Cost-effectiveness of implementing routine hearing screening using a tablet audiometer for pediatric cystic fibrosis patients receiving high-dose IV aminoglycosides.

BACKGROUND: Cystic fibrosis (CF) patients who receive high-dose aminoglycosides can acquire inner ear damage and subsequent hearing loss. There is no current standard protocol for assessing ototoxicity in CF centers in the United States. OBJECTIVE: To evaluate the cost-effectiveness of a pharmacist-implemented routine hearing screening for ototoxicity among pediatric patients using a clinically validated tablet audiometer to allow for earlier detection of hearing loss in an exploratory analysis. METHODS: A Markov decision-analytic model was developed to assess the cost-effectiveness of implementing routine screening with monthly cycles over a 3-year time horizon. The model measured the difference in promptly detected hearing loss, delayed detected hearing loss, and undetected hearing loss, compared with current screening practices. Model inputs were obtained through a comprehensive literature review. Primary model outcomes included total health care costs and quality-adjusted life-years (QALYs) gained with a 3% yearly discount. One-way, two-way, and probabilistic sensitivity analyses were conducted to evaluate model uncertainty. RESULTS: In a hypothetical cohort of 100 patients, routine screening using a tablet audiometer increased promptly detected hearing loss by 8 patients. There was an incremental gain of 3.2 QALYs at an increased cost of $333,826 compared with current screening practices. This resulted in an incremental cost-effectiveness ratio (ICER) of $103,771 per QALY. In the 1-way sensitivity analysis, the ICER ranged between $64,345 and $258,830 per QALY. CONCLUSIONS: Using a tablet audiometer for routine hearing screening appears to be a cost-effective option at a $150,000 per QALY willingness-to-pay threshold when only considering the immediate benefits gained. This analysis did not examine the long-term effects of early detection in language development for pediatric patients. DISCLOSURES: Huang reports funding from the University of North Carolina and GlaxoSmithKline Health Outcomes Fellowship. GlaxoSmithKline had no involvement in the study creation, analysis, or manuscript composition. The other authors have nothing to disclose.

Comprehensive Community Screening of Otological Patients by Trained Technicians Using a Telemedicine Device: An Efficient and Cost-Effective Way to Triage Patients With Ear Diseases.

OBJECTIVE: To emphasize the benefits of tele-otology in community screening of patients with ear diseases. METHODS: A retrospective study of all patients screened and treated under the Shruti tele-otology program between 2013 and 2019 was conducted. It involved screening, diagnosis, medical management, surgical intervention, and rehabilitation using hearing aid. The study focused on underprivileged and underserved community of rural and urban slums across 12 states of India. The study was conducted using a telemedicine device called ENTraview, that is, a camera-enabled android phone integrated with an otoscope and audiometry screening. RESULT: A total of 810 746 people were screened, and incidence of various ear diseases was recorded. Ear problems were found in 265 615 (33%) patients, of which 151 067 (57%) had impacted wax, 46 792(18%) had chronic suppurative otitis media, 27 875 (10%) had diminished hearing, 12 729 (5%) had acute otitis media and acute suppurative otitis media (ASOM), and 27 152 (10%) had problems of foreign body, otomycosis, and so on. Of the total 265 615 referred patients, 20 986 (8%) reported for treatment and received treatment at a significantly reduced cost through Shruti program partners. The conversion rate of nonsurgical and surgical procedure was also compared, and it was found that, while 9% of the patients opted for nonsurgical treatment, only 3% opted for surgery in the intervention group giving a significant P value of .00001. CONCLUSION: The potential for telemedicine to reduce inequalities in health care is immense but remains underutilized. Shruti has largely been able to bridge this gap as it is an innovative, fast, and effective programs that address the ear ailment in the community.

Perioperative cost evaluation of canal wall down mastoidectomy.

INTRODUCTION: To evaluate perioperative costs of canal wall-down (CWD) mastoidectomy as an initial surgery compared to revision surgery following initial canal wall-up (CWU) mastoidectomy. METHODS: This study is a retrospective chart review of adult patients who underwent CWD mastoidectomy for chronic otitis media with or without cholesteatoma at a tertiary referral center. Patients were divided into groups that had previous CWU surgery and were undergoing revision CWD and those that were having an initial CWD mastoidectomy. Cost variables including previous surgeries, imaging costs, audiometric testing, and post-operative visits were compared between the two groups using t-test analysis. RESULTS: There was no significant difference with regards to the cost of post-operative visits, peri-operative imaging, or revision surgeries between the two groups. Hearing outcomes based on mean speech reception threshold (SRT) were not statistically different between the two groups (p = 0.087). There was a significant difference in total cost with the revision group having a higher mean cost by $6967.84, most of which was accounted for by the difference in the cost of the previous surgeries of $6488.53. CONCLUSIONS: The revision CWD surgery group had increased total cost that could be attributed to the cost of previous surgery. Increased peri-operative cost was not noted with the initial CWD surgery group for any individual variables examined. Initial CWD mastoidectomy should be considered in the proper patient population to help decrease healthcare costs.

Variations in Stapes Surgery Cost within a Multihospital Network.

OBJECTIVE: To identify costs and operative times for stapedotomy and evaluate factors influencing cost variation. STUDY DESIGN: Case series with cost analysis. SETTING: Multihospital network. SUBJECTS AND METHODS: A multihospital network's standardized activity-based accounting system was used to determine costs and operative times of all patients undergoing stapedotomy from 2013 to 2017. Subjects with additional procedures were excluded. Correlations between variable factors and cost were calculated by Spearman correlation coefficients. Audiometric and cost data were compared with a Mann-Whitney U test. RESULTS: The study cohort included 176 stapedotomies performed by 23 surgeons at 10 hospitals. Mean ± SD patient age was 44.3 ± 17.4 years. Mean cut-to-close time was 61.1 ± 23.55 minutes. Mean total encounter cost was $3542.14 ± $1258.78 (US dollars). Significant factors correlating with increased total encounter cost were surgical supply cost (r = 0.74, P < .0001) and cut-to-close time (r = 0.66, P < .0001). Laser utilization ($563.37 ± $407.41) was the highest-cost surgical supply, with the carbon dioxide laser being significantly more costly than the potassium titanyl phosphate (KTP; $852.60 vs $230.55, P < .001). Additionally, the carbon dioxide laser was associated with a significantly higher mean total encounter cost than the KTP laser ($4645.43 vs $2903.00, P < .001) and cases where no laser was used ($4645.43 vs $2932.47, P < .001). There was no difference in mean total encounter cost between the KTP laser and cases of no laser use ($2903.00 vs $2932.47, P = .75). CONCLUSIONS: Significant cost variation exists in stapes surgery. Surgical supply cost, specifically laser use, may be associated with significantly increased costs. Reducing variation in costs while maintaining outcomes may improve health care value.

To Scan or Not to Scan-A Cross-Sectional Analysis of the Clinical Efficacy and Cost-Effectiveness of Audiometric Protocols for Magnetic Resonance Imaging Screening of Vestibular Schwannomas.

INTRODUCTION: Vestibular schwannomas (VS) are a rare cause of asymmetrical hearing loss, and routine screening with magnetic resonance imaging (MRI) can be costly. At present, no consensus exists on what qualifies as "asymmetrical sensorineural hearing loss" (ASNHL) and when a patient should be referred for screening. OBJECTIVES: 1) Evaluation of published audiometric protocols on the basis of sensitivity and specificity when applied to local clinical cohort of patients with ASNHL; 2) determination of clinical risks of missing VS and potential wastes in screening "radiologically normal" cases; 3) assessment of the cost of MRI screening. METHODS: Cross-sectional study with chart review in a 2-year (2015-2016) cohort of 1059 patients who underwent MRI screening and audiometry indicating sensorineural hearing loss. Fourteen previously published audiometric protocols were assessed for their sensitivity and specificity in guiding radiological diagnosis of VS, and cost analysis was performed. RESULTS: 6/14 audiometric protocols had a sensitivity greater than 85%. Diagnostic specificity ranged from 22.91 to 82.76%, clinical risks from 0 to 50%, and potential wastes from 17.24 to 77.09%. Average annual cost of screening was £64,069. Application of proposed local screening protocol had a projected cost saving of 32.19%. Cost of screening patients that benefit from treatment was compared with a utility function that quantified expected benefit. CONCLUSIONS: Development of an easy-to-apply algorithm incorporating high-sensitivity audiometric protocols may result in significant cost saving, with minimal clinical risk of missing cases. There was disparity between screening costs and monetary "benefit" of hearing.

Costs and effectiveness of hearing conservation programs at 14 US metal manufacturing facilities.

OBJECTIVE: This study characterised overall and specific costs associated with hearing conservation programmes (HCPs) at US metal manufacturing sites, and examined the association between these costs and several noise-induced hearing loss (NIHL) outcomes. DESIGN: We interviewed personnel and reviewed records at participating facilities. We also measured noise for comparison to the ten-year average of measurements made by each facility. NIHL outcomes assessed included rates of standard threshold shifts (STS) and high-frequency hearing loss, as well as prevalence of hearing impairment, for each participating facility. We used linear regression to identify per-person HCP costs that best predicted the NIHL outcomes. STUDY SAMPLE: We evaluated 14 US metal manufacturing facilities operated by a single company. RESULTS: Annual HCP costs ranged from roughly $67,000 to $397,000 (average $308 ± 80 per worker). Our full-shift noise measurements (mean 83.1 dBA) showed good agreement with the facilities' measurements (mean 82.6 dBA). Hearing impairment prevalence was about 15% overall. Higher expenditures for training and hearing protector fit-testing were significantly associated with reduced STS prevalence. Higher training expenditures were also related to lower hearing impairment prevalence and high-frequency hearing loss rates. CONCLUSIONS: HCP costs were substantial and variable. Increased workplace spending on training and fit-testing may help minimise NIHL.

Feasibility of a low-cost hearing screening in rural Indiana.

BACKGROUND: Hearing loss remains a neglected public health issue in the rural and agricultural communities in the United States and therefore, promotion of a low-cost hearing screening may be important for these underserved populations. The major objectives of our study were to assess feasibility of a low-cost telephone-administered hearing test in rural Indiana and to identify the challenges, barriers and viable implementation strategies associated with this test. Also, we evaluated whether a focus group session could change the hearing health attitude of rural residents. METHODS: We recruited 126 adults from six rural Indiana counties who participated in study activities in the following order: 1) a pre-focus group demographic, knowledge and attitude survey, 2) a focus group for discussing the feasibility of a telephone-administered hearing screening, 3) a post focus group attitude survey and 4) hearing was screened using an audiometer and self-assessment scale. These activities generated both qualitative and quantitative data, which were subsequently analyzed. RESULTS: Hearing impairment was perceived as an important public health issue. Many participants expressed interests to try the low-cost National Hearing Test (NHT). However, participants recommended NHT to be facilitated by community organizations to provide access to landline phones. The focus group turned out to be an excellent awareness building activity producing significant improvement in hearing health attitudes. Comparison of self and audiometric evaluations indicated underestimation of hearing handicap in our rural study population. CONCLUSIONS: The study results underscore the urgent need for an effective strategy to promote low-cost hearing screening in rural US communities.

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.

Risk indicators for congenital and delayed-onset hearing loss.

OBJECTIVE: To evaluate risk indicators for congenital and delayed onset hearing loss in a cohort of newborns who underwent newborn hearing screening, and to evaluate the impact of use of the Joint Committee on Infant Hearing (JCIH) recommendations on requirements for ongoing monitoring of infants identified as at risk for hearing loss. PATIENTS AND METHODS: Cohort of 26,341 newborns entered in a prospectively collected database as part of the University of Michigan Universal Newborn Hearing Screening program, with 90 patients identified. Logistic regression analysis was used to evaluate putative risk indicators for congenital and delayed onset hearing loss. An estimate of the cost burden of ongoing monitoring imposed by the use of differing risk indicators was performed. RESULTS: After controlling for the impact of other risk indicators, intensive care unit length of stay greater than 5 days and exposure to loop diuretics are not associated with an increased risk of congenital or delayed onset hearing loss. Inclusion of these risk indicators as a requirement for ongoing audiologic monitoring results in a high monitoring cost per additional case identified. DISCUSSION: This study confirms that the majority of the risk indicators currently recommended by the JCIH are effective at identifying infants at increased risk of congenital and delayed onset hearing loss. However, use of neonatal intensive care unit length of stay greater than 5 days and exposure to ototoxic medications are associated with small gains in the number of infants correctly identified as at risk of hearing loss. Further evaluation of the utility of these risk indicators, preferably with a diversity of patient population and healthcare settings, is warranted.

A diagnostic paradigm including cytomegalovirus testing for idiopathic pediatric sensorineural hearing loss.

OBJECTIVES/HYPOTHESIS: To determine the feasibility and cost effectiveness of incorporating cytomegalovirus (CMV) testing to determine the etiology of pediatric hearing loss. STUDY DESIGN: Retrospective study of children presenting with sensorineural hearing loss (SNHL) at one institution from 2008 to 2013. METHODS: Children aged 3 years or younger who presented to the senior author (A.P.) between May 2008 and September 2013 with confirmed SNHL were evaluated. These children underwent a sequential diagnostic paradigm that incorporated CMV testing if no obvious etiology could be determined from the history or physical examination. RESULTS: One hundred eleven children with SNHL were evaluated between 2008 and 2013. Eighty-three children underwent CMV testing, imaging, and a genetic evaluation. Those with confirmed or probable CMV-induced SNHL made up 30% of all children tested (n = 25), the largest group identified. CMV screening had the lowest cost compared to genetic testing or imaging for all types of hearing loss, except for those with auditory neuropathy spectrum disorder. CONCLUSION: We present the first sequential diagnostic paradigm utilizing CMV testing for children presenting with SNHL. The relatively high incidence of CMV-induced SNHL, the low cost for this assay, and the indirect benefits from early diagnosis support the role of early CMV testing for these patients. LEVEL OF EVIDENCE: 4.

Barriers to early pediatric cochlear implantation.

OBJECTIVES: Universal newborn hearing screening has significantly improved the ability to identify patients with congenital sensorineural hearing loss (SNHL), which results in earlier treatment and better hearing and development outcomes. It is recommended that patients born with SNHL who meet criteria receive cochlear implants (CIs) by a target age of 12 months, however many children are being implanted at an older age. This study aims to describe populations of pre-lingual patients with SNHL that are at risk for delayed implantation and to identify and analyze barriers that cause this delay. METHODS: Charts of patients receiving a CI between January 2008 and June 2012 at a tertiary care cochlear implant center were reviewed retrospectively. We looked at patient demographics, age at hearing loss diagnosis, age at implantation, and etiology of hearing loss. Barriers to implantation were identified through surveys completed by team members. RESULTS: Fifty-seven CI recipients were identified of which 42 were in patients with pre-lingual SNHL. SNHL etiology included: cochlear dysplasia (18%), GJB2/GJB6 (17%), acquired (10%) extreme prematurity (9%), and idiopathic (46%). The median age of SNHL diagnosis for pre-lingual patients was 15 months. Compared to private insurance, public insurance status was associated with SNHL diagnosis at a significantly later median age (20.0 vs. 4.0 months, p=0.024), and with a significantly longer median interval from diagnosis to implantation (25.5 vs. 11.0 months, p=0.029). While cochlear implant team members identified delayed insurance approval and medical comorbidities as reasons for delayed implantation, the most significant factor identified was parental, with delayed/missed appointments or reluctance for evaluations or surgery. CONCLUSION: 52% of patients with pre-lingual SNHL that met criteria for CI were implanted more than 12 months after diagnosis. Having public or no insurance was significantly associated with delayed implantation. Parental barriers were most common factors cited for delays in implantation. Overcoming these delays necessitates appropriate identification of at risk patients and creating a system to educate families and chaperone them through the process.

An economic evaluation of screening 60- to 70-year-old adults for hearing loss.

BACKGROUND: Hearing loss is common among older adults and has consequences for sufferers, families and society, but there is substantial unmet need for intervention. Screening could expedite intervention and improve outcomes. METHODS: We use Markov models to estimate the incremental cost-effectiveness ratio (ICER) of potential screening programmes compared with current provision (GP-referral), from a health service perspective. Alternative options are investigated through scenario analysis. One-way and probabilistic sensitivity analyses are undertaken. RESULTS: All modelled screens are cost-effective and reduce unmet need for hearing aids. The most cost-effective option identified is a one-stage audiometric screen for bilateral hearing loss ≥30 dB hearing level (HL) at age 60, repeated at ages 65 and 70. This option has an ICER of £1461 compared to GP-referral and would mean an additional 15 437 adults benefiting from hearing intervention per 100 000 population aged 60. The cost-effectiveness acceptability curve shows that screening is more cost-effective than GP-referral provided a Quality Adjusted Life Year is valued at £2000 or more. CONCLUSIONS: Adult hearing screening would provide a cost-effective way to improve quality of life for older adults. We recommend piloting an audiometric screen offered to all adults age 60, 65 and 70 years to identify bilateral hearing loss of at least 30 dB HL.

Bone-anchored hearing aids (BAHAs) for people who are bilaterally deaf: a systematic review and economic evaluation.

BACKGROUND: A bone-anchored hearing aid (BAHA) consists of a permanent titanium fixture, which is surgically implanted into the skull bone behind the ear, and a small detachable sound processor that clips onto the fixture. BAHAs are suitable for people with conductive or mixed hearing loss who cannot benefit fully from conventional hearing aids. OBJECTIVES: To assess the clinical effectiveness and cost-effectiveness of BAHAs for people who are bilaterally deaf. DATA SOURCES: Nineteen electronic resources, including MEDLINE, EMBASE and The Cochrane Library (inception to November 2009). Additional studies were sought from reference lists and clinical experts. REVIEW METHODS: Inclusion criteria were applied by two reviewers independently. Data extraction and quality assessment were undertaken by one reviewer and checked by a second. Prospective studies of adults or children with bilateral hearing loss were eligible. Comparisons were BAHAs versus conventional hearing aids [air conduction hearing aid (ACHA) or bone conduction hearing aid (BCHA)], unaided hearing and ear surgery; and unilateral versus bilateral BAHAs. Outcomes included hearing measures, validated measures of quality of life (QoL), adverse events and measures of cost-effectiveness. For the review of cost-effectiveness, full economic evaluations were eligible. RESULTS: Twelve studies were included (seven cohort pre-post studies and five cross-sectional 'audiological comparison' studies). No prospective studies comparing BAHAs with ear surgery were identified. Overall quality was rated as weak for all included studies and meta-analysis was not possible due to differences in outcome measures and patient populations. There appeared to be some audiological benefits of BAHAs compared with BCHAs and improvements in speech understanding in noise compared with ACHAs; however, ACHAs may produce better audiological results for other outcomes. The limited evidence reduces certainty. Hearing is improved with BAHAs compared with unaided hearing. Improvements in QoL with BAHAs were identified by a hearing-specific instrument but not generic QoL measures. Studies comparing unilateral with bilateral BAHAs suggested benefits of bilateral BAHAs in many, but not all, situations. Prospective case series reported between 6.1% and 19.4% loss of implants. Most participants experienced no or minor skin reactions. A decision analytic model was developed. Costs and benefits of unilateral BAHAs were estimated over a 10-year time horizon, applying discount rates of 3.5%. The incremental cost per user receiving BAHA, compared with BCHA, was £ 16,409 for children and £ 13,449 for adults. In an exploratory analysis the incremental cost per quality-adjusted life-year (QALY) gained was between £ 55,642 and £ 119,367 for children and between £ 46,628 and £ 100,029 for adults for BAHAs compared with BCHA, depending on the assumed QoL gain and proportion of each modelled cohort using their hearing aid for ≥ 8 or more hours per day. Deterministic sensitivity analysis suggested that the results were highly sensitive to the assumed proportion of people using BCHA for ≥ 8 hours per day, with very high incremental cost-effectiveness ratio values (£ 500,000-1,200,000 per QALY gained) associated with a high proportion of people using BCHA. More acceptable values (£ 15,000-37,000 per QALY gained) were associated with a low proportion of people using BCHA for ≥ 8 hours per day (compared with BAHA). LIMITATIONS: The economic evaluation presented in this report is severely limited by a lack of robust evidence on the outcome of hearing aid provision. This has lead to a more restricted analysis than was originally anticipated (limited to a comparison of BAHA and BCHA). In the absence of useable QoL data, the cost-effectiveness analysis is based on potential utility gains from hearing, that been inferred using a QoL instrument rather than measures reported by hearing aid users themselves. As a result the analysis is regarded as exploratory and the reported results should be interpreted with caution. CONCLUSIONS: Exploratory cost-effectiveness analysis suggests that BAHAs are unlikely to be a cost-effective option where the benefits (in terms of hearing gain and probability of using of alternative aids) are similar for BAHAs and their comparators. The greater the benefit from aided hearing and the greater the difference in the proportion of people using the hearing aid for ≥ 8 hours per day, the more likely BAHAs are to be a cost-effective option. The inclusion of other dimensions of QoL may also increase the likelihood of BAHAs being a cost-effective option. A national audit of BAHAs is needed to provide clarity on the many areas of uncertainty surrounding BAHAs. Further research into the non-audiological benefits of BAHAs, including QoL, is required.

An audiometer to monitor progressive hearing change in school-aged children.

OBJECTIVE: The purpose of this study was to develop a cost-effective and easy to use audiometer to monitor progressive hearing change in school-aged children. DESIGN: The hardware of the audiometer developed included a computer, an external sound blaster and a headphone. The hearing screening software was developed to control the pure tone sound level with modulability in the range of 0-45 dB HL at 1, 2, 4 and 0.5 kHz frequencies. Thirty sixth-grade children, aged 12-13 years old, were randomly divided into two groups for a hearing test in a conference room. Testing for one group was performed by a person with experience and the other group was examined by a graduate student who was not familiar with the device. After the hearing test, all children were immediately screened using a clinical diagnostic audiometer in a soundproof room by an audiologist. RESULTS: Most of the threshold dB values obtained by the audiometer in a conference room (55 ears, 93.2%) were significantly greater than those obtained by the clinical audiometer in a soundproof room. Most of the differences between these two measurements were within 5 dB (94.9%). Only 5.1% had a discrepancy within the maximum range of 10 dB. The correlation and intraclass correlation coefficients between the two measurements were 0.861 and 0.929, respectively. The results also indicated that the experience level of the screening personnel did not affect the testing. CONCLUSION: The newly developed audiometer is quite cost-effective and can be easily operated. The threshold dB values obtained by the audiometer developed in a conference room were comparable with the results of a clinical audiometer in a soundproof room. The audiometer developed could measure the hearing threshold values and, therefore, be useful in monitoring progressive hearing change in school-aged children.

Calibrated finger rub auditory screening test (CALFRAST).

BACKGROUND: Determination of auditory function is a fundamental part of a complete neurologic examination. Disability from permanent hearing loss is common in the general population. Current bedside auditory tests are unreliable and cumbersome. We evaluated the calibrated finger rub auditory screening test (CALFRAST) as a routine diagnostic tool. METHODS: The sound spectrum and mean peak intensities of standard finger rub were measured, as well as background noise. CALFRAST overlapped the frequency spectrum of normal speech. Patients and companions were recruited from a neurology clinic. With arms extended, two stimulus intensities were presented: strong finger rub (CALFRAST-Strong 70) and the faintest rub that the examiner could hear (CALFRAST-Faint 70). With subjects' eyes closed, each ear's CALFRAST threshold was ascertained and then compared with its audiometric measure. The normal threshold was considered to be 25 dB. Validity, reliability, and discrimination abilities were obtained using standard methods. RESULTS: Two hundred twenty-one subjects (442 ears; 58% women) were examined. Ages ranged from 18 to 88 years, with a mean of 46 years. Eighty-five subjects (39%) had some degree of hearing loss. Both specificity and positive predictive value of CALFRAST-Strong 70 were 100%. Both sensitivity and negative predictive value of CALFRAST-Faint 70 were 99%, with a negative likelihood ratio <0.1. Area under the receiver operating characteristic curve was 0.94, consistent with excellent discrimination ability. Both intrarater and interrater reliability were excellent, both kappa >0.8. Subjects' self-assessment of hearing was unreliable. CONCLUSION: The calibrated finger rub auditory screening test (CALFRAST) is simple, accurate, inexpensive, and reliable. As a routine screening tool, CALFRAST may contribute to more efficient identification of auditory impairment.

Cost-effectiveness of audiometric screening of first-year preparatory pupils in Dhofar Region, Oman.

Audiometric screening was conducted in Dhofar region to study the magnitude of ear problems and cost-effectiveness of screening first-year preparatory-school children in Oman. None of the 1894 pupils had otitis media with effusion or sensory neuronal hearing loss. Six children (0.32%) had impacted wax, 4 (0.21%) chronic suppurative otitis media and 2 (0.11%) dry perforation of eardrum. In all, 14 children (0.74%) with suspected hearing impairment were referred to a specialist but only 2 attended. Physicians and nurses spent 8-10 minutes for ear examination per child for a yield of less than 1%. The screening expenditure was US$ 5 per pupil. As the prevalence of serious ear conditions was low, we conclude that expanding the audiometric screening of schoolchildren to first-year preparatory pupils is not cost-effective.

Newborn hearing screening: costs of establishing a program.

OBJECTIVE: To evaluate the costs and performance characteristics associated with the start-up phase of Universal Newborn Hearing Screening Programs, one utilizing automated auditory brainstem response (AABR) and the other using transient evoked otoacoustic emissions (TEOAE). STUDY DESIGN: Economic and performance data were collected at the initiation of both screening programs. Data were collected until 1500 newborn infants were screened or until a referral rate for further audiologic evaluation at hospital discharge of less than or equal to 5% was achieved. Data collected included screening pass/fail rates, referral rates and personnel, equipment, and supply utilization. Actual costs of personnel, equipment, and supplies were used. Statistical comparisons of proportions using z-statistic with the one-tailed test and an alpha of 0.01 were made. RESULTS: Screening in the AABR program was performed by neonatal nurses, whereas screening in the TEOAE program was performed by master's level audiologists. The average age at initial screen was 29 hours for TEOAE, and 9.5 hours for AABR. Eighty-four percent of infants was screened within 24 hours in the AABR program, in contrast to 35% in the TEOAE program. Throughout the duration of the study, the referral rate at hospital discharge remained approximately 15% for the TEOAE program. The AABR referral rate began at 8% and was less than 4% at the completion of the study. Pre-discharge total costs for initiating and establishing the programs were US$49,316 for TEOAE and US$47,553 for AABR. Cost per infant screened was US$32.23 and US$33.68, respectively. When post-discharge screening and diagnostic evaluation costs were included, the total cost per infant screened was US$58.07 for TEOAE and US$45.85 for AABR. CONCLUSION: AABR appears to be the preferred method for universal newborn hearing screening. AABR was associated with the lowest costs, achieved the lowest referral rates at hospital discharge, and had the quickest learning curve to achieve those rates.

Volunteer-based universal newborn hearing screening program.

OBJECTIVE: To evaluate efficacy and costs of a volunteer-based universal newborn hearing screening program. METHODS: The Lucile Packard Children's Hospital at Stanford newborn hearing screening program database was reviewed. Results and costs of the hearing screens were analyzed. RESULTS: Hearing screens were performed on 5771 newborns treated in the well-baby nursery and nine infants from this population were identified with hearing loss, seven of whom had no risks factors for hearing loss. Using volunteers to perform the first-line screen with the automated auditory brainstem response (AABR) technology, 91% of infants registered for screening were evaluated prior to discharge. An additional 4% of infants were screened as outpatients. If an infant failed the AABR on two occasions, he or she was rescreened with the AABR or transient evoked otoacoustic emissions by a licensed audiologist, often while the infant was still in the hospital. Using this algorithm, 5% of infants tested in the well-baby nursery needed additional follow-up as an outpatient. Cost analysis of this volunteer-based program reveals a per/baby screening cost of $27.41. CONCLUSIONS: A volunteer-based hearing screening program is a viable option for hearing screening in well-baby nurseries but does not result in significant cost savings during the first 2 years of the program.

Universal infant hearing screening by automated auditory brainstem response measurement.

BACKGROUND: Our purpose was to identify infants with a bilateral, permanent, handicapping hearing loss and to provide them with amplification before age 6 months. METHODOLOGY: The study population consisted of 10,372 infants born during a 5-year period. Universal hearing screening by automated auditory brainstem response was done in the nursery. Infants who failed the screening test were followed up diagnostically. Infants who were not tested in the nursery were followed up as outpatients. Hearing aids were recommended for those infants who had bilateral hearing loss. RESULTS: Successful screening in the nursery was achieved for 96% of infants. The failure rate was 4%. The incidence of bilateral loss requiring amplification was 1.4/1000. The false-positive rate was 3.5% after the initial screening and .2% when a two-stage screening procedure was used. The incidence of congenital bilateral hearing loss in the well population was 1/1000, and in the neonatal intensive care unit population, 5/1000. The cost of screening was $17 per infant, and the cost to identify each true bilateral hearing loss was $17,750. Amplification was recommended for 15 infants; well infants who used hearing aids before age 6 months achieved age-appropriate speech and language development. CONCLUSIONS: Mild, moderate, and severe bilateral, persistent hearing loss can be identified in the nursery by automated auditory brainstem response measurement to provide amplification before age 6 months and thus optimize speech and language development.

Epidemiology of permanent hearing impairment in children in relation to costs of a hearing health surveillance program.

The objective of this investigation was to estimate the prevalence of any permanent hearing impairment (PHI) in the right and or left ear based on children included into a surveillance program in the local pediatric hearing health services (PHHS), and to analyze the costs, generated by the children. The study is a cross-sectional study, which is part of a major prospective study directed towards delineation of all aspects of pediatric audiology. The present sample comprises 228 children, 115 males and 113 females, at a median age of 13 years, range 0-24, and involves all children living in the health district of the City of Copenhagen, who are or have been included in a local surveillance program with one (school children) or two (pre-school children) annual visits for children with PHI > 20 dB HL at any frequency in either the left or the right ear. The prevalence of PHI increases with increasing age, reaching its peak in the age band 10-14 years exhibiting a rate of 5.32 1000 (95% confidence intervals: 4.27 to 6.64 per 1000). The estimated incidence of PHI in a ten year cohort born 1977-1986 is 325 100 000 children born (95% confidence intervals: 277 to 382 per 100 000). The most frequent factor causing PHI is inheritance, showing an increase from 20% in 1977-1981 cohorts, to 37% in 1982-1986 cohorts. The costs involved in the PHHS concerning PHI varies considerably from approximately 345 000 to 990 000 DKr.. depending on the model used for the economical analysis. No data on cost-benefit or cost-effectiveness can be given in this context, and it is concluded that the documented changes in the prevalence and causes of PHI in children emphasize the need for a continuous monitoring and evaluation of the epidemiological figures.