Should Newborn Hearing Screening be the Standard of Care in the United States

1
The Scientific Basis for
Newborn Hearing Screening
2
(No Transcript)
3
(No Transcript)
4
Number of Hospitals Doing Universal Newborn
Hearing Screening
Number of Programs
5
3
Status of Universal Newborn Hearing Screening in
the United States
.
Percentage of Births Screened
.
90
51 - 90
21 - 50
1 - 20
6
Newborn Hearing Screening Prior to 1990
Conventional ABR
2
Too expensive
!
7
Newborn Hearing Screening Prior to 1990
Conventional ABR
2
Too expensive
!
High-Risk Indicators
2
50 of children with congenital hearing losses do
!
not exhibit any high-risk indicators
Only about 1/2 of those who have a high-risk
!
indicator make an appointment for further testing
and only 1/2 of those are ever tested
8
How Many Hearing Impaired Children
were at High Risk as Infants?
49

Feinmesser et al. (1982)
54

Pappas Schaibly (1984)
48

Elssmann et al. (1987)
43

Watkin et al. (1991)

50
Mauk et al. (1991)
0
50
100
Limited to children with permanent bilateral
hearing loss
gt
50 dB
9
Newborn Hearing Screening Prior to 1990
Conventional ABR
2
Too expensive
!
High-Risk Indicators
2
50 of children with congenital hearing losses do
not exhibit any
!
high-risk indicators
Only about 1/2 of those who have a high-risk
indicator make an
!
appointment for further testing and only 1/2 of
those are ever tested
Home-Based Behavioral Screening
2
Programs
Requires very expensive infrastructure
!
Not as successful as widely believed
!
10
50
40
30
20
10
0
Severe/Profound
Mild/Moderate
Bilateral
Bilateral
Unilateral
(n 39)
(n 72)
(n 60)
Watkin, P. M., Baldwin, M., Laoide, S. (1990).
Parental suspicion and identification of hearing
impairment.
11
Newborn Hearing Screening
1990-1993
Healthy People 2000 Goals
,
Effectiveness of Automated ABR demonstrated
,
RIHAP and others demonstrate the effectiveness of
,
TEOAE-based universal newborn hearing screening
NIH Consensus Conference in March 1993
,
12
NIH Consensus Panel
Early Identification of Hearing Impairment in
Infants and Young Children
March, 1993
The consensus panel concluded that all
infants should be screened for hearing
impairment...this will be accomplished most
efficiently by screening prior to discharge
from the well-baby nursery. Infants who fail
... should have a comprehensive hearing
evaluation no later than 6 months of age.
13
NIH Recommended Screening Protocol
OAE Screening Prior
ABR
Comprehensive Hearing Evaluation Before 6 Months
of Age
to Hospital
Screening
Fail
Fail
Discharge
14
Statements Endorsing Early Detection of Hearing
Loss
The Department of Education, in collaboration
with the Department of Health and
Human Services, should issue federal guidelines
to assist states in implementing
improved hearing screening procedures for each
live birth.

Commission on Education of
the Deaf, 1988
Reduce the average age at which children with
significant hearing impairment are
identified to no more than 12 months.

Healthy
People 2000 Report, 1990
All hearing impaired infants should be identified
and treatment initiated by 6 months of
age. In order to achieve this ... the consensus
panel recommends screening of
all

newborns ... for hearing impairment prior to
hospital discharge.

NIH
Consensus Statement, 1993
The 1994 JCIH Position Statement endorses the
goal of universal detection of infants
with hearing loss ... and recommends the option
of evaluating infants before
discharge from the newborn nursery.

Joint Committee on
Infant Hearing, 1994
Universal detection of infant hearing loss
requires universal screening of all infants.


American Academy of Pediatrics, 1998
15
Implementing Universal Newborn Hearing Screening
Programs
out
Then a
miracle
occurs
Start
Good work,
but I think we might
need just a little more
detail right here.
16
The Solution?
?
17
Issues to be Considered
In Deciding Whether
Universal Newborn Hearing Screening Should Be the
Method of Choice in Detecting Hearing Loss?
Prevalence of Congenital Hearing Loss
I.
Consequences of Neonatal Hearing Loss
II.
Effects of Earlier Versus Later Identification
and Intervention
III.
Accuracy of Newborn Hearing Screening Methods
IV.
Efficiency of Existing Early Detection Programs
V.
Costs of Newborn Hearing Screening
VI.
Has Hospital-based Hearing Screening Become the
Standard of
VII.
Care?
18
Reported Prevalence Rates of Bilateral Permanent
Childhood
Hearing Loss (PCHL) in Population-based Studies
4.0
3.5
12
3.0
2.5
8
Prevalence per 1,000
9
2.0
3
4
1.5
5
7
2
1.0
11
10
.5
1
6
0
20
25
30
35
40
45
50
55
60
65
dB Threshold Level (loss criterion)
1. Barr (1980), n 65,000
7. Parving (1985), n 82,265
2. Downs (1978), n 10,726
8. Sehlin et al. (1990), n 63,463
3. Feinmesser et al. (1986), n 62,000
9. Sorri Rantakallio (1985), n 11,780
4. Fitzland (1985), n 30,890
10. Davis Wood (1992), n 29,317
5. Kankkunen (1982), n 31,280
11. Fortnum et al. (1996), n 552,558
6. Martin (1982), n 4,126,268
12. Watkin et al. (1990), n 51,250
19
Percentage of Sensorineural Hearing
Losses Which Are Unilateral

of Hearing Impaired
Author (year) Children
in Sample Unilateral
1307

48
Kinney (1953)
1829

37
Brookhauser, Worthington
Kelly (1991)
171

35
Watkin, Baldwin, Laoide (1990)
20
II. Consequences of Neonatal
Hearing Loss
Severe/Profound PCHL Losses
2
Mild Bilateral and Unilateral PCHL Losses
2
Fluctuating Conductive Loss
2
21
Reading Comprehension Scores of
Hearing and Deaf Students
10.0
'
9.0
Deaf
'
,
Hearing
'
8.0
'
7.0
'
6.0
'
Grade Equivalents
5.0
'
4.0
'
3.0
'
,
,
,
,
,
,
,
2.0
,
,
,
,
1.0
8
9
10
11
12
13
14
15
16
17
18
Age in Years
Schildroth, A.N., Karchmer, M.A. (1986).
Deaf children in America
. San Diego College Hill Press.
22
Effects of Unilateral Hearing Loss
Normal Hearing
Unilateral Hearing Loss
Math
Keller Bundy (1980)
(n 26 age 12 yrs)
Language
Math
Peterson (1981)
(n 48 age 7.5 yrs)
Language
Social
Bess Thorpe (1984)
(n 50 age 10 yrs)
Math
Blair, Peterson Viehweg (1985)
Language
(n 16 age 7.5 yrs)
Math
Culbertson Gilbert (1986)
Language
(n 50 age 10 yrs)
Social
Average Results
0th
10th
20th
30th
40th
50th
60th
Math 30th percentile
Percentile Rank
Language 25th percentile
Social 32nd percentile
23
Effects of Mild Fluctuating Conductive Hearing
Loss
Teele, et al., 1990
194 children followed prospectively from 0-7
years.
)
Days child had otitis media between 0-3 years
assessed during normal visits to physician.
)
Data on intellectual ability, school achievement,
and language competency individually
)
measured at 7 years by "blind" diagnosticians.
Results for children with less than 30 days OME
were compared to children with more than
)
130 days adjusted for confounding variables.

Effect Size for
Outcome Measure
Less vs. More OME
WISC-R Full Scale
.62
Metropolitan Achievement Test
Math
.48
Reading
.37
Goldman Fristoe Articulation
.43
Teele, D.W., Klein, J.O., Chase, C., Menyuk, P.,
Rosner, B.A., and the Greater Boston Otitis media
Study Group (1990).
Otitis media in infancy and intellectual
ability, school achievement, speech, and language
at age 7 years.
The Journal


of Infectious Diseases
,
162
, 685-694.
24
III. Effects of Earlier Versus Later
Identification and Intervention
Prospective randomized trials have not been done.
2
Most existing evidence is weakened by
2
potential for selection bias.
)
lack of long-term follow-up to assess "wash-out"
effect.
)
small sample sizes.
)
subjective assessments of outcomes.
)
25
Yoshinaga-Itano, et al., 1996
Compared language abilities of hearing-impaired
children identified
6
before 6 months of age (n 46) with similar
children identified after 6
months of age (n 63).
All children had bilateral hearing loss ranging
from mild to profound,
6
and normally-hearing parents.
Language abilities measured by parent report
using the Minnesota
6
Child Development Inventory (expressive and
comprehension scales)
and the MacArthur Communicative Developmental
Inventories
(vocabulary).
Cross-sectional assessment with children
categorized in 4 different
6
age groups.
Yoshinaga-Itano, C., Sedey, A., Apuzzo, M.,
Carey, A., Day, D., Coulter, D. (July 1996).
The effect of early


identification on the development of deaf and
hard-of-hearing infants and toddlers
. Paper presented at the
Joint Committee on Infant Hearing Meeting,
Austin, TX.
26
Expressive Language Scores for Hearing Impaired
Children Identified Before and After 6 Months of
Age
35
30
25
20
Language Age in Months
15
10
Identified BEFORE 6 Months
5
Identified AFTER 6 Months
0
13-18 mos
19-24 mos
25-30 mos
31-36 mos
(n 15/8)
(n 12/16)
(n 11/20)
(n 8/19)
Chronological Age in Months
27
Vocabulary Size for Hearing Impaired Children
Identified Before and After 6 Months of Age
300
250
200
Vocabulary Size
150
100
Identified BEFORE 6 Months
50
Identified AFTER 6 Months
0
13-18 mos
19-24 mos
25-30 mos
31-36 mos
(n 15/8)
(n 12/16)
(n 11/20)
(n 8/19)
Chronological Age in Months
28
Watkins, 1987
Comparisons made among 3 groups of bilaterally
hearing-impaired
6
children (n 23 in each group)
Group 1
Received average of 9 months home intervention
before
30
months age, followed by preschool intervention.
Group 2
Attended preschool beginning at an average of 36
months.
Group 3
Received no home intervention and no preschool
intervention.
Children matched on hearing severity (PTA 85
dBHL), presence of
6
other handicaps, and analysis of covariance used
to adjust for age at
post test, age of mother, SES, and number of
childhood middle ear
infections.
Data collected by uninformed, trained examiners
when children were 10
6
years old.
Watkins, S. (1987). Long term effects of home
intervention with hearing-impaired children.
American Annals of the Deaf
,

132
, 267-271.
Watkins, S. (1983).
Final Report 1982-83 work scope of the Early
Intervention Research Institute
, Logan, Utah Utah State
University.
29
Effects of Earlier Intervention
(Watkins, 1989)
Read
Math
Vocabulary
No EI or Preschool
Articulation
Preschool
Childrens Developmental Outcomes
Is Understood
EIlt9 mos Preschool
Understands
Social
Behavior
0
20
40
60
80
100
Percentile Scores
30
Boys Town National Research Hospital Study of
Earlier vs. Later
129 deaf and hard-of-hearing children assessed 2x
each year.
)
Assessments done by trained diagnostician as
normal part of early intervention program.
)
6
Identified lt6 mos (n 25)
5
Identified gt6 mos (n 104)
4
3
Language Age (yrs)
2
1
0
0.8
1.2
1.8
2.2
2.8
3.2
3.8
4.2
4.8
Age (yrs)
Moeller, M.P. (1997).
Personal communication
, moeller_at_boystown.org
31
IV. Accuracy of Newborn Hearing
Screening Methods
How many children with hearing loss are
identified?
,
How many children with hearing loss are missed?
,
32
Sensitivity of Various
UNHS Techniques
Although various rates of sensitivity are
reported, there are
)
no studies of UNHS with sufficient sample sizes
to
definitively establish sensitivity for any of the
techniques.
Weakness with existing studies of "sensitivity"
)
Small sample sizes.
2
One screening technique compared to another
screening
2
technique (e.g., OAE vs. ABR).
All screening passes are not followed.
2
Samples include only high-risk babies.
2
33
Accuracy of ABR for Newborn Hearing Screening
Hyde, Riko, and Malizia (1990)
713 at-risk infants screened with ABR prior to
hospital discharge.
)
Children evaluated by "blind" examiners at mean
of 3.9 years of age (range 3-8years).
)
Results based on 1367 ears with reliable ABR and
pure tone thresholds.
)
Hearing Status
Hearing Status
Impaired
Normal
Normal
Impaired
125
57
44
45
Refer
Refer
ABR Screen
ABR Screen (40
(30 dBHL)
dBHL)
0
1197
1265
1
Pass
Pass
Sensitivity 98
Sensitivity 100
Specificity 91
Specificity 96
Hyde, M.L., Riko, K., Malizia, K. (1990).
Audiometric accuracy of the click ABR in infants
at risk for hearing loss.

J Am Acad Audio
l,
1
, 59-66.
34
Accuracy of ABR for UNHS
Saint Barnabus Medical Center, NJ
15,749 infants born from 1/1/93 to 12/31/95
screened with Nicolet Compass
)
ABR system without sedation.
Normal care nursery babies screened at 35 dB HL
NICU and High Risk
)
screened at 40 dB HL and 70 dB HL.
Screening done by audiologists, usually within 24
hours of birth.
)
Babies with a High Risk Indicator who passed
initial screen were
)
re-evaluated at 6 months.
and
and
PCHL and
Births
Screened
Referred
Prevalence
16,229
15.749
485
52
(97)
(3.1)
3.3/1000
Barsky-Firkser, L., Sun, S. (1997). Universal
newborn hearing screenings A three year
experience.
Pediatrics
,
99
(6), 1-5.
35
What Percentage of Hearing Impaired
Children were High Risk as Infants?
49
Feinmesser et al. (1982)
54
Pappas Schaibly (1984)
48
Elssmann et al. (1987)
43
Watkin et al. (1991)
50
Mauk et al. (1991)
50
Mehl Thomson (1998)
0
50
100
36
Accuracy of High Risk Based UNHS Programs
Mahoney and Eichwald (1987)
Program operational from 1978-1995.
2
JCIH indicators incorporated into legally
required birth certificate.
2
Computerized mailing and follow-up, and free
diagnostic assessments at regional
2
offices and/or mobile van.
Program now discontinued because
2
parents only made appointments for about 1/2 the
children who had a risk
)
indicator.
only about 1/2 of the children with an
appointment showed up.
)
of difficulty obtaining accurate information from
hospitals for some risk
)
indicators.
Mahoney, T.M., Eichwald, J.G. (1987). The ups
and "downs" of high-risk hearing screening The
Utah statewide program.

Seminars in Hearing
,
8
(2), 155-163.
37
Results of Birth Certificate Based High Risk
Registry to
Identify Hearing Loss in Utah (1978-1984)
Births, 283,298
Live Births with High
Risk Indicators
24,082 (8.5)
No Response
Parent Response
11,383 (47.3)
12,699 (52.7)
Appointments for
No Concern
5,254 (41.4)
Diagnostic Evaluation
7,445 (58.6)
Diagnostic Evaluation
Broken
Completed
Appointments
5,644 (75.8)
1,801 (24.2)
Summary
23.4 of live births with high-risk indicators
completed a diagnostic evaluation
.36 SNHL per 1000 identified.
Mahoney, T.M., Eichwald, J.G. (1987). The ups
and "downs" of high-risk hearing screening The
Utah statewide
program.
Seminars in Hearing
,
8
(2), 155-163.
38
Accuracy of Home-Based Behavioral Screening
Watkin, Baldwin and Laoide, 1990
Retrospective analysis of 171 hearing impaired
children to determine how
)
they were identified.
Hearing loss first noticed by
)
Home
visitor or
Other than Parent
School
Screening Parent (e.g.,
teacher, doctor, etc.)
18
10
11
Severe/profound
(46)
(26)
(28)
Bilateral (n 39)
51
14
7
Mild/Moderate
(71)
(19)
(10)
Bilateral (n 72)
34
18
8
Unilateral
(57)
(30)
(13)
Parental suspicion and identification of hearing
impairment.
Archives of Disease in Childhood,
65, 846-850.
39
50
40
30
20
10
0
Severe/Profound
Mild/Moderate
Bilateral
Bilateral
Unilateral
(n 39)
(n 72)
(n 60)
40
Accuracy of OAE-Based
Newborn Hearing Screening
Plinkert et al. (1990)
Sample
95 ears of high-risk infants
Comparison
TEOAE vs. ABR (
gt
30 dB) _at_ mean age 9 weeks)
Results
TEOAE compared to ABR sensitivity 90
specificity 91
Plinkert, P.K., Sesterhenn, G., Arold, R.,
Zenner, H.P. (1990). Evaluation of otoacoustic
emissions in high-risk infants by
using an easy and rapid objective auditory
screening method.
European Archives of Otorhinolaryngology
,
247
, 356-360.
41
Kennedy et al. (1991)
Sample
370 infants (223 NICU, 61 normal nursery with risk
factors, and 86 normal lnursery with no risk
factors
Comparison
TEOAE, ABR (
gt
35 dB), and Automated ABR (
gt
35 dB)
all at 1 month vs. behaviorally confirmed hearing
loss, mean age 8 months
Results
TEOAE identified same 3 infants with
sensorineural
hearing loss as ABR and automated ABR
Kennedy, C.R., Kimm, L., Dees, D.C., Evans,
P.I.P., Hunter, M., Lenton, S., Thornton, R.D.
(1991). Otoacoustic emissions
and auditory brainstem responses in the newborn.
Archives of Disease in Childhood
,
66
, 1124-1129.
42
Rhode Island Hearing Assessment Project (RIHAP)
1850 infants (normal and special care) screened
prior to hospital discharge with TEOAE and ABR
)
Referrals for either TEOAE or ABR were rescreened
at 3-6 weeks and referred for diagnosis as
)
necessary
Fail TEOAE
Fail ABR
NICU
High-Risk
Failed test, Present in NICU, Risk Factor Present
Passed Test, Not in NICU, Risk Factors Absent
White, K.R., Behrens, T.R. (Editors) (1993).
The Rhode island Hearing Assessment Project
Implications
for universal newborn hearing screening.
Seminars in Hearing
,
14
(1).
43
Accuracy of TEOAE 2-Stage Screen
Sensorineural Loss
Hearing Status
Impaired
Normal
11
79
Refer
RIHAP
Screen
0
1643
Pass
"Sensitivity" 100
"Specificity" 95
Note Analysis is based on heads. Infants
initially screened but lost to follow-up
or rescreen because of parent refusal, lost
contact, or repeated broken
appointments (gt 3) are not included.
White, K.R., Vohr, B.R., Maxon, A.B., Behrens,
T.R., McPherson, M.G., Mauk, G.W. (1994).
Screening all
newborns for hearing loss using transient
evoked otoacoustic emissions.
International Journal of Pediatric


Otorhinolaryngology
,
29
, 203-217.
44
Accuracy of Automated ABR
Jacobson, Jacobson, Spahr
Hall, Kileny, Ruth, Kripal (1987)
(1990) (447 ears)
(336 ears)
Conventional ABR
Conventional ABR
Refer
Pass
Refer
Pass
18
11
33
17
Refer
Refer
ALGO I
ALGO I
397
307
0
0
Pass
Pass
Sensitivity 100
Sensitivity 100
Specificity 96
Specificity 97
45
Accuracy of Automated ABR
(continued)
Hermann et al. (1995)
Von Wedel, Schauseil-Zipf and
(304 ears)
Doring (1988) (100 ears)
Conventional ABR
Conventional ABR
Refer
Pass
Pass
Refer
8
4
6
42
Refer
Refer
ALGO I
ALGO I
256
86
0
2
Pass
Pass
Sensitivity 80
Sensitivity 98
Specificity 96
Specificity 100
46
Accuracy of Automated ABR
Summary of 4 Studies
(1187 ears)
Conventional ABR
Pass
Refer
101
38
Refer
ALGO I
1046
2
Pass
Sensitivity 96
Specificity 98
Herrmann, B.S., Thornton, A.R., Joseph, J.M.
(1995). Automated infant hearing screening using
the ABR Development
and validation.
American Journal of Audiology
,
4
(2), 6-14.
47
NIH Study Identification of Neonatal Hearing
Impairment
Multi-Center Study Based at University of
Washington
Null Hypothesis ABR, TEOAE, and DPOAE are
equally effective for newborn hearing
2
screening.
7178 infants (4510 NICU and 2668 normal nursery)
screened prior to discharge with
2
ABR, TEOAE, and DPOAE in random order.
Screening results will be compared with ear
specific VRA at 8-12 months.
2
Other issues investigated
2
Influence of co-existing medical factors on
characteristics of OAE and ABR.
!
Optimum stimulus and recording parameters for
OAE.
!
Time and cost-efficiency of ABR and OAE.
!
Influence of external and middle ear status, test
environment, and tester
!
characteristics.
Data collection completed October, 1997 data
expected to be reported April 1998.
48
V. Efficiency of Existing UNHS
Programs
Coverage and Referral Rates
2
Effects on Parents
2
Follow-up
2
49
Births Per Year, Percent of Babies Screened, and
Reported Referral Rates of Universal Newborn
Hearing Screening Programs
Percent Babies
Reported Pass
Average Births
Screened Before
Rate at
of
Per year
Discharge
Discharge
Hospitals
a
64
94.9
2140
91.6
OAE-Based Programs
b
56
1348
96.2
96.0
ABR-Based Programs
120
93.7
95.5
1767
All Programs
a
55 of 64 OAE-based programs were TEOAE, 9 were
DPOAE
b
54 of 56 ABR-based programs were automated ABR
White, K.R., Mauk, G.W., Culpepper, N. B.,
Weirather, Y. (1997). Newborn hearing screening
in the United States
Is it becoming the standard of care? In L.
Spivak (Ed.),
Neonatal hearing screening
. Thieme New York.

50
Possible Adverse Effects for Parents of
Various Hearing Screening Results
False-Positive
)
Adversely affect parent-child bonding (e.g.,
rejection or over-protection).
2
Anger, resentment, or confusion when child is
confirmed normal.
2
Lingering concerns about whether child's hearing
is normal.
2
False Negative
)
Inappropriate confidence that child hears
normally, thus delaying
2
identification.
True Positive
)
Emotional stress during time of emerging
parent-child relationship.
2
Incomplete or inaccurate information may be used
to make future
2
reproductive decisions.
Adapted from Clayton, E.W. (1992). Screening and
treatment of newborns.
Houston Law Review
,
29
(1), 85-148.
51
Parents Perceptions of Screening
Questionnaires administered by nurses to 169
babies born between 6/1/94 and 7/15/94.
Question
Answering Yes
If you were in a hospital where you had to give
your
98
permission to have your baby's hearing screened,
would you give it?
If this screening were conducted for a fee of
71
approximately 30, would you be willing to pay it?
Do you believe that any anxiety caused by your
baby
88
not passing the hearing screening would be
outweighed by the benefits of early detection if
a
hearing loss was found to be present?
Barringer, D.G., Mauk, G.W. (1997). Survey of
parents' perceptions regarding hospital-based
newborn hearing
screening.
Audiology Today
,
9
(1), 18-19.
52
Parents' Views About Newborn Hearing Screening
Watkin, Beckman, and Baldwin, 1995
208 parents of children with sensorineural
hearing loss (average age of
2
child 12.3 years) answered written
questionnaires.
None of the children participated in a newborn
hearing screening program.
2
58 wished their child had been identified
earlier.
)
Only those whose children's impairments were mild
or who
)
were confirmed in the first 18 months of life
were satisfied with
the age of confirmation.
89 preferred having a newborn hearing screening
program
)
instead of what they had.
Watkin, P.M., Beckman, A., Baldwin, M. (1995).
The views of parents of hearing impaired children
on the need for
neonatal hearing screening.
British Journal of Audiology
,
29
, 259-262.
53
Hearing Loss Identified
Parent's Reaction
Constructive
Grief
Action
Depression
Denial
Acknowledgment
Anger
Guilt
Parental
Adjustment
Parental
Expectation
Cultural Model
Disability Model
of Learning
of Learning
Language Communication
54
"...the 'harm-benefit ratio' of not
implementing a universal newborn
hearing screening program is
better documented than the
alleged dangers of implementing
such a program."
White Maxon, 1995, p. 208
55
VI. Cost Efficiency of Newborn
Hearing Screening
What does early detection and intervention
cost
?
,
Is protocol A more
cost-effective
than protocol B?
,
Is early hearing detection and intervention
,
cost-beneficial
?
56
Actual Costs of Operating a Universal
Newborn Hearing Screening Program
Cost
Personnel
60,654
Screening Technicians (avg. 103 hrs./week)
Clerical (avg. 60 hrs./week)
Audiologist (avg. 18 hrs./week)
Coordinator (avg. 20 hrs./week
Fringe Benefits
16,983
(28 of Salaries)
Supplies, Telephone, Postage
12,006
Equipment
5,575
Hospital Overhead
14,557

(24 of Salaries)
TOTAL COSTS
110,775
Cost Per Infant Screened 110,775 4,253
26.05

Maxon, A. B., White, K. R., Behrens, T. R.,
Vohr, B. R. (1995) Referral rates and cost
efficiency in a universal newborn
hearing screening program using transient
evoked otoacoustic emissions (TEOAE).
Journal of the American Academy


of Audiology
,
6
, 271-277.
57
CDC Cost Study (1997)
Multi-center pilot UNHS cost study using 6
hospitals (one
2
each in CO, GA, LA, TN, UT, and VA).
Cost estimates based on self-report
questionnaires with site
2
visits to 4 of 6 sites.
Standardized estimates used for equipment and
overhead
2
costs.
Grosse, S. (September, 1997).
The costs and benefits of universal newborn
hearing screening
. Paper presented to the Joint
Committee on Infant Hearing, Alexandria, VA.
58
Results of CDC Cost Study

3 Hospitals
3 Hospitals
Cost category
using TEOAE
using AABR
Staff time
13.04
10.73
Equipment
0.91
2.63
Supplies
0.51
9.33
Overhead
3.49
3.34
Total Cost
17.96
26.03
(Range)
(15-22)
(22-30)
Initial refer rate
8
2
Screening minutes per child
31.4
42.9
Audiologist minutes per child
17.0
5.4
59
Prevalence of Various "Screenable"
Diseases Among Newborns
4
3.5
3
2.5
Incidence of Disease
2
1.5
1
0.5
0
Permanent
Hearing Loss
PKU
Hypothyroidism
Sickle Cell
3.0/1000
.10/1000
.25/1000
.20/1000
Johnson, J.L., Mauk, G.W., Takekawa, K.M., Simon,
P.R., Sia, C.C.J., Blackwell, P.M. (1993).
Implementing a statewide
system of services for infants and toddlers
with hearing disabilities.
Seminars in Hearing
, 14(1), 105-119.
60
Cost of Identifying Infants with Various Diseases
Using
Current Screening Protocols in Rhode Island
50,000
40,000
Cost Per Infant Identified (1990 Dollars)
30,000
20,000
10,000
0
Permanent
Hearing Loss
PKU
Hypothyroidism
Sickle Cell
(8,683)
(40,960)
(40,960)
(40,960)
Johnson, J.L., Mauk, G.W., Takekawa, K.M., Simon,
P.R., Sia, C.C.J., Blackwell, P.M. (1993).
Implementing a statewide
system of services for infants and toddlers
with hearing disabilities.
Seminars in Hearing
, 14(1), 105-119.
61
Cost of Educating Children with Hearing Loss
in Various Settings
40,000
35,000
30,000
Annual Cost
25,000
20,000
15,000
10,000
5,000
0
Regular Classes
Self-Contained Classes
Residential Programs
(3,383)
(9,689)
(35,780)
Johnson, J.L., Mauk, G.W., Takekawa, K.M., Simon,
P.R., Sia, C.C.J., Blackwell, P.M. (1993).
Implementing a statewide
system of services for infants and toddlers
with hearing disabilities.
Seminars in Hearing
, 14(1), 105-119.
62
VII. Establishing a Standard
of Care
Expectations for a reasonable practitioner under
,
similar circumstances
Guidelines and standards
,
Availability of technology
,
63
A physician ... impliedly represents that he
possesses ... that reasonable degree of learning
and
skill ... ordinarily possessed by physicians in
his
locality.... It is the physician's duty to use
reasonable care and diligence in the exercise of
his
skill and learning ... he must keep abreast of
the
times ... departure from approved methods and
general use, if it injures the patient, will
render him
liable.
Pike v. Honsinger, 1898
64
Guidelines and Standards
Healthy People 2000
,
NIH Consensus Conference
,
Joint Committee on Infant Hearing
,
Joint Commission on Accreditation of Health
,
Organizations
65
STANDARD OF CARE
... when does a guideline become a standard? The
answer is when an inexpensive and reliable device
comes onto the market, the technology and concept
of which have already been adopted by a group
who specialize in the concept ... A guideline
becomes a standard of care when the device behind
the guideline is available and readily usable as
a
practical matter by members of other medical
specialities who have cause and reason to
consider
its use.
Wm H. Ginsburg, Jr.,
Annals of Emergency
Medicine
, 1993,
22
, 1891-1896
66
What are the Objections to
Hospital-based Universal Newborn
Hearing Screening?
It's too hard to do it in the newborn nursery.
,
It's too expensive / Insurance won't pay for it.
,
Pediatricians can do it easier as a part of
well-baby
,
care.
There's no evidence that earlier is better.
,
It's not mandated.
,
67
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