PU685 Unit 7 Child Health Program Analysis Example

Ninety-Eight Percent Screened, Sixty-One Percent Reached in Time: A Unit 7 Child Health Program Analysis Judging a Composite State's Newborn Hearing Program by the Outcome It Exists to Change

[Student Name]

Purdue University Global

PU685: Issues and Concepts in Maternal and Child Health

Unit 7 Child Health Program Analysis

[Instructor Name]

[Date]

The state, its program and its counts are composite; the benchmarks, the language evidence and the research cited are real.

What the Program Is For

Permanent hearing loss present at birth affects one to three infants per thousand. Without amplification and language support, a child who cannot hear speech misses the period when language is most easily learned. The program exists to change one thing: whether children with hearing loss enter school with language near their peers'. The evidence that timing matters is strong. Children whose hearing loss was identified by six months of age showed significantly better language scores than those identified later, across communication modes, degrees of loss and socioeconomic groups (Yoshinaga-Itano et al., 1998). The national benchmarks follow from that finding: screening by one month, diagnostic audiology by three months and enrollment in early intervention by six months (Joint Committee on Infant Hearing, 2007).

The Cascade

1. Births: 71,800.

2. Screened by one month: 70,795, or 98.6 percent.

3. Did not pass: 1,420. Of these, 1,008, or 71.0 percent, had a documented diagnostic audiology evaluation by three months. That leaves 412 infants with no diagnosis on record at three months.

4. Confirmed permanent hearing loss: 122 infants. Of these, 74, or 60.7 percent, were enrolled in early intervention by six months.

The program's annual report leads with 98.6. The number that measures its purpose is 60.7, and it appears on page eleven.

Reading the Cascade Backward

The final step loses 48 of 122 confirmed infants, about four in ten, before six months. Some enroll later, some never, and the program cannot say which without linking its records to the state's Part C early intervention data. That gap in data is itself a finding: a program cannot manage what it does not follow. The middle step is where most infants leave the pathway. Four hundred and twelve infants who did not pass had no diagnostic evaluation on record by three months. The analysis distinguishes two different problems here. Some of those infants were evaluated but the result was never reported to the program, a documentation failure fixed by audiologists reporting. Others were never evaluated, a true loss to follow-up fixed by families getting to appointments. An audit of 60 of the 412 records found 23 with an evaluation done but not reported and 37 with none. If that split holds, about four in ten of the apparent losses are paperwork, and six in ten are children.

The first step is genuinely strong. Hospital-based screening reaches nearly every newborn, and the program should keep doing what works there.

The Logic Model

Inputs: hospital screening equipment and staff, a state program coordinator, two pediatric audiology centers, Part C early intervention, and a tracking database. Activities: screening before discharge, outpatient rescreening, referral and scheduling for diagnostic audiology, family notification, referral to early intervention. Outputs: infants screened, rescreened, evaluated and enrolled, each by the benchmark age. Short-term outcomes: amplification or other support begun by six months. Long-term outcome: language at school entry within the range expected for age. The model shows that every output the program currently reports sits at the left end. None of its reports measures the long-term outcome.

Who Falls Out

The 412 infants were not a random group. In the program's records they were more likely to have mothers with Medicaid coverage, to live more than an hour from either audiology center and to have a home language other than English. That pattern is consistent with a multistate study of children who are hard of hearing, in which higher maternal education was associated with earlier confirmation and fitting of hearing aids, and only about one third of children met every benchmark on time (Holte et al., 2012).

Recommendations

1. Report the cascade, not the screening rate, as the program's headline measure, with the six-month figure first.

2. Require audiologists to report every diagnostic result within seven days, and follow up unreported cases by phone before classifying them as lost.

3. Fund a family navigator for infants who do not pass, who schedules the diagnostic visit before hospital discharge and calls the family twice before the appointment.

4. Add tele-audiology or a rotating clinic in the region more than an hour from the centers.

5. Link program records with Part C enrollment data to measure the final step completely.

6. Within five years, link to kindergarten language screening to measure the outcome the program exists for.

Why the Middle Step Deserves the First Dollar

The cascade could be improved at any step, but the arithmetic favors the middle. Raising screening from 98.6 to 99 percent would add fewer than 300 screened infants, of whom perhaps one or two would have hearing loss. Getting the 37 in every 60 unevaluated infants to a diagnostic visit, scaled to the full 412, would bring roughly 250 more infants to diagnosis each year, and at the confirmation rate seen among evaluated infants, about 12 percent, some thirty of them would have permanent hearing loss that is currently found late or not at all. A navigator costs roughly the salary of one full-time community health worker, and thirty children reaching amplification months earlier is the program's whole purpose expressed in a single year. The documentation fix costs even less. Requiring audiologists to report within a week, and calling the 23 in 60 whose evaluations were done but never reported, would correct the program's own picture of itself at almost no cost. Until that is done, the program cannot know whether its loss to follow-up is a problem of families or of forms.

How Next Year's Report Should Read

The annual report should open with one sentence: of the infants confirmed with permanent hearing loss this year, this share began early intervention by six months. Beneath it should sit the four-step cascade with the number lost at each step, the split between missing records and missing children, and the same figures for families on Medicaid, families living more than an hour from audiology and families whose home language is not English. Screening coverage belongs in the cascade, not in the headline. A report built this way will look worse than the current one in its first year. It will also be the first report that tells the program where to act.

Limits

The audit sample was small. Benchmark ages measure timeliness, not quality of intervention. And language at school entry depends on many things beyond the program, so linking to it will measure the system as a whole, which is still the right thing to measure.

References

Holte, L., Walker, E., Oleson, J., Spratford, M., Moeller, M. P., Roush, P., Ou, H., & Tomblin, J. B. (2012). Factors influencing follow-up to newborn hearing screening for infants who are hard of hearing. American Journal of Audiology, 21(2), 163-174. https://doi.org/10.1044/1059-0889(2012/12-0016)

Joint Committee on Infant Hearing. (2007). Year 2007 position statement: Principles and guidelines for early hearing detection and intervention programs. Pediatrics, 120(4), 898-921. https://doi.org/10.1542/peds.2007-2333

Yoshinaga-Itano, C., Sedey, A. L., Coulter, D. K., & Mehl, A. L. (1998). Language of early- and later-identified children with hearing loss. Pediatrics, 102(5), 1161-1171. https://doi.org/10.1542/peds.102.5.1161