Kai Uus

Effectiveness of population-based newborn hearing screening in England: Ages of interventions and profile of cases

OBJECTIVE. The objective of this study was to determine the effectiveness in routine practice of the first phase of a national population-based newborn hearing screening and follow-up program that seeks to identify infants with bilateral permanent hearing loss of ≥40-dB hearing loss. METHODS. The study was a part of the independent evaluation of the 23 first phase sites (annual birth population ∼120000) of the national newborn hearing screening program in England. For each infant identified with the defined hearing loss, the measures of interest were degree and type of hearing loss, presence of risk factors, age of first audiologic assessment, age of identification of hearing loss, age of enrollment in an early support program, and age of hearing aid fitting. Data collection took place over the first 2 years of the program. RESULTS. Data were provided on 169 infants with permanent bilateral moderate or greater hearing loss identified through screening 169487 infants. Fifty-four percent of all cases were from an “at-risk” population. Three fourths of these “at-risk” infants spent ≥48 hours in the NICU. For the whole sample, the median age at first audiologic assessment was 5 weeks; the median age of identification of the hearing loss and of enrollment in early support program was 10 weeks irrespective of the degree of hearing loss; and the median age at hearing aid fitting was 16 weeks. Infants with moderate hearing loss were fitted with hearing aids significantly later than those with severe and profound hearing loss. CONCLUSIONS. Properly implemented, a newborn hearing screening program based on whole populations and routine service provision can deliver satisfactory outcomes in terms of age of referral, identification, and intervention. The distribution of degree and type of hearing loss and proportion with risk factors was similar to that expected. The numbers identified were such as to suggest that very few cases were missed by the screening program.

An analysis of the costs of implementing the National Newborn Hearing Screening Programme in England

Objective: The primary aim of this analysis was to prospectively assess the full economic costs associated with implementing Newborn Hearing Screening Programme (NHSP) based on a two-stage screen, transient evoked otoacoustic emissions followed, if there is no clear response, by automated auditory brainstem response. Economic data were also collected from the Infant Distraction Test Screening (IDTS) service performed by health visitors at around eight months of age, which was being phased out. A comparison of costs and outcomes associated with NHSP and IDTS was conducted. Design: 20 NHSP sites were invited to provide detailed cost data on NHSP implementation and 14 of these sites were selected to provide costs on the IDTS service that was being supplanted. Results: There was marked variability in the costs. Given the higher yield of NHSP sites, the average cost per case detected across NHSP sites (£31,410/case) was approximately half that of IDTS sites (£69,919/case). Including family costs, the average total cost per case of NHSP (£34,826/case) was almost a quarter of IDTS (£117,942/case). Conclusions: Family costs and cost per case associated with NHSP are considerably less than that with IDTS. These findings support the policy of implementation of NHSP and the phasing out of the IDTS.

Screening for hearing loss in childhood: issues, evidence and current approaches in the UK

Until recently, screening for childhood hearing loss in the UK was based on two universal (i.e. whole population) screens: the infant distraction test screen at age eight months and the school entry hearing screen at age four to five years. Evidence reviewed in the 1990s indicated that the infant distraction test screen was seriously underperforming, but that (based on technology that had become available in the 1980s and 1990s) universal newborn hearing screening could be efficacious. At the same time, evidence was emerging on the importance and value of very early identification and intervention for permanent congenital childhood hearing loss. This led to the decision to implement a national newborn hearing screening programme (NHSP) in England and to phase out the distraction test at eight months. The initial implementation of the programme will be completed in 2005, and we summarize the evidence on the effectiveness of the first phase of the programme here. A number of important issues concerning childhood hearing loss and its management remain unresolved: the burden of late-onset and temporary childhood hearing losses, the most effective approaches to intervention and management, the case for screening for mild and/or unilateral hearing loss, and the role of the School entry screen. Some of the current research efforts to address these are outlined.

Neonatal hearing screening: Modelling cost and effectiveness of hospital- and community-based screening

BackgroundChildren with congenital hearing impairment benefit from early detection and management of their hearing loss. These and related considerations led to the recommendation of universal newborn hearing screening. In 2001 the first phase of a national Newborn Hearing Screening Programme (NHSP) was implemented in England. Objective of this study was to assess costs and effectiveness for hospital and community-based newborn hearing screening systems in England based on data from this first phase with regard to the effects of alterations to parameter values.MethodsDesign: Clinical effectiveness analysis using a Markov Model. Outcome measure: quality weighted detected child months (QCM).ResultsBoth hospital and community programmes yielded 794 QCM at the age of 6 months with total costs of £3,690,000 per 100,000 screened children in hospital and £3,340,000 in community. Simulated costs would be lower in hospital in 48% of the trials. Any statistically significant difference between hospital and community in prevalence, test sensitivity, test specificity and costs would result in significant differences in cost-effectiveness between hospital and community.ConclusionThis modelling exercise informs decision makers by a quantitative projection of available data and the explicit and transparent statements about assumptions and the degree of uncertainty. Further evaluation of the cost-effectiveness should focus on the potential differences in test parameters and prevalence in these two settings.

Increasing knowledge about a screening test: preliminary evaluation of a structured, chart-based, screener presentation

The provision and understanding of good quality information is one of the key characteristics of an informed choice. However, written materials alone often fail to achieve good understanding of screening tests. The present study describes the preliminary evaluation of a structured, chart-directed presentation, aimed at increasing knowledge of a screening test. Forty mothers of babies undergoing a newborn hearing test received either a standard, or a standard plus structured, presentation of the screening test. Standard presentation was a leaflet and short verbal explanation of the test. Structured presentation comprised an illustrated chart explaining the process and possible outcomes of screening, followed by screeners checking mothers understanding of key points and, if necessary, giving further explanation. After screening, maternal knowledge of the test was assessed using seven multiple choice items. Overall knowledge was high. For women with lower levels of education, the structured presentation resulted in significantly higher levels of knowledge than the standard presentation only.

Epidemiology of Permanent Childhood Hearing Impairment in Estonia, 1985-1990: Epidemiologia de los trastornos auditivos permanentes de la infancia en Estonia (1985–1990)

This paper describes a retrospective study of permanent childhood hearing impairment (PCHI) ⩾ 40 dB HL in the better ear in children born between 1985 and 1990 and resident in Estonia. The prevalence rate of all permanent hearing impairment for the birth cohort 1985–1990 was 172 (95 per cent (CI 151-194) per 100,000 live births and that of congenital impairment was 152 (CI 134-170) per 100,000. For the con-genitally-impaired children, 11 per cent had stayed in a neonatal intensive care unit for 48 hours or more, 2 per cent had a craniofacial abnormality, and 31 per cent had a family history of PCHI. As for aetiology, hereditary causes were stated most frequently in 36 per cent of all of the cases of PCHI. The aetiology remained unknown in 34 per cent of cases. Additional disabilities were found in 23 per cent of all cases. Specific syndromes were recognized in 2 per cent of hereditary cases. The mean age at the confirmation of hearing impairment was 46.4 months and at hearing aid fitting 57.0 months. The results were compared with other European studies, particularly the Trent study. Sumario Se describe un estudio retrospectivo de trastornos auditivos permanentes de la infancia (PCHI) en niños nacidos entre 1985 y 1990, que residen en Estonia, y con una audición de 40 dB HL en el mejor oído. La tasa de prevalencia para todas las formas de trastorno auditivo permanente, en la cohorte de nacidos entre 1985 y 1990, fue de 172 (95 por ciento de intervalo de confianza - CI 151-194) por 100.000 nacidos vivos y el de trastornos congénitos fue de 152 (CI 134-170) por 100.000. De los niños con alteraciones congénitas, 11 por ciento habían permanecido en unidades de cuidado intensivo neonatal por 48 horas o más, 2 por ciento tenían anomalías cráneofaciales, y un 31 por ciento tenía historia familiar de PCHI. Con respecto a la etiología, las causas hereditarias fueron las más fre-cuentes en un 36 por ciento de todos los casos de PCHI. La etiologia fue desconocida en el 34 por ciento de las veces. Se encontraron discapacidades adicionales en un 23 por ciento de las veces. Se reconocieron síndromes específicos en un 2 por ciento de los casos hereditarios. La edad promedio de confirmation del trastornos auditivo fue de 46.4 meses y la de adaptation de un auxiliar auditivo fue de 57.0 meses. Los resultados se compararon con otros estu-dios europeos, particularmente con el estudio de Trent.

To What Extent Do the Characteristics of the Object of Evaluation Influence the Choice of Epistemological Framework? The Case of Universal Newborn Hearing Screening

In this article, the authors explore the role that characteristics and circumstances attendant on the object of an evaluation might play in the choice of epistemological framework underpinning research design. They consider examples from the consumer-focused evaluation of the introduction of universal newborn hearing screening in England. In particular, they look at how screen-and program-specific issues exerted influence at the levels of epistemology and method, arguing that these choices are not simply a product of values and questions that underpinned one kind of approach to knowledge production in comparison with another.

Why don't health professionals check patient understanding? A questionnaire-based study.

Abstract Checking patient understanding, by asking questions about information presented in a medical consultation, is a core communication skill but its use is not frequently assessed. The newborn hearing screening commenced in England with a pilot of its implementation in January 2002. Because it is a new screening test, it provided an opportunity for studying the effective communication of novel information. A randomized controlled trial of training newborn hearing screeners to present information about the screening test and to ask questions to check understanding was commenced but had to be prematurely ended as the majority of the screeners did not ask the questions. The aim of this study was to understand why the screeners did not ask questions to check understanding of the information provided. Questionnaires were sent to screeners who participated in the study to elicit their responses to the use of the questions to check understanding. A response rate of 87% (26/30) was achieved. Screeners who reported not asking the questions were more likely to express a lack of confidence in their ability to ask questions, and to perceive asking questions as an ineffective way of increasing patient understanding. The study suggests that the ability and willingness of healthcare professionals to use simple communication skills may have been overestimated and training needs to target skills as well as beliefs about the effectiveness of using them.

Readiness of paediatric audiology services for newborn hearing screening: Findings and implications from the programme in England

As well as evaluating the newborn hearing screen itself, the government-funded evaluation of the implementation of a Newborn Hearing Screening Programme (NHSP) in England is assessing the impact of the screen on follow-up services. In the UK context, these are principally paediatric audiology, education, and social services. This article presents results from a mixed method research study involving paediatric audiology services specifically. Results demonstrate significant variety in current practice with regard to routine tests and procedures, considerable variability in number of current referrals and time allocated to caseloads, and considerable variability in expectations of how the numbers will change following newborn screening implementation. The challenges of and opportunities afforded by NHSP which were identified by respondents, highlight the urgent need for further training. The study has implications for paediatric audiology services that are yet to start NHSP in the UK, as well as for services and professionals in other countries. Sumario Además de evaluar la propia prueba de identificación auditiva en recién nacidos, la evaluación financiada por el gobierno del Programa de Tamizaje Auditivo en Recién Nacidos (NHSP) en Inglaterra está valorando el impacto del procedimiento de identificación sobre los servicios de seguimiento. En el contexto del Reino Unido (U.K.), estos son: audiología pediátrica, servicios de educación y servicios sociales. Este artículo presenta los resultados de un estudio de investigación de metodología mixta, que involucra, específicamente, a los servicios de audiología pediátrica. Los resultados demuestran una variedad significativa en la práctica clínica actual en relación con las pruebas y procedimientos rutinarios, una considerable variabilidad en el número actual de referencias y el tiempo requerido para los casos, así como una considerable variabilidad en las expectativas de cómo cambiarán las cifras posteriormente a la implementación del tamiz neonatal. Los retos y las oportunidades ofrecidas por el NHSP identificadas por los encuestados, destacan la urgente necesidad de entrenamiento adicional. El estudio tiene implicaciones para los servicios de audiología pediátrica que aún no han iniciado el NHSP en el UK, así como para servicios y profesionales en otros países.

Auditory neuropathy spectrum disorder in the wider health context: Experiences of parents whose infants have been identified through newborn hearing screening programme

Abstract Objective: This paper presents an insight into the parental experiences of how parents made sense of having their child identified with auditory neuropathy spectrum disorder (ANSD), given the broader context of their childs other health issues. Design: Qualitative narrative study. Study sample: Twenty-one families participated whose children had been identified with ANSD through the newborn hearing screening programme. Results: The majority of parents in the sample were overwhelmed with perinatal health issues and initially gave the diagnosis of ANSD very low priority. Conclusions: An understanding of parents’ perspective is particularly relevant to everyone involved in early support and management of infants with ANSD.