Although early hearing detection and intervention (EHDI) programs have been the standard of care for the past 20 years, there are surprisingly few audiologists who oversee hospital screening programs throughout the United States. Research has proven that screening of infants by 1 month of age, audiological diagnosis by 3 months, and early intervention by 6 months greatly improve the outcomes for infants who are deaf or hard of hearing (Pediatrics. 1998 Nov;102(5):1161). The greatest challenges that EHDI programs face are lost to follow-up (LTF) and lost to documentation (LTD) of infants from hospital screening to rescreening and diagnosis. Since the inception of the EHDI program in 1992, it has been recommended that hospitals offer an outpatient rescreen when an infant does not pass the newborn hearing screen at discharge. This decreases the number of infants who need more costly diagnostic evaluations, but adds a step to the EHDI process. The goal of the study was to identify factors associated with infants not receiving their outpatient rescreen (Am J Audiol. 2018 Sep 12;27(3):283).
Colorado has many frontier and rural areas and also a paucity of pediatric audiologists. Unusual among the 50 U.S. states, Colorado also has a statewide system of Audiology Regional Coordinators who work about four hours per month to provide technical assistance to local hospitals, midwives, and birthing centers. They do not provide direct service in this capacity. However, at the time of the study, only about half of the hospitals indicated that they had oversight and coordination with an audiologist largely because of the minimal funding for this aspect of the system.
The study included the population of children in Colorado in 2005. Data analysis focused on infants born from Jan. 1, 2005, through Dec. 31, 2005. In 2005, Colorado had 69,487 live births, and 68,478 of those births occurred in 56 birthing hospitals. Of the 68,478 births, 67,261 (98.22%) infants were screened and 1,217 (1.77%) were not. Additionally, 3,153 (4.7%) infants did not pass the initial inpatient screen; of these, 622 (19.7%) did not receive a follow-up outpatient screen. Of the 2,531 (80.3%) infants who did receive an outpatient follow-up screen, 115 were found to have permanent hearing loss.
Data were collected using hospital survey results, and variables were collected from electronic birth certificates and screening results in the EHDI Integrated Data System (IDS) at the Colorado Department of Public Health and Environment. The methodologies used were linear and logistical regression, as well as descriptive analyses across demographic and hospital variables associated with infants who did not receive a follow-up outpatient hearing screening.
AREAS WITH HIGHER LTF/LTD
The study results showed higher loss to follow-up/documentation for outpatient screening in five areas.
Infants born to Hispanic mothers: The Hispanic population accounted for 32.3 percent of the entire birth cohort and was most likely to not receive the outpatient rescreen. Hispanic infants accounted for 47.7 percent (N = 261) of those who did not receive the outpatient rescreen. Non-Hispanics were 45 percent more likely to receive the outpatient rescreen than the Hispanic population. The EHDI program needed to identify ways to improve this process. An analysis of more recent data demonstrated that there was not a significant difference between Hispanic and non-Hispanic populations (Acad Pediatr. 2018 Mar;18(2):188). This was most likely due to an increase in education following the initial analysis.
Infants with an Apgar score of seven or below at five minutes after birth: Infants with a low Apgar score were 54 percent less likely to receive a rescreen. Increasing education in neonatal intensive care units by having Audiology Regional Coordinators and recommending an immediate referral to a pediatric audiologist have decreased this percentage, which was no longer a significant factor in the recent analysis.
Mother's education level: About 32 percent of infants were born to mothers with 12 years or less of education, and they were 49 percent less likely to obtain the rescreen. Unfortunately, this continues to be a risk factor.
Infants born in hospitals with low rates of returning for the outpatient rescreen: In the regression model, the variables were dummy coded. Hospital rescreen rates were broken down into three groups: 90 percent or greater, 80-90 percent, and less than 79 percent. Infants born in hospitals with less than 79 percent were 6.3 times less likely to obtain an outpatient rescreen. Hospitals that did not have an audiologist involved, such as the Audiology Regional Coordinator, had less than 79 percent return rates overall for the outpatient rescreen. Action was taken to increase the visibility of the Audiology Regional Coordinators in providing technical assistance to improve the rescreen rates. It was also found that audiologists were no longer a significant factor in rescreen rates because all hospitals had audiology involvement.
ROLE OF AUDIOLOGISTS
Audiologists who are visible and provide technical assistance based on a hospital's outcomes such as screening rates, referral rates, and rescreen rates improve overall rescreen rates. They can also impact the referral rates. Interestingly, we found that hospitals with higher referral rates had better rescreen rates. Investigating this further, we found that those hospitals had an audiologist involved in the program to help ensure that the infants returned for a rescreen. Audiology involvement also decreased the impact of other factors like the type of technology used for screening and the personnel (e.g., nurse, technician, volunteer) who performed the screen. Our study also found that who scheduled the rescreen (e.g., hospital prior to discharge or parent calling back to make an appointment) was not significant when an audiologist was involved. Hospitals that scheduled the outpatient rescreen prior to discharge had a higher rescreen rate but only if an audiologist was not involved with the program. Audiologists who partner with screening programs can also have an effect on where the outpatient rescreen is performed. Hospitals that referred out to local audiologists had much poorer rescreen rates than those that brought infants back to the hospital. Audiology coordinators worked directly with these hospitals to encourage them to bring infants back to the birthing center, which improved their follow-up.
Health care systems have no control over factors such as the ethnicity and education of the mother, the child's Apgar score, or whether an infant is born in a hospital with a low follow-up rate. However, all systems can develop a cost-effective audiology oversight and partnership with hospital screening programs. In the individual hospital protocol development, many decisions are made about the type of technology used, protocol for equipment usage, information provided to the parent(s) or family, process for making outpatient appointments, people responsible for the screening, and other variables. Audiology oversight and coordination can assure that these hospital choices and variables do not adversely affect a family's decision to follow up. Newborn hearing screening programs are only successful if the parents of infants who fail the screen have a clear path for obtaining a rescreen. Audiologists can provide important education to hospitals, midwives, and birthing centers to help them understand their critical roles in making sure that infants obtain a rescreen and a referral to a pediatric audiologist. Follow-up is and continues to be the greatest challenge for EHDI programs. Increasing the role of audiologists can be an opportunity to improve EHDI programs.