Measuring Hearing Aid Outcomes Using the Satisfaction with Amplification in Daily Life (SADL) Questionnaire: Australian Data

The aims of this study were to investigate hearing aid satisfaction for a group of older Australians fitted with government-funded hearing aids using the Satisfaction with Amplification in Daily Life (SADL) questionnaire; to compare the Australian data gathered with the provisional normative data reported by Cox and Alexander (1999); and to investigate the relationship between SADL satisfaction and several participant variables, hearing aid variables, and other outcome measures.

The SADL questionnaire and a Client Satisfaction Survey (CSS) were distributed by mail to 1284 adults fitted with government-funded hearing aids three to six months previously. 1014 surveys were returned. The mean age of participants was 75.32 years; 54.4% of participants were male, and 54.8% were fitted binaurally. Participants were fitted primarily with digitally programmable hearing aids of various styles (22.5% BTEs, 34.8% ITEs, 41.8% ITCs, 0.9% nonstandard [NS] devices).

Overall, participants reported a considerable level of satisfaction with their devices. SADL Global and subscale scores were significantly higher for the Australian sample than the U.S. norms described by Cox and Alexander (1999).

How Medicare Could Provide Dental, Vision, and Hearing Care for Beneficiaries

ISSUE

The Medicare program specifically excludes coverage of dental, vision, and hearing services. As a result, many beneficiaries do not receive necessary care. Those that do are subject to high out-of-pocket costs.

GOAL

Examine gaps in access to dental, vision, and hearing services for Medicare beneficiaries and design a voluntary dental, vision, and hearing benefit plan with cost estimates.

METHODS

Uses the Medicare Current Beneficiary Survey, Cost and Use File, 2012, with population and costs projected to 2016 values.

FINDINGS AND CONCLUSIONS

Among Medicare beneficiaries, 75 percent of people who needed a hearing aid did not have one; 70 percent of people who had trouble eating because of their teeth did not go to the dentist in the past year; and 43 percent of people who had trouble seeing did not have an eye exam in the past year. Lack of access was particularly acute for poor beneficiaries. Because few people have supplemental insurance covering these additional services, among people who received care, three-fourths of their costs of dental and hearing services and 60 percent of their costs of vision services were paid out of pocket. We propose a basic benefit package for dental, vision, and hearing services offered as a premium-financed voluntary insurance option under Medicare. Assuming the benefit package could be offered for $25 per month, we estimate the total coverage costs would be $1.924 billion per year, paid for by premiums. Subsidies to reach low-income beneficiaries would follow the same design as the Part D subsidy.

Burden of Sickness Absence Due to Chronic Disease in the Dutch Workforce from 2007 to 2011

INTRODUCTION

Chronic diseases are associated with productivity loss costs due to sickness absence. It is not always clear, however, which chronic diseases in particular are involved with how many sickness days and associated costs.

OBJECTIVE

To determine the prevalence, additional days of sickness absence, and associated costs of chronic diseases among the Dutch working population from 2007 to 2011.

METHODS

Prevalence of chronic diseases and additional days of sickness absence were derived from the Netherlands Working Conditions Survey (NWCS) from 2007 to 2011. The cost of each sickness absence day was based on linked personal income data. We used multiple regression analysis to derive the unconfounded additional days of sickness absence due to each chronic disease.

RESULTS

Annually, approximately 37 % of the Dutch working population reported some type of chronic physical or psychological disease. No clinically relevant changes in prevalence of specific chronic diseases were observed in the studied period, nor in the number of additional sickness absence days or associated costs. The national financial burden due to sickness absence associated with chronic musculoskeletal disorders amounted to €1.3 billion annually.

CONCLUSIONS

Chronic diseases result in substantial productivity loss due to sickness absence. Given the ageing population, the proposed increase in the state pension age and an increase in sedentary lifestyle and obesity, the prevalence of chronic diseases may be expected to rise. Coordinated efforts to maintain and improve the health of the working population are necessary to minimize socioeconomic consequences.

The Cost-Effectiveness of Different Hearing Screening Strategies for 50- to 70-Year-Old Adults: A Markov Model

OBJECTIVE

To assess the cost-effectiveness of screening 50- to 70-year-old adults for hearing loss in The Netherlands. We compared no screening, telephone screening, Internet screening, screening with a handheld screening device, and audiometric screening for various starting ages and a varying number of repeated screenings.

METHODS

The costs per quality-adjusted life-year (QALY) for no screening and for 76 screening strategies were analyzed using a Markov model with cohort simulation for the year 2011. Screening was deemed to be cost-effective if the costs were less than €20,000/QALY.

RESULTS

Screening with a handheld screening device and audiometric screening were generally more costly but less effective than telephone and Internet screening. Internet screening strategies were slightly better than telephone screening strategies. Internet screening at age 50 years, repeated at ages 55, 60, 65, and 70 years, was the most cost-effective strategy, costing €3699/QALY. At a threshold of €20,000/QALY, this strategy was with 100% certainty cost-effective compared with current practice and with 69% certainty the most cost-effective strategy among all strategies.

CONCLUSIONS

This study suggests that Internet screening at age 50 years, repeated at ages 55, 60, 65, and 70 years, is the optimal strategy to screen for hearing loss and might be considered for nationwide implementation.

Willingness to accept versus willingness to pay in a discrete choice experiment

OBJECTIVES

Our main objective was to compare willingness to accept (WTA) and willingness to pay (WTP) in a discrete choice experiment on hearing aid provision. Additionally, income effect and endowment effect were explored as possible explanations for the disparity between WTA and WTP, and the impact of using a WTA and/or WTP format to elicit monetary valuations on the net benefit of the new organization of hearing aid provision was examined.

METHODS

Choice sets were based on five attributes: performer of the initial assessment; accuracy of the initial assessment; duration of the pathway; follow-up at the ear, nose, and throat specialist; and costs. Persons with hearing complaints randomly received a WTP (costs defined as extra payment) or WTA (costs defined as discount) version of the experiment. In the versions, except for the cost attribute, all choice sets were equal.

RESULTS

The cost coefficient was statistically significantly higher in the WTP format. Marginal WTA was statistically significantly higher than marginal WTP for the attributes accuracy and follow-up. Disparity was higher in the high educational (as proxy for income) group. We did not find proof of an experience endowment effect. Implementing the new intervention would only be recommended when using WTP.

CONCLUSIONS

WTA exceeds WTP, also in a discrete choice experiment. As this affects monetary valuations, more research on when to use a payment or a discount in the cost attribute is needed before discrete choice results can be used in cost-benefit analyses.

Benefits and costs of universal hearing screening programme

Hearing loss affects 1-3 out of 1000 newborns. A programme of universal newborn hearing screening (UNHS) was implemented in our ENT department in February 2000. In 2001, the programme was extended to all the hospitals of the canton Geneva. The programme is based on the recording of transient evoked otoacoustic emissions (TEOAE) from all newborns. In addition, automated auditory brainstem responses (aABR) are recorded in high-risk neonates. In the report, we compare the mean age at which rehabilitation of hearing was undertaken during a 5-year period before and after the screening programme was instituted. We also identify some causes of delayed diagnosis and intervention and the pitfalls of universal hearing screening. The price of the UNHS programme is estimated at 26 Swiss francs (17 Euros; 21 US dollars) per infant screened, including the material required, the personal involved to run the programme, and the follow-up.

Choosing between measures: comparison of EQ-5D, HUI2 and HUI3 in persons with hearing complaints

Objectives

To generate insight into the differences between utility measures EuroQol 5D (EQ-5D), Health Utilities Index Mark II (HUI2) and Mark III (HUI3) and their impact on the incremental cost-effectiveness ratio (ICER) for hearing aid fitting

Methods

Persons with hearing complaints completed EQ-5D, HUI2 and HUI3 at baseline and, when applicable, after hearing aid fitting. Practicality, construct validity, agreement, responsiveness and impact on the ICER were examined.

Results

All measures had high completion rates. HUI3 was capable of discriminating between clinically distinctive groups. Utility scores (n = 315) for EQ-5D UK and Dutch tariff (0.83; 0.86), HUI2 (0.77) and HUI3 (0.61) were significantly different, agreement was low to moderate. Change after hearing aid fitting (n = 70) for HUI2 (0.07) and HUI3 (0.12) was statistically significant, unlike the EQ-5D UK (0.01) and Dutch (0.00) tariff. ICERs varied from €647,209/QALY for the EQ-5D Dutch tariff to €15,811/QALY for HUI3.

Conclusion

Utility scores, utility gain and ICERs heavily depend on the measure that is used to elicit them. This study indicates HUI3 as the instrument of first choice when measuring utility in a population with hearing complaints, but emphasizes the importance of a clear notion of what constitutes utility with regard to economic analyses.

Magnitude of impacted earwax in Oman, its impact on hearing impairment and economic burden of earwax on health services

BACKGROUND

Wax in ear canal causes a sizeable burden on resources of health services to a country.

AIM

The magnitude of impacted wax, its effect in a survey and cost of managing this problem were reviewed in 2002.

SETTINGS AND DESIGNS

A study was conducted during 1996 to estimate the magnitude and causes of hearing impairment and ear diseases in Oman. The authors further reviewed the data of community-based prevalence study to assess the role of impacted wax.

MATERIALS AND METHODS

Trained physicians used portable audiometers to test the hearing status of each ear. They used otoscopes to examine the ear. Persons suspected to have hearing impairment or ear disease were reexamined by audiologists and otologists to determine the causes of hearing impairment. The resources for managing impacted wax were also calculated.

RESULTS

In this survey, 11,402 subjects of all ages were examined. Prevalence of impacted wax was 11.7% (CI 95% 11.1-12.2). Impacted wax was significantly higher in females compared to males [RR = 1.22 (CI 95% 1.10-1.35)]. It was more common in residents of regions with humid environment than those of regions with less humidity [RR = 1.91 (CI 95% 1.67-2.18)]. Impacted wax in ear canal was associated with ear diseases. A total of 181,000 Omani people were estimated to have impacted wax in the ear canal. Managing impacted wax could cost 3.6 million US dollars to the ear care services.

CONCLUSIONS

Impacted wax was a hindrance in the hearing survey and countries should plan to deal with earwax in such surveys. Its impact on hearing impairment and resource burden should be considered while formulating policies for ear care.

An Alternate Approach for Surgical Dressing of Bone-Anchored Hearing Aid Abutment Sites

OBJECTIVE

To present an alternative surgical dressing for bone-anchored hearing aid (BAHA) abutment sites, comparing it with the manufacturer's recommended "healing cap" in terms of split thickness skin graft (STSG) survival.

STUDY DESIGN AND SETTING

A retrospective review of 30 patients who underwent unilateral BAHA implantation at a tertiary referral center. Patients were divided into two groups on the basis of the surgical dressing for the BAHA abutment site. Group 1 had a "healing cap" dressing, and group 2 had a bolster dressing. STSG survival was evaluated.

RESULTS

Between May 2002 and July 2006, 30 patients underwent BAHA implantation. Seven patients received the "healing cap" dressing, and 23 patients received the bolster dressing. There was 100% STSG survival in the bolster dressing group and 71% skin graft survival in the healing cap group (P = .048).

CONCLUSION

A traditional bolster dressing had improved STSG survival as compared with the manufacturer's recommended "healing cap." Additional benefits of a bolster are that it is maintenance free, well suited for noncompliant patients, and inexpensive.

Neonatal newborn hearing screening: four years' experience at Ferrara University Hospital (CHEAP project): part 1

The Child Hearing Early Assessment Programme (CHEAP) regional project, was a combined departmental approach (Audiology, Neonatology) of the University Hospital of Ferrara, aimed at identifying neonatal hearing impairment and defining early intervention strategies. Aims of this project have been: (i) construction of a neonatal screening programme using evoked otoacoustic emission and auditory brainstem responses; (ii) the calculation of a precise estimate of cost-benefits for every child tested; (iii) the development of an information flow instrument (database) for the storage of data and the statistical analysis of the results. The present report refers only to the results of the project related to the otoacoustic emission data from well-babies and intensive care unit residents. In the period January 2000-December 2004, 4269 full-term newborns and 654 Neonatal Intensive Care Unit babies were tested at the Neonatology Department. The cost of the Universal Neonatal Hearing Screening was estimated at Euro 9.20 per child, considering the use of the ILO-292 apparatus, and Euro 8.28 per child in the case of an automatic screener. In this screening model, the initial hardware costs can be re-iterated into budget in a period of two years, if 1000 children per year are tested.

Costs of congenital rubella syndrome (CRS) in Oman: Evidence based on long-term follow-up of 43 children

As part of the national plan for elimination of rubella and congenital rubella syndrome (CRS), Oman established a national registry of CRS cases. As of May 2005, the registry included 43 surviving CRS cases, with a mean age of 11.9 years. Clinical examinations found that 84% had ocular defects, 84% had auditory/speech defects, 70% had neurological manifestations, and 42% had cardiac defects. Lifetime medical, special education, and rehabilitation costs were assessed. Using a discount rate of 3%, the average direct lifetime cost per surviving CRS patient was estimated at 18,644 US dollars. When including predicted lost productivity due to CRS, the average discounted direct and indirect lifetime costs per surviving CRS patient amounted to 98,734 US dollars.

General review of tinnitus: prevalence, mechanisms, effects, and management

Tinnitus is an increasing health concern across all strata of the general population. Although an abundant amount of literature has addressed the many facets of tinnitus, wide-ranging differences in professional beliefs and attitudes persist concerning its clinical management. These differences are detrimental to tinnitus patients because the management they receive is based primarily on individual opinion (which can be biased) rather than on medical consensus. It is thus vitally important for the tinnitus professional community to work together to achieve consensus. To that end, this article provides a broad-based review of what is presently known about tinnitus, including prevalence, associated factors, theories of pathophysiology, psychological effects, effects on disability and handicap, workers' compensation issues, clinical assessment, and various forms of treatment. This summary of fundamental information has relevance to both clinical and research arenas.

[Age influence in otoacoustic emissions for hearing loss screening in infants]

OBJECTIVE

To determine the most favorable age for detection of otoacoustic emissions in newborns and for repeated testing.

METHODS

Observational, retrospective, descriptive study in 2,567 newborns.

RESULTS

The incidence of any degree of hearing loss was 7 per thousand newborns. It was proportionately higher in the group that did not have otologic risk factors The distribution of otoacoustic emissions by age groups followed a significant linear trend in the first month of life. The time lapse to obtain a positive result on the second otoacoustic emission test was 6 days from the first one.

CONCLUSIONS

Otoacoustic emission screening should be performed in all newborns as late as possible after birth (from the first 48 hours after birth), but before hospital discharge for the test to be effective and efficient. A repeat test, if required, must be performed at least six days after failing the first one.

Balancing societal costs and users' quality of life--priority setting of interventions for the hard-of-hearing

In this paper, the need for priority setting in rehabilitation, especially in audiology, and various approaches to providing information for priority setting are discussed. A set of outcome measures is proposed, and their applicability to vertical and horizontal prioritization are considered. Two types of measures are proposed: individual problems assessment, and utility analysis. Results from a European multicentre study and a Swedish study illustrate the performance of the measures in the areas of mobility, hearing, and speech communication. For rehabilitation in the hard-of-hearing, the two types of measures provide different kinds of information, illustrated by the results of simultaneous use of the instruments.

Neonatal hearing screening

Neonatal hearing screening can be performed using reliable and reproducible methods. Intervention before the age of 6 months with hearing aids and appropriate educational support services will give the infant the best possible opportunity to develop language. Potential barriers to efficient implementation of a neonatal hearing screening program include access to appropriate and timely diagnostic and support services and insurance to cover the services. Without universal neonatal hearing screening, many children with hearing loss will be missed, which will have a direct negative impact on their speech, language, educational, and social development.

[Model project of hearing screening in new-born in Hanover (preliminary results)]

In Germany, congenital hearing disorders are usually detected too late resulting in insufficient therapy of the disorder. To investigate these problems, the Federal Ministry of Health and the principal associations of statutory health insurance commissioned a pre-operative study. The study's aim is to verify whether introduction of a universal new-born hearing screening results in earlier diagnosis of hearing disorders and thus improves medical care for children with impaired hearing. Feasibility, effectiveness and economic tenability of this hearing screening programme will be investigated. The study is realised in the Hanover region and aims at carrying out a hearing test in all new-born during the first days of life. The tests will be performed in all 10 birth clinics and 2 paediatric clinics in the relevant region and in 24 otolaryngological practices. Hearing ability is controlled via an automated screening device measuring otoacoustic emissions. Sensitivity and specificity of the test is more than 95%. Economical feasibility is investigated by cost-effectiveness analyses. During a 6-month period the screening has been implemented in all clinics in every day routine. The mean coverage rate in the clinics has been stabilised to 97% of the total number. 4.7% of the children were presumed to suffer from unilateral hearing disorders and 2.3% from bilateral. In 13 cases the diagnosis of hearing disorder was confirmed. The mean age of diagnosis in these children was 3.7 months. The average age of therapy onset was 4.4 months. According to the present experience, area-wide implementation of hearing screening seems feasible in existing health care structures. The intention to advance the time of diagnosis and the therapy onset can be achieved by this method. Systematic training, introduction and quality assurance measures of screening are mandatory. Tracking of suspicious cases is necessary, even if it challenges data privacy regulations.

Will hearing healthcare be affordable in the new millennium

Calculations of the needs of healthcare, hearing healthcare included, are usually based on clinical data rather than on valid prevalence figures. According to our recent population study, the number of citizens needing hearing aids in Finland will be twice the figure usually presented, 280 000 for the country as a whole (population 5.1 million). The penetration of hearing aids was only 41%. Taking this and the ageing of the population into account, the economic challenges of hearing healthcare will be alarming in the new millennium.

Systematic review of the clinical and cost effectiveness of digital hearing aids

The aim of the present study was to systematically review the clinical and cost effectiveness of hearing aids which use digital signal processing relative to other forms of hearing aid technology, in particular analogue-based aids. A comprehensive search for randomized controlled trials, randomized crossover trials and economic studies was undertaken. Trial quality assessment and data extraction were undertaken by two independent reviewers. Eight trials comparing digital to non-digital devices were identified--one randomized controlled trial and seven randomized crossover trials. The majority of these studies were of small sample size and of poor methodological quality. In the majority of cases (nine out of 13), there was no evidence of a significant difference in either laboratory scores (nine out of 13 outcomes assessed) or user function/quality of life scores (six out of nine outcomes assessed) between digital and non-digital devices. In addition, there was no significant difference in patient preference for digital compared to control aids (relative risk 1.93; 95% CI 0.70-5.35) when pooled across studies. No cost-effectiveness studies directly comparing digital to non-digital devices were identified. In conclusion, the evidence identified by this review provides no significant evidence of the clinical benefit of digital devices compared to analogue-based aids. However, these results are difficult to generalize to current UK practice as the analogue aids and types of fitting in the trials are not those typically used in the NHS.

Neonatal hearing screening with transient evoked otoacoustic emissions--retrospective analysis on performance parameters

The present paper reports on the implementation of a maternity based neonatal hearing-screening program in a private hospital. A retrospective analysis is performed on the test pass rate, the coverage and the number of children that become lost to follow-up. The data show a steady learning curve with a time course of several years. In the current screening practice, the test pass rate is at 99.0%, the coverage is at 96% (birth rate of 2000 per annum) and almost no babies get lost to follow-up.

Measuring hearing aid benefit using a willingness-to-pay approach

The value associated with self-perceived hearing aid benefit was assessed using a "willingness-to-pay" (WTP) approach. Abbreviated Profile of Hearing Aid Benefit (APHAB) data were obtained from 79 veterans who also indicated how much they were willing to pay for each hearing aid. The results of a multiple regression analysis revealed that veterans were willing to pay $22.06 more for a hearing aid for each 1-point increase in APHAB global benefit. A second multiple regression analysis revealed that the APHAB subscale scores for Ease of Communication (EC) benefit and understanding speech in Background Noise (BN) benefit, as well as income level, were all significant predictors of WTP. In addition, each 1-point increase in EC, BN, and Reverberation benefit increased the value associated with amplification by $16.32, $16.88, and $13.78, respectively. Each 1-point increase in the Aversiveness of Sounds subscale decreased the value associated with amplification by $7.63. The mean WTP across all income groups was $981.71 per hearing aid. These data are interpreted to support the use of WTP as a valid measure of hearing aid benefit.

Cost and cost-effectiveness of universal screening for hearing loss in newborns

OBJECTIVE

To estimate the cost and cost-effectiveness of universal newborn hearing screening.

STUDY DESIGN AND SETTING

Decision analysis model utilizing the hospital perspective. This model evaluated 4 distinct protocols for screening a fixed and defined hypothetical cohort of newborn infants.

OUTCOME MEASURES

Cost of screening and the number of infants with hearing loss identified through universal screening.

RESULTS

Otoacoustic emissions testing at birth followed by repeat testing at follow up demonstrated the lowest cost ($13 per infant) and had the lowest cost-effectiveness ratio ($5100 per infant with hearing loss identified). Screening auditory brainstem evoked response testing at birth with no screening test at follow-up was the only protocol with greater effectiveness, but it also demonstrated the highest cost ($25 per infant) and highest cost-effectiveness ratio ($9500 per infant with hearing loss identified). These findings were robust to sensitivity analysis, including best-case and worst-case estimation. The prevalence of hearing loss and the fraction of infants returned for follow-up testing had a large impact on the absolute level, but not relative level of protocol cost and cost-effectiveness.

CONCLUSION

The otoacoustic emissions testing protocol should be selected by screening programs concerned with cost and cost-effectiveness, although there are certain caveats to consider.

SIGNIFICANCE

The most significant barriers to implementation of universal newborn hearing screening programs have been financial, and this study compares the most common protocols currently in use. This study can assist program directors not only in the decision to initiate universal screening but also in their choice of screening protocol.

Evaluation of the use of a questionnaire to detect hearing loss in Kenyan pre-school children

In developing countries, there is a lack of trained personnel and testing equipment to facilitate the early detection of hearing impairment in children. A questionnaire offers a low cost option and the value of this for detecting hearing impairment in pre-school children was determined in several districts in Kenya. The questionnaire was completed by either teachers, parents/carers or community nurses. The children were subsequently tested using pure tone audiometry and visual examination of the ear by ENT Clinical Officers, who were not given prior access to the results of the questionnaire. A total of 757 (88%) questionnaires were completed. Of the 735 children, who could be tested using pure tone audiometry, four were found to have a unilateral hearing impairment and one was detected by the questionnaire. A total of 13 children had a bilateral hearing impairment >40 dB HL. All were detected using the questionnaire. There were eight males and five females with ages ranging from 4.2 to 6.9 years, mean age 5.7 years and median age 5.8 years. Eight had a sensorineural hearing impairment and two a mixed hearing impairment. Three of the children with a sensorineural hearing loss had a family history of hearing impairment. No question detected all children with a hearing impairment and some questions were more discerning than others. There was 100% sensitivity for the questionnaire when a hearing loss of >40 dB was considered, but specificity was lower at 75%. Negative predictive value was 100%, but the positive predictive value was low, 6.75%. It was concluded that a questionnaire of this nature could be usefully applied at Primary Health Care level for detecting hearing impairment at the pre-school stage. There would be need for services available for diagnosis, treatment and habilitation before a screening programme was introduced.

Performance of neonatal and infant hearing screens: sensitivity and specificity

The terms 'sensitivity' and 'specificity' are defined and some of the factors that determine their values are discussed in the context of screening for permanent childhood hearing loss. There is a need to distinguish between the values observed in 'simple experiments' and those that may be obtained under more realistic 'field' conditions. It is not feasible to give a meta-analytic overview of published data because of the variety of methods and objectives used in those studies published in the literature. However, a qualitative synthesis of the data is possible. This suggests that most proposed neonatal hearing screening tests, when implemented in accordance with a programme of quality assurance, can be reasonably accurate at a modest cost. However, the optimal combination of tests and test parameters for given populations has not yet been fully researched. The infant distraction test screen has a lower sensitivity than neonatal hearing screening tests, particularly for moderate impairments, accompanied by a fairly low specificity.

Some issues relevant to establishing a universal newborn hearing screening program

This article describes some of the factors relevant to the establishment of a universal newborn hearing screening (UNHS) program. First, the difficulty in providing precise estimates of test sensitivity and specificity are reviewed. This section is followed by hypothetical estimates of overall programmatic costs, first for a fixed number of babies to be screened and then as a function of the number of babies to be screened in a year. Included in these estimates are the costs for equipment, disposables, personnel, and follow-up testing. These estimates are provided for three different screening protocols: auditory brainstem response (ABR) alone, otoacoustic emission (OAE) alone, and OAE followed by ABR only for those babies who failed the OAE screening. If follow-up costs are not included, it is less expensive to screen newborns with OAEs compared with the other two protocols. However, once follow-up testing is included as part of the program costs and there are at least 400 births per year, procedures in which OAEs are performed first, followed by an ABR on those infants who do not pass the OAE test, result in the lowest costs. Hospitals with as few as 400 births per year should expect per-baby costs not exceeding $30, regardless of which protocol is used. For all three protocols, the unit costs decrease as the number of babies screened increases. The final section describes data from a local UNHS program in which all infants are screened first with an OAE test, followed by an ABR test on infants not passing the OAE screening. Idiosyncratic features to this program are described, including the fact that all screening tests are performed by audiologists, who are paid on a part-time basis, adding cost to the program. Even under these circumstances, the unit cost is under $30. These data lead us to conclude that all infants can be screened in a cost-effective manner.

Auditory evoked response test strategies to reduce cost and increase efficiency: the postauricular muscle response revisited

We describe a number of techniques in auditory evoked response (AER) testing for hearing loss which should decrease its cost and increase its efficiency, making its use in infant hearing screening more viable. We demonstrate the use of bit-stream averaging of the electrical signals from the head as a cheap alternative to analogue averaging and show that the average waveforms obtained are similar with both techniques. We demonstrate how the postauricular muscle response (PAMR) can be potentiated by lateral rotation of the eyes and argue that uncontrolled eye movements in previous studies have led to an unfounded belief that the PAMR is not stable. When eye rotation is used to potentiate the PAMR, the response becomes very stable and so large in most subjects that it is clearly visible in the raw traces. We also demonstrate that when the PAMR is potentiated by eye rotation, stable PAMR waveforms can be reliably obtained with tone bursts with frequencies up to and above 8 kHz and with sound levels within 30 dB of the subjective detection threshold. As a result the PAMR can be used to rapidly determine an objective audiogram in most subjects within minutes. Finally, we demonstrate a correlation technique for detecting the PAMR without waveform averaging and the need for an expensive computer. We are sure that a combination of these techniques can be used to increase the efficiency of AER screening for infant deafness and lower its cost dramatically.

Screening strategies for neonatal hearing loss: which test is best?

OBJECTIVE

The objective of this study was to evaluate the accuracy and cost effectiveness of three different methods of hearing screening in newborns.

DESIGN

A prospective, randomized cohort design was used. One hundred and five newborns were tested in this preliminary study.

SETTING

The study was conducted in a tertiary care hospital setting in both the well baby and special care nurseries.

METHODS

Consenting subjects had their hearing tested using automated auditory brainstem response (AABR), distortion-product otoacoustic emissions, and click-evoked otoacoustic emissions. The time to perform the tests was recorded and the cost of each test was calculated.

MAIN OUTCOME MEASURES

The main outcomes measured were the time taken to perform each test, the pass/fail rate for each test, and the estimated cost of the tests.

RESULTS

In this small cohort of patients, we found that AABR was the most accurate test, but it took longer to perform and was more expensive than either of the otoacoustic emission tests. However, the sensitivity and specificity of otoacoustic emissions were less than that of AABR. Test time decreased as the examiner gained experience, and we anticipate that experience will also result in better accuracy for the otoacoustic emission tests.

CONCLUSIONS

Hearing screening in a hospital-based newborn population is both feasible and cost effective. Although AABR was more expensive, its better accuracy must be considered. As technology improves, the cost of all three tests will diminish. More robust conclusions cannot be made based on this small patient population.

Hearing impairment in Latin America: an inventory of limited options and resources

The availability of information about prevalence/incidence of hearing impairment in Latin American countries is very limited. A questionnaire on the subject was mailed to most Latin American and Caribbean countries. The information returned by 12 respondents (Argentina, Chile. Columbia, Costa Rica, Cuba, Grenada, Guatemala, Mexico, Nicaragua, Panama, Puerto Rico, and Uruguay) was analyzed. Data are presented about available epidemiological studies on hearing impairment, national registers on deafness, publications on otitis media, and programs on hearing screening. Presence of training programs and available human resources in the broad field of hearing impairment is also discussed. Estimates of the enrollment of deaf children in schools for the deaf is also shown. This review concludes that hearing impairment is a low priority for national health systems in Latin America. material and human resources are limited, audiology services are scarce, and technology continues to be very costly by regional standards.

Screening infants for hearing loss--an economic evaluation

STUDY OBJECTIVE

The aim was to carry out an economic evaluation of the programme implemented in one district health authority for the screening of infants for hearing loss.

DESIGN

The approach taken was a cost-effectiveness analysis using the methodology of decision analysis to model the options appraised: (1) the conventional screening policy was for a health visitor and colleague to screen at 8-9 months, and at 10 months for each child to be seen again by a clinical medical officer for a developmental assessment plus hearing screen if necessary; (2) the alternative policy was for screening to take place at 10 months only if concern is expressed (or if there is a clinical indication) at the developmental assessment; the introduction of a "clue list" was considered; (3) the third option was no screening.

MAIN RESULTS

The annual expected cost per unit output was pounds 20.57 for the conventional screening policy, between pounds 11.13 and pounds 11.23 for the alternative policy, and pounds 11.27 for the third option of no screening. Introducing the "clue list" under the alternative screening policy is likely to raise the cost per unit output, but the effects are uncertain.

CONCLUSIONS

The results suggest that the alternative screening policy is more cost-effective than the conventional policy, but has little advantage over not screening at all. The effects of introducing a clue list need further investigation.

Hearing impairments in middle age: the acceptability, benefit and cost of detection (ABCD)

The major epidemiological investigations of hearing impairment, disability and handicap show that the elderly are the group most disabled by their hearing impairment. There is considerable debate concerning the most efficient way of reducing this inevitable burden of age-related hearing impairments in the next generation. Early fitting of 'targeted' individuals with hearing aids may help but there are a large number of methodological problems associated with conducting and evaluating such a programme of research (especially retrospectively). The logical prerequisite to early fitting as a means of reducing later disability is to ascertain the acceptability of and benefit given by intervention at this early stage. This study therefore set out to investigate the age/sex register provided by the primary physician (GP) as an appropriate base to identify candidates for early aid fitting among a sample of middle-aged patients (50-65 years) living in Roath, Cardiff. Of the 662 who replied to an initial contact letter (1050 were on the age/sex register), 21 already possessed hearing aids. After screening and examination 66 people were offered some form of management which was accepted by 43 during the course of the study. Aid use thereby increased from about 3% to over 9% in this middle-aged group. A 2 year follow-up indicated continued use of the aids, and benefit on a speech reception task was measured. The cost of detecting those who might benefit was calculated using a two-question 'paper and pencil' screen as the first step. A national programme for Wales would cost at least 188,000 pounds per annum at 1990 prices over an initial 5 year span if a criterion which aimed to find at least 45 dB HTL impairments over mid-frequencies was implemented. For a criterion of 35 dB the cost would be 378,000 pounds pa.

Audiology--state of the art

From its origin in the 1940s audiology--the discipline concerned with hearing in all its aspects--has grown in many directions. Knowledge about the functioning of the auditory system has improved for both the normal and disordered state. Hearing loss can greatly diminish the quality of life of the individual affected and of those closely associated with him/her. It is more widespread than generally recognized, a fifth of the adult population having hearing below the level of social adequacy, with the cost to the community in monetary terms probably being between 200 million pounds and 300 million pounds a year. Detection of hearing loss in infancy, or even in the foetus, is vital to early and effective treatment; a number of new techniques are being investigated to improve the accuracy of hearing screening procedures. Transient hearing loss in early childhood is very common. In this age group the problem to which much attention is being directed is the identification of a minority in whom the usually transient condition becomes permanent and handicapping. In adult subjects the diagnosis of hearing problems is now well developed and effective. For those unable to benefit from medical or surgical treatment the situation is less satisfactory. For the elderly hearing impaired and for some of the less elderly also, the principal form of remediation is through amplification--mainly, but not exclusively, hearing aids. Yet of those likely to benefit from this form of assistance only about one quarter are actually receiving help. The poor take up of hearing aids stems partly from the somewhat thoughtless and ill-informed public attitude to hearing impairment and partly from weaknesses in service provision. The audiologist has a role to play in remedying this situation and also in the area of hearing loss prevention. Noise is the major cause of avoidable hearing loss, both in the industrial and entertainment areas. Education about, and prevention of hearing loss are likely to be significant growth areas for audiologists in the future.