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.

Community health workers obtain similar results using cell-phone based hearing screening tools compared to otolaryngologists in low resourced settings.

OBJECTIVE: To establish community health workers as reliable hearing screening operators in a technology-based pre-surgical hearing screening program in a low and middle-income country (LMIC). METHODS: This is a cross sectional study that evaluated community health worker driven hearing screening that took place in semi-rural Malindi, Kenya during an annual two-week otolaryngology surgical training mission in October 2017. At five separate locations (four schools) near Malindi, Kenya, children between the ages of 2-16 underwent hearing screening using screening audiometry (Android-based HearX Group). Children were screened by a community health worker who underwent a short training course, a senior otolaryngology resident, or both. Hearing screening results were compared to determine the reliability and concordance between independent, blinded community health worker and otolaryngology resident testing. RESULTS: One hundred and four participants (53% males) underwent hearing screening. Hearing screening pass rate was 93%. Community health workers obtained a similar result to otolaryngology residents 96% of the time (McNemar test: p = 0.16, OR 0.96, 95% CI 0.9-1.0). CONCLUSION: Community health workers can obtain reliable results using a technology-based, pre-surgical hearing screening platform when compared to otolaryngology residents. This finding has profound implications in low-resourced settings where hearing healthcare specialists (audiologists and otolaryngologists) are limited and can ultimately improve the surgical yield of patients presenting to local otolaryngologists in these settings.

Use of otoacoustic emissions to improve outcomes and reduce disparities in a community preschool hearing screening program.

INTRODUCTION: Hearing loss substantially impacts pediatric development, and early identification improves outcomes. While intervening before school-entry is critical to optimize learning, early-childhood hearing screening practices are highly variable. Conditioned play audiometry (CPA) is the gold standard for preschool hearing screening, but otoacoustic emission (OAE) testing provides objective data that may improve screening outcomes. OBJECTIVES: To compare outcomes of a community-based low-income preschool hearing program before and after implementation of OAE in a single-visit, two-tiered paradigm. We hypothesized that this intervention would reduce referral rates and improve follow-up while maintaining stable rates of diagnosed sensorineural hearing loss. METHODS: We performed a cohort study of 3257 children screened from July 2014-June 2016. Department of Public Health data were analyzed pre- and post-implementation of second-line OAE testing for children referred on CPA screening with targeted follow-up by DPH staff. Primary outcomes included referral rates, follow-up rates, and diagnosis of sensorineural hearing loss. RESULTS: Demographics, pure-tone pass rates, and incidence of newly-diagnosed permanent hearing loss were similar across years. After intervention, overall pass rates increased from 92% to 95% (P = 0.0014), while only 0.7% remained unable to be tested (P<0.0001). 5% of children were unable to be tested by CPA screening but passed OAE testing, obviating further evaluation. Referral rate decreased from 8% to 5% (P = 0.0014), and follow-up improved from 36% to 91% (P<0.0001). Identification of pathology in children with follow-up increased from 19% to over 50%. Further, disparities in pass rates and ability to test seen in Year 1 were eliminated in Year 2. CONCLUSION AND RELEVANCE: In a community setting, implementation of second-line OAE screening for CPA referrals reduced referral rates, increased identification of hearing loss, reduced outcome disparities, and improved follow-up rates. This study provides lessons in how to improve outcomes and reduce disparities in early-childhood hearing screening.

The calibration of a prototype occluded ear simulator designed for neonatal hearing assessment applications.

An innovative family of ear simulators has been conceived for the calibration and traceability of audiometric equipment. Each device within the family has been designed for a particular key age group, covering neonates through to adults. The age-specific ear simulators are intended to improve the quality of hearing assessment measurements for all test subject age groups, and will be proposed as the next generation of standardised ear simulators for audiometric applications. The family of ear simulators shares a common design and modeling approach, and the first prototype devices for neonatal applications have been manufactured. The objectives of this study were to develop calibration methods, verify conformance to the design goals, demonstrate that the device is capable of being calibrated reliably, and show that its performance is ultimately suitable for international standardisation and eventual adoption into clinical practices. Four national measurement institutes took part in a round-robin calibration comparison and an analysis of the results showed that these objectives were achieved.

Initial assessment of hearing loss using a mobile application for audiological evaluation.

OBJECTIVE: This study aimed to compare an Apple iOS mobile operating system application for audiological evaluation with conventional audiometry, and to determine its accuracy and reliability in the initial evaluation of hearing loss. METHODS: The study comprised 32 patients (16 females) diagnosed with hearing loss. The patients were first evaluated with conventional audiometry and the degree of hearing loss was recorded. Then they underwent a smartphone-based hearing test and the data were compared using Cohen's kappa analysis. RESULTS: Patients' mean age was 53.59 ± 18.01 years (range, 19-85 years). The mobile phone audiometry results for 39 of the 64 ears were fully compatible with the conventional audiometry results. There was a statistically significant concordant relationship between the two sets of audiometry results (p < 0.05). CONCLUSION: Ear Trumpet version 1.0.2 is a compact and simple mobile application on the Apple iPhone 5 that can measure hearing loss with reliable results.

[The assessment of the ventilation function of the eustachian tubes after shunting of the tympanic cavity].

The objective of the present work was to study specific features of the eustachian tube after the insertion of the shunt into the tympanic membrane and to measure the pressure necessary to ensure passive opening of the tube in the patients presenting with exudative otitis medium (EOM). The study included 87 patients with this pathology who underwent shunting of the tympanic cavity following a course of conservative treatment. Threshold audimetry and acoustic impedancemetry were performed in all the patients to estimate the patency of the eustachian tube with the perforated tympanic membrane. It is concluded that the shunting of the tympanic cavity resulted in markedly disturbed dynamic function of the Eustachian tube in the majority of the patients (59%) regardless of the severity of hearing impairment.

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.

Internet-based tele-audiometry system for the assessment of hearing: a pilot study.

The application of tele-audiology is in its infancy. Several systems have been developed to screen hearing, yet the application of real-time diagnostic audiology to a remote location is new. This paper describes a tele-audiometric system developed for the application of realtime diagnostic audiometry via the Internet. A pilot study evaluated 31 adult participants in a double-blind study of two different systems (i.e., conventional versus Internet-based) for assessing auditory thresholds. The threshold data show substantial agreement between the two systems. Mean thresholds varied by no more than 1.3 dB, well within established variability of audiometric testing. This pilot study demonstrated the feasibility of real-time Internet-based assessment of hearing. The system allows this remote assessment of hearing without an audiologist on site. Further investigation will assess of outcomes and costs.

Measurement method for the assessment of transmission properties of implantable hearing aids.

Over the last five years the Symphonix Vibrant soundbridge (VSB), an implantable hearing device, has proven an effective alternative treatment modality for patients suffering from moderate to severe sensorineural hearing loss. The results from the majority of our 40 patients are very encouraging but reveal clinical variations in benefit influenced by the coupling of the transducer to the ossicular chain. This study describes a set-up for measuring the sound pressure level in the external auditory canal when the middle ear implant is activated. The reverse transfer function allows the transducer performance to be determined both intra- and postoperatively. The sound pressure level shows a strong correlation with the stapes footplate displacement and free-field audiometry.

Experience with the audiologic assessment of infants and toddlers.

Experience with the behavioral assessment of hearing sensitivity is reported for 211 babies and toddlers aged 6-24 months. The visually reinforced head-turn procedure, visual reinforcement audiometry (VRA), was utilized to obtain threshold estimates for infants evaluated for both research and clinical purposes. At the initial test session, 90% of the infants and toddlers provided useful audiometric threshold data for air-conducted tonal signals; 84% could be assessed using standard earphones. The equipment arrangement described allows a single audiologist to complete the VRA assessment. The behavioral test technique offers the clinician a simple, efficient procedure for the routine audiometric assessment of the vast majority of very young children.

[Assessment of a hearing test procedure, the MIRA (Multichannel Infant Reflex Audiometry) and biofeedback. 2. Influences on threshold determination]. / Wertabschätzung der Hörprüfungsverfahren MIRA (Multichannel Infant Reflex Audiometry) und Biofeedback. 2. Einflüsse auf die Schwellenfindung.

Four years of experience with the hearing tests for babies MIRA (electrical registration of sucking, breathing and localisation reactions, respectively, due to acoustic stimuli with following evaluation of the curves) and biofeedback (1 1/2 years of experience, frequency modulation of the stimulus by the sucking activity and thus examination of the interaction between articulation and hearing) show different kinds of influence on the threshold determination. These are, in the first year of life, influences of a physical nature (room acoustics, audiometric apparatus and activity transducers) and of organisation and action (taking care of the babies, problems arising from simultaneous action and observation), as well as of different weighting of the number of reactions. These are compared with each other in respect of the reactions they provoke, rated individually, and discussed.

A calibration procedure for the assessment of thresholds above 8000 Hz.

A technique is described to estimate the sound pressure level developed by a broad frequency response transducer at the tympanic membrane. Real-ear probe tube measurements near the tympanic membranes of 10 subjects were used to obtain frequency-dependent correction values for a custom-designed flat-plate coupler. These latter measures can be used for routine calibration of the transducer. Audiometric thresholds from 250 to 16000 Hz were obtained on 14 children (5-18 years). Threshold estimates were found to be comparable to previously reported values. Potential application and limitations of this technique are discussed.

Electrodermal response, delayed auditory feedback, and lengthened off-time procedures. Comparison of use for medical-legal audiological assessment.

Results of conventional audiological procedures, lengthened off-time Békésy, and electrodermal response audiometry are compared with pure-tone delayed auditory feedback procedures for 100 subjects referred for medical-legal audiological evaluation. Specific attention is given to a new economical prototype unit for pure-tone delayed auditory feedback, to the comparison of results of special test procedures, and to the nonorganic hearing loss population.