Protocol and programme factors associated with referral and loss to follow-up from newborn hearing screening: a systematic review

Abstract

Background An effective newborn hearing screening programme has low referral rate and low loss to follow-up (LTFU) rate after referral from initial screening. This systematic review identified studies evaluating the effect of protocol and programme factors on these two outcomes, including the screening method used and the infant group. Methods Five databases were searched (latest: April 2021). Included studies reported original data from newborn hearing screening and described the target outcomes against a protocol or programme level factor. Studies were excluded if results were only available for one risk condition, for each ear, or for < 100 infants, or if methodological bias was observed. Included studies were evaluated for quality across three domains: sample, screening and outcome, using modified criteria from the Ottawa-Newcastle and QUADAS-2 scales. Findings from the included studies were synthesised in tables, figures and text. Results Fifty-eight studies reported on referral rate, 8 on LTFU rate, and 35 on both. Only 15 studies defined LTFU. Substantial diversity in referral and LTFU rate was observed across studies. Twelve of fourteen studies that evaluated screening method showed lower referral rates with aABR compared to TEOAE for well babies (WB). Rescreening before hospital discharge and screening after 3 days of age reduced referral rates. Studies investigating LTFU reported lower rates for programmes that had audiologist involvement, did not require fees for step 2, were embedded in a larger regional or national programme, and scheduled follow-up in a location accessible to the families. In programmes with low overall LTFU, higher LTFU was observed for infants from the NICU compared to WB. Conclusion Although poor reporting and exclusion of non-English articles may limit the generalisability from this review, key influential factors for referral and LTFU rates were identified. Including aABR in WB screening can effectively reduce referral rates, but it is not the only solution. The reported referral and LTFU rates vary largely across studies, implying the contribution of several parameters identified in this review and the context in which the programme is performed. Extra attention should be paid to infants with higher risk for hearing impairment to ensure their return to follow-up.

Implementation of Newborn Hearing Screening in Albania

“…LTFU was the main problem throughout the two years of screening. LTFU is not only a serious problem in low-income countries and middle-income countries but was also found in NHS programmes in high-income countries [ 33 , 34 , 35 ]. In our study, LTFU was highest in the MG maternity hospital where the most infants were born and the workload per screener was the highest.…”

Longitudinal Analysis of Early Hearing Detection and Intervention Program Performance

“…Four scenarios are proposed to explain low diagnostic testing completion rates, the first three of which have previously been well-explored in the literature: (1) states may have insufficient diagnostic capacity (e.g., lack of screening equipment or pediatric audiologists, as highlighted in Shulman et al 2010), (2) states may have high diagnostic capacity that remains under-utilized due to lack of provider knowledge (under-emphasis of positive screen actionability) or family socioeconomic barriers (Shulman et al 2010; Cree et al 2022), (3) states may have otherwise adequate diagnostic capacity but are overwhelmed by a high volume of false-positive screens due to poor screening specificity (Clemens & Davis 2001; Mackey et al 2022), or (4) diagnostic testing completion rates may be higher than documented due to underreporting of completed diagnostic test results to state EHDI programs (Shulman et al 2010 acknowledges information gaps and found hearing results missing in records). The authors intend to explore these potential contributors to low diagnostic testing rates further in subsequent studies.…”

Neonatal hearing screening - does failure in TEOAE screening matter when the AABR test is passed?

“…Currently, two methods are internationally recommended as screening technologies: detection of transient evoked otoacoustic emissions (TEOAE) which record the response of the cochlear outer hair cells to a click or tone-burst stimulus, and automatic auditory brainstem response (AABR) detection which records neurophysiological responses from the brainstem to acoustic stimuli and, therefore, reflects the function of the cochlea, auditory nerve and brainstem. Both methods have high sensitivity and specificity, provided that ideal conditions for measurement such as experienced screening staff and a quiet setting are available [ 2 ].…”

“…Although AABR screening is associated with a lower referral rate than TEOAE screening [ 2 , 3 ], neonates without an increased risk of hearing loss are often initially screened with TEOAE owing to the simplicity and rapidness of measurement compared to AABR. AABR screening is recommended for newborns with an increased risk of hearing impairment, [ 4 , 5 ].…”