Establishment of the Norwegian hearing register for children.

Introduction: The Norwegian Directorate of Health approved the Norwegian Hearing Register for Children in 2022. The main objective of the register is to improve the quality of treatment for children with permanent hearing loss, by measures, follow-ups and monitoring the quality and results of the health care system. Methods: Inclusion criteria are children who do not pass universal newborn hearing screening and/or children with permanent hearing loss <18 years of age. Hearing loss is defined as pure-tone audiometry threshold of (PTA4) > 20 dB in at least one ear. Data are registered at the Ear, Nose and Throat departments at inclusion and at follow-ups at the age of 3, 6, 10, and 15 years. The register collects information about the child within a holistic perspective. The key elements of the register are (a) data concerning newborn hearing screening; (b) data concerning hearing, medical information, hearing amplification and intervention (c) patient reported outcome measures registered by caregivers using three questionnaires; Pediatric Quality of Life Inventory, Strengths and Difficulties Questionnaire and Parents' Evaluation of Aural/Oral Performance of Children. Results: The register has established four quality indicators regarding newborn hearing screening and early intervention (a) the rate of false positive neonatal screens; (b) testing for congenital cytomegalovirus within 3 weeks of age for children who do not pass newborn hearing screening; (c) audiological evaluation to confirm the hearing status no later than 3 months of age and (d) initiated intervention within 3 months after confirmation of hearing status. Discussion: The register will include the total population of hearing impaired children over long time periods. Thus, the register enables each hospital to monitor their quality indicator scores continuously and compare them with national levels in real time. This facilitates and accelerates identification of improvement areas in the hospitals and will be an important contributor for quality improvement in NHS, diagnostics and hearing intervention for children in Norway. In addition, data from the register will be a unique source for research, and study designs with a long follow-up time can be applied.

A validation study of the 30-day questionnaire in the national Norwegian Tonsil Surgery Register: can we trust the data reported by the patients?

PURPOSE: The aim of this study was to validate the Patient Reported Outcome Measure (PROM) in the Norwegian Tonsil Surgery Register (NTSR) and to examine whether any improvements to the questionnaire could be useful. METHODS: This is a prospective, descriptive study. NTSR collects data from patients who undergo tonsil surgery and the intention of the register is to improve the quality of treatment and to contribute to research. The patients answers questions about admission due to postoperative haemorrhage, infection and pain 30 days after surgery. 305 patients were contacted on phone 1-2 weeks after answering the questionnaires electronically (ePROM) and asked the same questions. 180 of 305 patients we contacted had some kind of complications after surgery. They were asked additional questions to search for possible points for improvement of the questionnaire. RESULTS: When comparing the results on the ePROM with the answers on phone, we found that 12 out of 14 variables achieve almost perfect agreement (AC1 ≥ 0.81). Two variables are categorized to be substantial agreement (AC1 = 0.61-0.80). The additional questions showed us that the questionnaire can be improved with more detailed information regarding the severity of the postoperative haemorrhage and the need of better treatment against postoperative pain. CONCLUSION: This study shows that the information from the 30-day ePROM has high reliability. The questions were understood as they were intended, and the answers reflect what the patients had of complications. Some changes can be done to improve the questionnaire and to open up for more research around the tonsillectomy procedure.

Reducing post-tonsillectomy haemorrhage: a multicentre quality improvement programme incorporating video-based cold technique instruction.

OBJECTIVE: Data from the Norwegian Tonsil Surgery Register (NTSR) showed large differences between the hospitals in Norway in the readmission rate due to post-tonsillectomy haemorrhage (rrPTH; range, 0%-25%; national average, 8%). Because of these large variations in the rrPTH, we conducted a quality improvement project involving hospitals with good and bad readmission rates. METHODS: Seven hospitals with readmission rates greater than 10% and four with rates lower than 5% participated in this project. We recorded videos of ear, nose and throat surgeons from the hospitals with low readmission rates when they performed extracapsular tonsillectomy, and these videos of cold dissection tonsillectomy were used as teaching material for examples of good surgical skills for the other hospitals. After a 2-day workshop, all participants from the hospitals went back to their institutions and prepared local plans to improve their results. We used the Plan-Do-Study-Act model. The primary outcome variable was the patient-reported rrPTH in the NTSR. As secondary goal, we aimed to identify aspects of the tonsillectomy procedure that could help achieve a lower rrPTH. RESULTS: The participating hospitals reduced their rrPTH from 18% at baseline (2017/2018) to 7% in 2020. Six of seven hospitals changed their dissection technique significantly to more use of cold dissection. CONCLUSION: By learning cold dissection tonsillectomy from surgeons with low rrPTH, it seems possible to decrease the rates of bleeding complications after tonsillectomy. A combination of videos as a teaching tool, new treatment plans, and focus on quality and improvement may effectively improve surgical results. The videos can show details that are difficult to convey in the literature. Quality registers can be used to identify areas requiring improvement and evaluate the effects of changes in practice.

Comparison of clinical practice of tonsil surgery from quality register data from Sweden and Norway and one clinic in Denmark.

OBJECTIVES: To compare the application of indications, demographics, surgical and haemostatic techniques in tonsil surgery in three countries. DESIGN: Non-randomised, prospective, observational cohort. SETTING: All patients registered in the National Tonsil Surgery Quality Registers in Sweden, Norway and West Jutland, Denmark. PARTICIPANTS: Data were retrieved from 2017 to 2019; registered surgeries: Sweden: 20 833; Norway: 10 294 and West Jutland, Denmark: 505. RESULTS: Tonsil surgery for obstruction was twice as common in Sweden (62.2%) compared with Norway (31%) and Denmark (27.7%). Recurrent tonsillitis was registered twice as frequently in Norway (35.7%) and Denmark (39%) compared with Sweden (16.7%). Chronic tonsillitis was registered more frequently in Norway (29.8%) than in Sweden (13.8%) and Denmark (12.7%). Day surgery (>76%) was comparable. The higher frequency of obstruction in Sweden affected age and gender distributions: Sweden (7 years, 50.4% boys), Norway (17 y, 42.1%) and Denmark (19 y, 38.4%). For obstructive disorders, tonsillotomy with adenoidectomy was used in a majority of Swedish children (72%), whereas tonsillectomy with or without adenoidectomy dominated in Norway (53.5%) and Denmark (57.9%). Cold steel was the technique of choice for tonsillectomy in all three countries. For tonsillotomy, hot dissection techniques dominated in all countries. Disparities were observed with regard to haemostatic techniques. Bipolar diathermy was commonly used in all countries. Monopolar diathermy was practically only used in Sweden. Infiltration with epinephrine in the tonsillar bed was registered in Sweden and Norway but not at all in Denmark. Combined cold surgical and cold haemostatic techniques were more commonly used in Sweden (22.7%) than in Norway (10.4%) and Denmark (6.2%). CONCLUSIONS: This study demonstrates disparities among the Nordic countries in tonsil surgery in terms of indications plus surgical and haemostatic techniques. Increased coverage and further monitoring of outcomes is needed to identify best practices and ideal guidelines for improved care.

Providing quality data in health care - almost perfect inter-rater agreement in the Norwegian tonsil surgery register.

BACKGROUND: The Norwegian Tonsil Surgery Register (NTSR) was launched in January 2017. The purpose of the register is to present data on tonsil surgery to facilitate improvements in patient care. Data used for evaluating the quality of medical care needs to be of high reliability. This study aims to assess the inter-rater reliability (IRR) of the variables reported to the register by medical professionals. METHODS: The study population consists of the first 137 tonsil surgery patients who were included in the NTSR at St. Olav's University Hospital in Trondheim. An experienced rater completed the register's paper form for all 137 patients based on their electronic medical records, blinded for the data already in the register. To assess the inter-rater reliability between the register and the external rater, we calculated observed agreement, Cohen's kappa and Gwet's AC1 coefficients with 95% confidence intervals. RESULTS: All tested variables in the NTSR have almost perfect reliability except for the variable for the cold steel technique, which had a substantial to almost perfect reliability. The inter-rater agreement was substantial to almost perfect for every variable, with substantial (kappa/AC1 > 0.61) to almost perfect (kappa/AC1 > 0.81) agreement for all the examined variables. CONCLUSION: This study shows that the reliability of the NTSR is high for all variables registered by the professionals at the hospital immediately after surgery.

Can general practitioners do the follow-ups after surgery with ventilation tubes in the tympanic membrane? Two years audiological data.

BACKGROUND: A university hospital in Mid-Norway has modified their guidelines for follow-up after insertion of ventilation tubes (VTs) in the tympanic membrane, transferring the controls of the healthiest children to general practitioners (GPs). The aim of this study was to evaluate the implementation of these guidelines by exploring audiological outcome and subjective hearing complaints two years after surgery, assessing if follow-ups in general practice resulted in poorer outcome. METHODS: A retrospective observational study was performed at the university hospital and in general practice in Mid-Norway. Children below 18 years who underwent surgery with VTs between Nov 1st 2007 and Dec 31st 2008 (n = 136) were invited to participate. Pure tone audiometry, speech audiometry and tympanometry were measured. A self-report questionnaire assessed subjective hearing, ear complaints and the location of follow-ups. This study includes enough patients to observe group differences in mean threshold (0.5-1-2-4 kHz) of 9 dB or more. RESULTS: There were no preoperative differences in audiometry or tympanometry between the children scheduled for follow-ups by GPs (n = 23) or otolaryngologists (n = 50). Two years after surgery there were no differences between the GP and otolaryngologist groups in improvement of mean hearing thresholds (12.8 vs 12.6 dB, p = 0.9) or reduction of middle ears with effusion (78.0 vs 75.0%, p = 0.9). We found no differences between the groups in terms of parental reports of child hearing or ear complaints. CONCLUSIONS: Implementation of new clinical guidelines for follow-ups after insertion of VTs did not negatively affect audiological outcomes or subjective hearing complaints two years after surgery.

Implementing guidelines for follow-up after surgery with ventilation tube in the tympanic membrane in Norway: a retrospective study.

BACKGROUND: When clinical guidelines are being changed a strategy is required for implementation. St. Olavs University Hospital in Norway modified their guidelines for the follow-up care of children after insertion of ventilation tubes (VT) in the tympanic membrane, transferring the controls of the healthiest children to General Practitioners (GPs). This study evaluates the implementation process in the hospital and in general practice by exploring two issues: 1) Whether the hospital discharged the patients they were supposed to and 2) whether the children consulted a GP for follow-up care. METHODS: A retrospective observational study was performed at St. Olavs University Hospital, Norway and general practice in Mid-Norway. Children under the age of 18 who underwent insertion of VT between Nov 1st 2007 and Dec 31st 2008 (n = 136) were included. Degree of guideline adherence at the hospital and in general practice was measured. RESULTS: The hospital adhered to the guidelines in two-thirds (68.5%) of the patients, planning more patients for follow-up by their GP than recommended in the guidelines (25.8% vs. 12.4%). All except one contacted their GP for control. In total 60% were referred back to specialist health services within two years. CONCLUSIONS: The methods for guideline implementation were successful in securing consultations for follow-up care in general practice. Lack of guideline adherence in the hospital can partly be explained by the lack of quality of the guideline. Further studies are needed to evaluate the quality of controls done by the GPs in order to consider implications for follow-up after VT surgery.

[Use of hearing aid--coping and functional disability]. / Bruk av høreapparat--mestring og funksjonstap.

BACKGROUND: Hearing loss is a common health problem and affects social life. We studied how adults' use of hearing aids was influenced by socio-demographic and audiological characteristics, use of coping strategies, and perceived functional disability. MATERIAL AND METHODS: 162 adult patients (82 men) who had previously used hearing aids and were referred to St. Olavs University Hospital (Trondheim, Norway) for a renewed assessment and prescription, were consecutively included in the study. Questionnaires were used to capture their experience with using hearing aids and the negative consequences of hearing loss, as well as use of specific coping strategies and the presence of tinnitus. Relations between reported use and explanatory variables were assessed by using logistic regression analyses. RESULTS: Advanced hearing loss increased the probability of using aids more frequently, while non-persistent tinnitus and a medium long experience with using hearing aids (7?-?17 years) reduced the probability. Maladaptive behaviour interferring with effective communication reduced the daily use. Use of verbal and nonverbal communication strategies, and degree of perceived functional disability did not influence the use of hearing aids. INTERPRETATION: A low degree of hearing loss, occasional tinnitus, a medium long experience in the use of hearing aids, and frequent use of dysfunctional communication strategies were associated with little use of the aids.

Activity limitation and participation restriction in adults seeking hearing aid fitting and rehabilitation.

PURPOSES: We first aimed to describe demographic and audiological characteristics of adults referred to a university hospital for hearing aid (HA) fitting and rehabilitation. Our second aim was to employ an inventory that assesses life consequences of hearing impairment (HI) in terms of perceived activity limitation and participation restriction for the first time in a Norwegian adult outpatient population. A third aim was to study life consequences by audiological and demographic characteristics. SUBJECTS AND METHODS: During one year consecutive patients (n = 343) were requested to answer the Hearing Disability and Handicap Scale (HDHS) assessing activity limitation and participation restriction in relation to an audiological examination and medical consultation. The mean threshold of hearing (MTH) was ascertained by pure tone thresholds at 0.5 - 1 - 2 - 4 kHz in the better ear. RESULTS: Activity limitation and participation restriction were both higher for HA experienced than HA naïve subjects ( p < 0.01). In a multivariable model, the explained adjusted variance of activity limitation (R2) was 43.4% with MTH, perceived duration, and severity of hearing problems as predictor variables. Correspondingly, the explained adjusted variance of participation restriction was 28.4% for a model with MTH, age, gender and perceived severity of hearing problems as predictors. CONCLUSIONS: As a standard supplement to audiometric tests, HDHS may be successfully applied as a clinical tool among similar hearing impaired outpatients in order to assess activity limitation and participation restriction as part of audiological rehabilitation.