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

Abstract

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.

Conflict of interest statement

The authors have declared that no competing interests exist.

Figures

Fig 1. Flowchart of screening outcomes, year 1 (2014–2015) and year 2 (2015–2016).

Children who ultimately passed their hearing screening are highlighted in green outcome boxes. Those diagnosed with sensorineural hearing loss are marked in orange boxes.

Fig 2. Outcome by age.

Percentage of children ATT and passed (Pass), ATT but referred (Refer), or UTT (Unable) are indicated. In Year 1, children aged 4. In Year 2, the difference in ability to test was eliminated. * p

Fig 3. Outcome by primary language.

Percentage of children grouped by primary language ATT and passed (Pass), ATT but referred (Refer), or UTT (Unable). In Year 1, primary non-English speakers were 2x more likely to pass than primary English-speakers, while all were equally likely to be ATT. This disparity resolved in Year 2. Improvements in UTT rates were seen in both English- and non-English-speaking groups from Year 1 to Year 2. ** p

Fig 4. Outcome by teacher concern.

Percentage of children grouped by teacher concern for speech, language, or hearing problems who were ATT and passed (Pass), ATT but referred (Refer), or UTT (Unable). Statistically significant differences between the Pass and UTT rates of children with concerns compared to those with no concerns were noted in Year 1 but not Year 2. Pass and UTT rates improved from Year 1 to Year 2 in children with concern and those with no concern.* p

Fig 5. "Not Pass" subsets.

All children referred in years 1 and 2 were categorized according to their hearing screening outcome, with those unable to be tested further divided by age and the presence of concern for delay.