of receiving on-guideline audiology care during the first hearing evaluation. Conclusions Following the onset of the QI Project, infants and their families had greater access to initial hearing evaluation after failed newborn hearing screening. This improvement could have cascading effects on timeliness of later intervention among those with confirmed permanent childhood hearing loss.

Assessment of hearing screening programmes across 47 countries or regions II: coverage, referral, follow-up and detection rates from newborn hearing screening

OBJECTIVES

To assess the performance of newborn hearing screening (NHS) programmes, through selected quality measures and their relationship to protocol design.

DESIGN

NHS coverage, referral, follow-up and detection rates were aggregated. Referral rates were compared to age at screening step 1, number of steps, and test method: OAE or aABR.

STUDY SAMPLE

A questionnaire on existing hearing screening was completed by experts from countries in Europe, plus Russia, Malawi, Rwanda, India and China.

RESULTS

Out of 47 countries or regions, NHS coverage rates were reported from 26, referral rates from 23, follow up from 12 and detection rates from 13. Median coverage rate for step 1 was 96%. Referral rate from step 1 was 6-22% where screening may be performed <24 h from birth, 2-15% for >24 h, and 4% for >72 h. Referral rates to diagnostic assessment averaged 2.1% after one to two steps using OAE only, 1.7% after two steps including aABR, and 0.8% after three to four steps including aABR. Median detection rate for bilateral permanent hearing impairment ≥40dB was 1 per 1000 infants.

CONCLUSION

Referral rates were related to age, test method and number of screening steps. Quality measures were not available for many NHS programmes.

Population-based Cancer Screening: Measurement of Coordination and Continuity of Care

BACKGROUND

European guidelines for the quality of screening programs for breast and colorectal cancer describe process, structure, and outcome indicators. However, none of them specifically evaluate coordination and continuity of care during the cancer screening process.

OBJECTIVES

The aim of this study was to identify and adapt care quality indicators related to the coordination and continuity of the cancer screening process to assess nursing care in cancer screening programs.

METHODS

The indicators proposed in this study were selected in 2 phases. The first consisted of a literature review, and the second was made by consensus of an expert group. An electronic literature search was conducted, through June 2016. From a total of 225 articles retrieved, 14 studies met inclusion criteria, and these 14 documents were delivered to the group of experts for evaluation and to propose a final list of agreed-upon indicators.

RESULTS

The group of experts selected 7 indicators: adequacy and waiting time derivation of participants, delivery and availability of the report of the process, understanding professionals involved in the process, and satisfaction and understanding of participants.

CONCLUSIONS

These indicators should help identify areas for improvement and measure the outcome of coordination and continuity of care.

IMPLICATIONS FOR PRACTICE

The results provided a common set of indicators to evaluate the coordination and continuity of care for cancer screening and to consequently assess the contribution of nursing care in cancer screening programs. The identification and adaptation of these quality indicators will help to identify areas for improvement and measure the effect of coordination and continuity of care.

[The Russian and international experience with the implementation of the programs of universal audiological screening of the newborn infants]

The problem of diagnostics of congenital hearing impairment has acquired special importance in the light of new possibilities for the early rehabilitation of the patients presenting with this condition. The implementation of the programs of universal audiological screening into the clinical practice of Russia and many other countries made it possible to significantly reducethe time necessary to confirm congenital impairment of hearing and begin the rehabilitative treatment. The present paper was designed to analyze the international experience with the implementation of the programs of universal audiological screening of the newborn infants as exemplified by such countries as Great Britain, USA, Germany, and Poland. The main indicators of the quality and the efficiency of such programs are considered taking into account the results of the epidemiological studies on the prevalence of congenital hearing impairment. A total of 1.8 mln newborn infants were examined in Russia during 2013. The first stage of screening involved 96.7% of the children, and only 2.9% of them remained uncovered by the examination. As many as 5,659 children were found to present with the congenital loss of hearing,with the prevalence of this condition being 3 per 1.000 newborn infants and the prevalence of deafness 0.6 per 1.000. The principal problem to be resolved for the organization of the management of these patients, both in Russia and other countries, remains the enhancement of the availability of comprehensive diagnostic examination and the timelyreferral of the patients to such examination (if appropriate based on the results of the screening). The successful solution of this problem requires personalized recording of the screening data with the use of the commonly accepted medical information systems.

Comparison of Newborn Hearing Screening in Well-Baby Nursery and NICU: A Study Applied to Reduce Referral Rate in NICU

OBJECTIVES

To determine whether newborn hearing screening in a well-baby nursery (WBN) and neonatal intensive care unit (NICU) nursery: 1) meet three targeted, screening, referral, and diagnostic follow-up rates; 2) compare the average age of diagnosis for infants admitted to the WIN and NICU; and 3) determine prevalence of hearing loss in neonatal population; and 4) try to find a practical newborn hearing screening time algorithm to reduce refer rate in NICU.

MATERIALS AND METHODS

It examined 15,624 newborns in the WBN (13,676) and NICU (1948) screened for congenital HL using AABR. The variables analyzed in it were the screening rate, referral rate, follow-up rate, diagnostic rate and diagnostic age, prevalence rate, degrees of congenital bilateral HL. The study was approved by the hospital's institutional review board (13MMHISO23).

RESULTS

The screening rates were 99.8% and 99.6% in the WBN and NICU groups, respectively, without significant difference. The referral rates were 0.7% and 2.8% in the WBN and NICU groups, with significant difference. Furthermore, the diagnostic follow-up rates were 76.7% and 89.1% in the WBN and NICU groups, without significant difference. The average initial diagnostic ages were 1.9 months and 3.8 months in the WBN and NICU groups, with significant difference. The prevalence of congenital bilateral hearing loss were 0.27% and 1.6% in the WBN and NICU groups, with significant difference.

CONCLUSION

The screening, referral and follow-up rate in the WBN and NICU groups were equivalent to the quality indicators. For NICU group, screening and diagnostic follow up were performed later than those in WBN group; however the lower referral rate in our NICU group was successfully achieved in this study and can be applied clinically. The prevalence of congenital bilateral hearing loss was higher in the NICU group than in the WBN group.

Hearing aid validation based on 40 Hz auditory steady-state response thresholds

BACKGROUND AND AIM

Aided thresholds can be used for prediction of success of hearing aids and to choose between hearing aids and cochlear implants. This study aimed to compare characteristics of aided and unaided auditory steady-state responses (ASSRs).

METHODS

A total of 30 moderate to profoundly hearing-impaired subjects participated in this study. The subjects underwent acoustic immittance, behavioral audiometry, and ASSR with the modulation rate of 40 Hz, first without a hearing aid and then with a hearing aid. Sixteen people with normal hearing and 17 people with severe hearing loss were included in biological calibration of the sound field.

RESULTS

There was a significant difference between unaided behavioral and ASSR thresholds in all test frequencies (mean difference of unaided behavioral ASSR thresholds: 6.19 dB; P = 0.02 at 500 Hz, P < 0.001 at 1000 and 2000 Hz, and P = 0.02 for 4000 Hz). There was also a significant difference between aided behavioral and ASSR thresholds at 1000 and 2000 Hz (P < 0.001) but not at 500 (P = 0.14) and 4000 (P = 0.23) Hz (mean difference of behavioral ASSR thresholds was 4.33 dB). Despite observing any unaided responses, aided thresholds could be recorded in some severe to profoundly hearing-impaired subjects. The number of recordable thresholds was directly related to speech clarity and speech-reading ability. Multi-frequency stimulation elevated the ASSR threshold, especially for the higher frequencies and in the aided condition.

CONCLUSION

Functional and ASSR gains show less difference than threshold data. Therefore, comparing gains instead of thresholds is more accurate for validation of hearing aids. The probability of success of hearing aids appears to be poor if ASSRs (especially aided ones) cannot be recorded. If special care is taken in the fitting of hearing aids and the testing conditions, aided ASSR testing could be a useful tool for validation of hearing aids and the cochlear implant decision-making process.

Inventory of current EU paediatric vision and hearing screening programmes

OBJECTIVE

To examine the diversity in paediatric vision and hearing screening programmes in Europe.

METHODS

Themes for comparison of screening programmes derived from literature were used to compile three questionnaires on vision, hearing, and public health screening. Tests used, professions involved, age, and frequency of testing seem to influence sensitivity, specificity, and costs most. Questionnaires were sent to ophthalmologists, orthoptists, otolaryngologists, and audiologists involved in paediatric screening in all EU full-member, candidate, and associate states. Answers were cross-checked.

RESULTS

Thirty-nine countries participated; 35 have a vision screening programme, 33 a nation-wide neonatal hearing screening programme. Visual acuity (VA) is measured in 35 countries, in 71% of these more than once. First measurement of VA varies from three to seven years of age, but is usually before age five. At age three and four, picture charts, including Lea Hyvarinen, are used most; in children over four, Tumbling-E and Snellen. As first hearing screening test, otoacoustic emission is used most in healthy neonates, and auditory brainstem response in premature newborns. The majority of hearing testing programmes are staged; children are referred after 1-4 abnormal tests. Vision screening is performed mostly by paediatricians, ophthalmologists, or nurses. Funding is mostly by health insurance or state. Coverage was reported as >95% in half of countries, but reporting was often not first-hand.

CONCLUSION

Largest differences were found in VA charts used (12), professions involved in vision screening (10), number of hearing screening tests before referral (1-4), and funding sources (8).

Effects of policy changes to universal newborn hearing screening follow-up in a university clinic

PURPOSE

The purpose of this study was to evaluate the effects of policy changes on loss to follow-up rates and the ability to achieve the goals of the American Academy of Pediatrics Joint Committee on Infant Hearing Screening (2007) for diagnosis of hearing loss by 3 months, amplification within 1 month of diagnosis, and start of intervention by 6 months.

METHOD

From the files of 111 infants, data were extracted on the following: date of birth, birth hospital, hometown, parents' ages, ethnicity, nursery status, medical history, age at initial evaluation and diagnosis, results of evaluation(s), and age at hearing aid fitting and start of early intervention. Data were compared with previously published data from the clinic (Krishnan, 2009).

RESULTS

Policy changes led to a decrease in loss to follow-up and a younger age at diagnosis of hearing loss. Infants identified with hearing loss were fit with amplification at younger ages but not within 1 month of diagnosis of hearing loss. Policy changes had positive outcomes on loss to follow-up and age of diagnosis and amplification.

CONCLUSIONS

Challenges remain in meeting the goals of amplification within 1 month of diagnosis and documenting the start of early intervention. Improved communication between and education of all parties involved in the care of infants is needed.

[Using an employee survey as a means of quality assurance in newborn hearing screening]

BACKGROUND AND OBJECTIVES

Studies drawing information not only from technical data but also from surveying human resources behind the universal newborn hearing screening (UNHS) appear to be a rarity. This study aims at showing how the state of both knowledge and practical skills among the screening staff are essential aspects in future quality management.

MATERIALS AND METHODS

A self-developed questionnaire was sent to hospital staff addressing a total of 710 nurses who were registered as having undertaken a UNHS training course. Questions were aimed at aspects of organization, personal practical skills, current problems and improvement possibilities.

RESULTS

High rates of occupancy, lack of trained personnel, technical issues and background noise disturbances were considered to be factors that increased time pressure and slowed down procedures. Of the participants 16 % considered communicating a "refer" result to parents a difficult step and 8 % felt insecure when explaining the aims and procedures to parents. There was a high interest in further training sessions.

CONCLUSIONS

This survey served well to reveal aspects of improvement in screening procedures and meeting staff needs. The training sessions should outline practical aspects of conducting screening and also professional, sensitive communication to parents.