Patient profiles and cost of otolaryngologic surgeries in an LMIC Country

Objectives@#This study aims to analyze the cost of patient care among ORL-HNS patients admitted in a tertiary, teaching government hospital in a low- to middle-income country.@*Methods@#This is a prevalence-based, prospective, bottom-up, cost-of-illness analysis among patients of the Department of Otorhinolaryngology-Head and Neck Surgery in a tertiary training government hospital admitted from July 2021 to March 2022. The value assessment method used is the human capital approach. The societal perspective is used for analysis to estimate and reflect payer (insurance providers) and patient perspectives.@*Results@#A total of one hundred fifty seven (157) patients were admitted for elective surgery under the service of ORL-HNS consisting of 75 females and 82 males. The average total overall cost was $3,851.10 (Php 199, 870.50 ± 164, 725.60). The total direct health care cost for all patients within the study period amounted to $3,712.18 (Php 192, 662.22 ± 159, 548.60) while the direct non-health care cost was $58.60. The workforce cost (58.5%) and medication cost (18.8%) comprised the majority of in-patient expenses with a mean cost of $2,221.36 (Php 37,083.66) and $714.51 (Php 44,363.14), respectively. In this study, an average of $80.29 was lost due to illness and hospitalization (± $81.74). The total PHIC coverage pays a range from zero to 67.5% with an average coverage of only 17%.@*Conclusion@#Our analysis has shown that workforce and medication expenses are the main cost drivers for the direct healthcare costs among Otolaryngology patients admitted for elective procedures. Stakeholders, such as the otolaryngologists and hospitals should coordinate closely to create a more encompassing coverage of Philhealth to prevent patients from suffering from financial crises due to their illness.

Evaluation of an investigational hearing screening device (HeLe) to demonstrate acoustic brainstem response among normal-hearing adults

Objective@#This pilot human trial demonstrates the ability of the investigational newborn hearing screening device to provide acoustic stimulation to produce evoked potentials, as well as its ability to capture and acquire auditory evoked potentials, especially the auditory brainstem response (ABR) wave V. This pilot study also demonstrates the ease of recognizing and identifying ABR waves in the graphical presentation of the evoked potentials over time. @*Methods@#Fourteen normal-hearing adults or a total of twenty-eight (28) normal-hearing adult ears underwent auditory brainstem response testing using the investigational hearing screening device. A commercially available auditory brainstem response detection device was used to confirm that the acquired ABR waves of the investigational device are normal. The ABR waves displayed by the investigation device were also reviewed by the clinical audiologists to determine their recognizability and identifiability. @*Results@#The pilot trial demonstrates the ability of the investigational newborn hearing screening device in providing acoustic stimulation to produce evoked potentials, and in acquiring and capturing ABR waves, specifically the wave V, among normal-hearing adult ears. The clinical audiologists recognized and identified the ABR wave V among the evoked potentials at 40dB, 60dB, and 80dB acoustic stimulation. About eighty-nine percent (89.2%) of all ears tested had identifiable and recognizable wave V upon acoustic stimulation at 40dB. @*Conclusion@#The investigational hearing screening device: (1) can provide acoustic stimulation to produce evoked potentials, (2) can accurately capture and acquire these evoked potentials, (3) can present these evoked potentials in a voltage per time graphical display which an audiologist and trained HCP can easily read and interpret (diagnostic ABR), and (4) can present wave V auditory brainstem potentials that can be easily identified by an audiologist and trained HCP (screening ABR).

Pilot implementation of a community-based, eHealth-enabled service delivery model for newborn hearing screening and intervention in the Philippines

Objectives@#This study explores the potential of the HeLe Service Delivery Model, a community-based newborn hearing screening (NHS) program supported by a web-based referral system, in improving provision of hearing care services. @*Methods@#This prospective observational study evaluated the HeLe Service Delivery Model based on records review and user perspectives. We collected system usage logs from July to October 2018 and data on patient outcomes. Semi-structured interviews and review of field reports were conducted to identify implementation challenges and facilitating factors. Descriptive statistics and content analysis were used to analyze quantitative and qualitative data, respectively. @*Results@#Six hundred ninety-two (692) babies were screened: 110 in the RHUs and 582 in the Category A NHS hospital. Mean age at screening was 1.4±1.05 months for those screened in the RHU and 0.46±0.74 month for those in the Category A site. 47.3% of babies screened at the RHU were ≤1 month old in contrast to 86.6% in the Category A hospital. A total of 10 babies (1.4%) received a positive NHS result. Eight of these ten patients were referred via the NHS Appointment and Referral System; seven were confirmed to have bilateral profound hearing loss, while one patient missed his confirmatory testing appointment. The average wait time between screening and confirmatory testing was 17.1±14.5 days. Facilitating factors for NHS implementation include the presence of champions, early technology adopters, legislations, and capacity-building programs. Challenges identified include perceived inconvenience in using information systems, cost concerns for the patients, costly hearing screening equipment, and unstable internet connectivity. The lack of nearby facilities providing NHS diagnostic and intervention services remains a major block in ensuring early diagnosis and management of hearing loss in the community. @*Conclusion@#The eHealth-enabled HeLe Service Delivery Model for NHS is promising. It addresses the challenges and needs of community-based NHS by establishing a healthcare provider network for NHS in the locale, providing a capacity-building program to train NHS screeners, and deploying health information systems that allows for documentation, web-based referral and tracking of NHS patients. The model has the potential to be implemented on a larger scale — a deliberate step towards universal hearing health for all Filipinos.

Assessment of readiness for a community-based teleaudiology program of selected primary care health facilities in the Philippines

Introduction@#Access to appropriate and timely care underpins the Republic Act 9707 or the Universal Newborn Hearing Screening and Intervention Act of 2009. However, less than 10% of babies born every year have been screened for hearing loss. The Hearing for Life (HeLe) research program aims to increase the rate of newborn hearing screening (NHS) nationwide through the development and deployment of novel digital health or eHealth technologies in government rural primary care health centers (PCHC). The HeLe is also built on the global call for increased and systematic use of eHealth to strengthen health systems. Effectiveness of eHealth innovations requires acknowledgment of the product’s life cycle; one consideration is organizational readiness at this development stage of the HeLe. @*Objective@#This study assessed readiness of the eight PCHC selected to use the HeLe technologies. @*Methods@#This research utilized the Khoja-Durrani-Scott (KDS) eHealth evaluation tool to assess the PCHC’s readiness level prior to the implementation of HeLe. The KDS tool was distributed through a self-administered survey; data was analyzed using descriptive statistics. Readiness is measured in terms of seven dimensions or outcomes resulting from the use of the HeLe technologies. @*Results@#The study revealed that the eight PCHC were most to least ready, in decreasing order, in the following areas: Ethical, Health, Technology, Social & Cultural, Readiness & Change Management, as well as Economic, and Policy outcomes. The study affirms the PCHCs’ value for equity in health care, i.e., providing accessible NHS services in the community setting closest to where the families and their newborns are. Likewise, results confirm the PCHC staff’s preparedness for another set of innovations, through agreement with statements on Technology, Social & Cultural as well as Readiness & Change Management parameters. @*Conclusions@#The results informed the training and technical support strategies to be implemented by the HeLe program proponents. However, even in this early development phase of the HeLe technologies, the PCHC are already concerned with how to sustain NHS services after the research. Fully aware that the HeLe ICT tools need to be maintained and upgraded, the PCHC views that economic and policy support should also be in place to ensure continuous delivery of the ICT-enabled NHS services. While results are illustrative, usefulness is limited by the small sample size and character of the study sites. Nevertheless, social dimensions still have to be carefully considered as innovative NHS tools are introduced to primary care health workers nationwide. Researchers have to be deliberate in working with broader health systems and policy advocacy efforts to allow novel NHS technologies to be smoothly introduced at the community level and frontlines of care.

Design of a blended learning course for training community healthcare providers on ehealth-enabled newborn hearing screening

Objectives@#We present in this article the design and evaluation of a blended learning approach for training community healthcare providers in performing newborn hearing screening (NHS).@*Methods@#We developed a blended learning course for training community healthcare providers on eHealth-enabled NHS, following Bloom’s revised taxonomy of educational objectives. The training involved three components: computer-based training (CBT), face-to-face (FTF) training, and on-site coaching. We used surveys and post-training interviews following Level 1 Kirkpatrick’s training evaluation model to get initial feedback on the training program. @*Results@#Thirty-one community healthcare providers from five rural health units and a private hearing screening center, with a mean age of 42.2 ± 12.0 years, participated in the pilot. 93.5% of the participants agreed that the program content met stated objectives and was relevant to their practice. The length of the course was perceived to be adequate. Overall satisfaction with the program was rated at 8.5 ± 0.9 (with ten as the highest). The majority expressed that the CBT and FTF course were satisfactory at 93.5% and 100%, respectively. All participants agreed that the course enhanced their knowledge of newborn hearing screening and telehealth. Positive reviews were received from participants on the use of CBT to improve theoretical knowledge before FTF training. Participants declared that FTF training and on-site coaching helped improved NHS skills and implementation. @*Conclusion@#Competent community healthcare providers are critical to strengthening the performance of the health system, and advances in the education and technology sectors offer promising potential in upskilling local healthcare providers. The increasing access of Filipino healthcare providers to improved information and communications technology (ICT) is a significant catalyst for pedagogical innovation, like the use of blended learning in the continuous professional development of health practitioners. As ICTs gradually penetrate the health sector, the challenge we now face is not whether but how we can use innovations in education strategies to benefit healthcare providers.

Pilot implementation of a computer-based training course on newborn hearing screening and teleaudiology among primary healthcare providers in low resource settings

Objective@#Newborn hearing screening (NHS) in the Philippines has been mandated by law since 2009. However, lack of awareness and knowledge about NHS remains a challenge, especially among healthcare providers. This paper describes the pilot implementation of a computer-based training (CBT) course on NHS and teleaudiology among primary healthcare providers (PHCPs) in rural Philippines. @*Methods@#A four-module web-based training course on newborn hearing screening and teleaudiology in an online learning management system (LMS) was field-tested among PHCPs from eight rural communities in the Philippines. Participants were given four weeks to complete the course. @*Results@#Forty-two PHCPs participated in the CBT. Thirty-four (81%) completed the whole course (mean attrition rate of 4.8% per module) at a mean duration of 10.2 days. Baseline data shows that participants had no NHS training, although the majority (83%) had information and communications technology (ICT) training. Comparison of preand post-test mean scores showed a 24.0% (p<0.001) significant increase in the post-test in all four modules. Passing rates (i.e., score ≥70%) from pre- to post-test increased by 54.6% (range: 38-80% increase). Usability of the CBT was rated high with a mean score of 4.32 out of 5 (range: 4.13 to 4.47), covering all eight parameters. Participants expressed general satisfaction and a positive attitude on CBT to improve knowledge on NHS and teleaudiology. @*Conclusion@#Even in low resource settings where gaps in ICT infrastructure exist, eLearning can be used as an alternative approach to increase awareness and support training of healthcare providers on newborn hearing screening.

Management of isolated mandibular body fractures in adults

Objective@#The mandible is the most common fractured craniofacial bone of all craniofacial fractures in the Philippines, with the mandibular body as the most involved segment of all mandibular fractures. To the best of our knowledge, there are no existing guidelines for the diagnosis and management of mandibular body fractures in particular. General guidelines include the American Academy of Otolaryngology – Head and Neck Surgery Foundation (AAOHNSF) Resident Manual of Trauma to the Face, Head, and Neck chapter on Mandibular Trauma, the American Association of Oral and Maxillofacial Surgeons (AAOMS) Clinical Practice Guidelines for Oral and Maxillofacial Surgery section on the Mandibular Angle, Body, and Ramus, and a 2013 Cochrane Systematic Review on interventions for the management of mandibular fractures. On the other hand, a very specific Clinical Practice Guideline on the Management of Unilateral Condylar Fracture of the Mandible was published by the Ministry of Health Malaysia in 2005. Addressing the prevalence of mandibular body fractures, and dearth of specific guidelines for its diagnosis and management, this clinical practice guideline focuses on the management of isolated mandibular body fractures in adults.@*Purpose@#This guideline is meant for all clinicians (otolaryngologists – head and neck surgeons, as well as primary care and specialist physicians, nurses and nurse practitioners, midwives and community health workers, dentists, and emergency first-responders) who may provide care to adults aged 18 years and above that may present with an acute history and physical and/or laboratory examination findings that may lead to a diagnosis of isolated mandibular body fracture and its subsequent medical and surgical management, including health promotion and disease prevention. It is applicable in any setting (including urban and rural primary-care, community centers, treatment units, hospital emergency rooms, operating rooms) in which adults with isolated mandibular body fractures would be identified, diagnosed, or managed. Outcomes are functional resolution of isolated mandibular body fractures; achieving premorbid form; avoiding use of context-inappropriate diagnostics and therapeutics; minimizing use of ineffective interventions; avoiding co-morbid infections, conditions, complications and adverse events; minimizing cost; maximizing health-related quality of life of individuals with isolated mandibular body fracture; increasing patient satisfaction; and preventing recurrence in patients and occurrence in others.@*Action Statements@#The guideline development group made strong recommendationsfor the following key action statements: (6) pain management- clinicians should routinely evaluate pain in patients with isolated mandibular body fractures using a numerical rating scale (NRS) or visual analog scale (VAS); analgesics should be routinely offered to patients with a numerical rating pain scale score or VAS of at least 4/10 (paracetamol and a mild opioid with or without an adjuvant analgesic) until the numerical rating pain scale score or VAS is 3/10 at most; (7) antibiotics- prophylactic antibiotics should be given to adult patients with isolated mandibular body fractures with concomitant mucosal or skin opening with or without direct visualization of bone fragments; penicillin is the drug of choice while clindamycin may be used as an alternative; and (14) prevention- clinicians should advocate for compliance with road traffic safety laws (speed limit, anti-drunk driving, seatbelt and helmet use) for the prevention of motor vehicle, cycling and pedestrian accidents and maxillofacial injuries.The guideline development group made recommendations for the following key action statements: (1) history, clinical presentation, and diagnosis - clinicians should consider a presumptive diagnosis of mandibular fracture in adults presenting with a history of traumatic injury to the jaw plus a positive tongue blade test, and any of the following: malocclusion, trismus, tenderness on jaw closure and broken tooth; (2) panoramic x-ray - clinicians may request for panoramic x-ray as the initial imaging tool in evaluating patients with a presumptive clinical diagnosis; (3) radiographs - where panoramic radiography is not available, clinicians may recommend plain mandibular radiography; (4) computed tomography - if available, non-contrast facial CT Scan may be obtained; (5) immobilization - fractures should be temporarily immobilized/splinted with a figure-of-eight bandage until definitive surgical management can be performed or while initiating transport during emergency situations; (8) anesthesia - nasotracheal intubation is the preferred route of anesthesia; in the presence of contraindications, submental intubation or tracheostomy may be performed; (9) observation - with a soft diet may serve as management for favorable isolated nondisplaced and nonmobile mandibular body fractures with unchanged pre - traumatic occlusion; (10) closed reduction - with immobilization by maxillomandibular fixation for 4-6 weeks may be considered for minimally displaced favorable isolated mandibular body fractures with stable dentition, good nutrition and willingness to comply with post-procedure care that may affect oral hygiene, diet modifications, appearance, oral health and functional concerns (eating, swallowing and speech); (11) open reduction with transosseous wiring - with MMF is an option for isolated displaced unfavorable and unstable mandibular body fracture patients who cannot afford or avail of titanium plates; (12) open reduction with titanium plates - ORIF using titanium plates and screws should be performed in isolated displaced unfavorable and unstable mandibular body fracture; (13) maxillomandibular fixation - intraoperative MMF may not be routinely needed prior to reduction and internal fixation; and (15) promotion - clinicians should play a positive role in the prevention of interpersonal and collective violence as well as the settings in which violence occurs in order to avoid injuries in general and mandibular fractures in particular.

Otorhinolaryngology Out-Patient Practice in the “Post”-COVID-19 Era: Ensuring a Balance Between Service and Safety

Objective@#To review available resources and provide evidence-based recommendations that may optimize otorhinolaryngologic out-patient health care delivery in the “post”-COVID-19 era while ensuring the safety of our patients, healthcare workers and staff.@*Data Sources@#Relevant peer-reviewed journal articles; task force, organizational and institutional, government and non-government organization recommendations; published guidelines from medical, health-related, and scientific organizations.@*Methods@#A comprehensive review of the literature on the COVID-19 pandemic as it pertained to “post”-COVID 19 out-patient otorhinolaryngologic practice was obtained from peer-reviewed articles, guidelines, recommendations, and statements that were identified through a structured search of the data sources for relevant literature utilizing MEDLINE (through PubMed and PubMed Central PMC), Google (and Google Scholar), HERDIN Plus, the World Health Organization (WHO) Global Health Library, and grey literature including social media (blogs, Twitter, LinkedIn, Facebook). In-patient management (including ORL surgical procedures such as tracheostomy) were excluded. Retrieved material was critically appraised and organized according to five discussion themes: physical office set-up, patient processing, personal protection, procedures, and prevention and health-promotion.@*Conclusion@#These recommendations are consistent with the best available evidence to date, and are globally acceptable while being locally applicable. They address the concerns of otorhinolaryngologists and related specialists about resuming office practice during the “post”-COVID-19 period when strict quarantines are gradually lifted and a transition to the “new” normal is made despite the unavailability of a specific vaccine for SARS-CoV-2. While they target practice settings in the Philippines, they should be useful to ENT (ear, nose & throat) surgeons in other countries in ensuring a balance between service and safety as we continue to serve our patients during these challenging times.