A Comprehensive Analysis of an EHDI Program: A Retrospective Study

Vickie Thomson, MA

EHDI Program Manager

Colorado Department of Public Health and Environment

Acknowledgements The Colorado Infant Hearing Program would

like to express its gratitude to the Center’s for Disease Control and Prevention for entering into a cooperative agreement to build and maintain a surveillance infrastructure (RFA 05028).

Vickie would like to thank Mathew Christensen, PhD, Stat Analyst and Bill Letson, MD for their vision, support and assistance with this analysis

The Role of Public Health in EHDI Programs Public Health criteria for population

based screening Easy Not detected by other means Interventions available Results in improved outcomes Acceptable cost

10 Essential Public Health Services

Program Evaluation for CDC’s Operating Principles

Using science as a basis for decision-making and action;

Expanding the quest for social equity; Performing effectively as a service

agency; Making efforts outcome-oriented; and Being accountable

Research or Evaluation? State hypothesis Collect data Analyze data Draw conclusions

Engage stakeholders Describe the

program Focus the evaluation Gather credible

evidence Justify conclusions Ensure use and

share lessons learned

Framework for Program Evaluation

Analyzing an EHDI Program

Advisory Committee Improve follow-up Factors associated with missing the

screen, rescreen, & late diagnosis Data integration, hospital surveys Conclusions Plan and implement programmatic

changes for improvement

The Colorado EHDI Follow-up Program:A Historical Perspective

0

10

20

30

40

50

60

70

80

90

1992-96

1999 2000 2001 2002 2003 2004

F/U

Factors that Influenced Improved Follow-up Rates

Pressure from the Pediatric Chapter Champion - Al Mehl, MD

Integration with the EBC Track from screening to diagnosis to early intervention Send accurate MONTHLY reports to hospital

coordinators Letter campaign to parents from missed, failed

screens (EBC provides demographic information)

Colorado Infant Hearing Program

Factors that Affect Screening and Follow-up Rates

Factors Initially Tested Mother’s age Mother’s education Mother’s weight gain Martial status Gestational age Mother Smoke Infant gender Race/ethnicity Hospital Year of birth Birth weight APGAR Scores Urban, rural, frontier populations

Population Results from Hospital Screen

Births 2001-2004 204,694 Screened 200,666 (98 %) Failed 8,124 (4%) Rescreened 6,686 (82%)

Explaining Initial Screening Rates

2002-2004 Screened Not Screened

Total Hospital Births

Hospitals > 98% (N=31)

Birth weight >2500 gms

>7 on APGAR5

195,208

132,741 (68%)

177,639 (91%)

193,255 (99%)

3,712

1,373 (37%)

2,301 (62%)

2,969 (80%)

<2500 Grams &

<7 on APGAR5

529 (.26%) 692 (17%)

USPSTF and NICU Screening “The USPSTF found good evidence that

the prevalence of hearing loss in infants in the newborn intensive care unit and those with other specific risk factors is 10-20 times higher than the prevalence of hearing loss in the general population of newborns. Both the yield of screening and the proportion of true positive results will be substantially higher when screening is targeted at these high-risk infants…”

Conclusions Lack of reporting results Early discharge Significant health problems Out of state residents (7%) Deceased

Recommendations Presentations and education to

neonatologists Enhanced tracking for transfers Enhanced protocols for NICU’s Letters to the medical

home/PCP

Explaining Current Follow-up Rates with Birth Certificate Data

2002-2004 Screened Not Screened

Total 8,124 6,686 (82%) 1,438 (18%)

Mom Educ 13+

Latino

39%

42%

27%

45%

Age at Birth 25+ 60% 50%

Smoked 9% 13%

Hospital >82% (N=28) 54% 29%

Rescreen Percents by Race, Education, and Hospital Program

2001310

328

1471

1243

1122

1012

1114

50

55

60

65

70

75

80

85

90

95

<82% & HS <82% & >HS >82% & HS >82% & >HS

Latino

Non Latino

Percent Rescreened by Race/Ethnicity and Hospital Grouping

Hospital Survey Data1. What is the highest level of care is offered in your hospital?

2. Is an audiologist involved with your hospitals screening program?

3. Level of audiology involvement

4. Who provides the screening?

5. Type of Screening equipment used:

6. Does your hospital provide the outpatient rescreen?

7. For infants that do not pass the initial hearing screen, does your program set up an appointment for a follow-up rescreen prior to discharge?

8. Is there a charge assessed for outpatient rescreening?

2005 Stats Births = 69,487 Screened = 67,451 (97%) Not Passed = 3,154 (4.7%) Rescreened = 2,629 (83.4%) Confirmed Hearing Loss = 128

Demographic for Follow-up Screens

Not Passed = 3,154 (4.7%)

11 Hospitals = 100% Birth Range = 2,4048 - 24

11 Hospitals < 70% Birth Range = 2,729 - 134

Variables Technology

AABR = 60% OAE = 12% AABR/OAE = 30%

Who Screens? Nurses, Medical Assistants, Techs = 58% Volunteers = 30% Audiologists = .5% Contract = 12%

Audiologist Involvement 50% report they have audiology

involvement Consultant to screening 71% of the infants who failed were

born in hospitals affiliated with an audiologist

Follow-up Appointment

Does your Program set up an appointment for infants who fail?

Yes before discharge = 42% No, after discharge = 14% Parents responsibility = 43% Which infants are more likely to

receive the follow-up?

Follow-up ProtocolDoes your hospital provide the outpatient

rescreen? Return to the nursery = 52% Return to audiology in the same hospital =

48% Return to audiology different campus = 2% Do not return to hospital =1% Will the protocol affect the return percent? Charge? 50% yes, 50% no

Failed Screens and Diagnostic Follow-up

What factors are associated with an infant who fails newborn hearing screening and rescreen yet not confirmed with hearing loss by three months of age?

Variables for Analysis Co morbidities – link to birth defects registry Hospital factors Race Ethnicity Gender Mother’s age Mother’s education Mother’s marital status

The Role of Public HealthResearch Based Plans

Identify the gaps and educate the “medical homes” on the importance of follow-up for the NICU and Latino infants

Develop strategies to assist hospitals with protocols to capture these populations

Work with communities to ensure a seamless transition from screening into appropriate diagnostics

The Role of the Medical Home

Included in the hospital recommended protocol and informed of the steps

Informed regarding every outcome from screening, diagnostics, and EI

The Role of our Federal Partners

Continuing to ‘raise the bar’ for EHDI programs

Encourage data integration with newborn screening and immunization

Support the concept of the child health profile to ensure the Medical Home/PCP are informed of outcomes

Outcomes: Happy, Healthy Families

Comprehensive Culturally

Competent Seamless Knowledgeable

Providers Parent to Parent

Support