Background:

Identification of permanent hearing impairment at the earliest possible age is crucial to maximise the development of speech and language. Universal newborn hearing screening identifies the majority of the 1 in 1000 children born with a hearing impairment, but later onset can occur at any time and there is no optimum time for further screening. A universal but non-standardised school entry screening (SES) programme is in place in many parts of the UK but its value is questioned.

Objectives:

To evaluate the diagnostic accuracy of hearing screening tests and the cost-effectiveness of the SES programme in the UK.

Design:

Systematic review, case–control diagnostic accuracy study, comparison of routinely collected data for services with and without a SES programme, parental questionnaires, observation of practical implementation and cost-effectiveness modelling.

Setting:

Second- and third-tier audiology services; community.

Participants:

Children aged 4–6 years and their parents.

Main outcome measures:

Diagnostic accuracy of two hearing screening devices, referral rate and source, yield, age at referral and cost per quality-adjusted life-year.

Results:

The review of diagnostic accuracy studies concluded that research to date demonstrates marked variability in the design, methodological quality and results. The pure-tone screen (PTS) (Amplivox, Eynsham, UK) and HearCheck (HC) screener (Siemens, Frimley, UK) devices had high sensitivity (PTS ≥ 89%, HC ≥ 83%) and specificity (PTS ≥ 78%, HC ≥ 83%) for identifying hearing impairment. The rate of referral for hearing problems was 36% lower with SES (Nottingham) relative to no SES (Cambridge) [rate ratio 0.64, 95% confidence interval (CI) 0.59 to 0.69; p < 0.001]. The yield of confirmed cases did not differ between areas with and without SES (rate ratio 0.82, 95% CI 0.63 to 1.06; p = 0.12). The mean age of referral did not differ between areas with and without SES for all referrals but children with confirmed hearing impairment were older at referral in the site with SES (mean age difference 0.47 years, 95% CI 0.24 to 0.70 years; p < 0.001). Parental responses revealed that the consequences to the family of the referral process are minor. A SES programme is unlikely to be cost-effective and, using base-case assumptions, is dominated by a no screening strategy. A SES programme could be cost-effective if there are fewer referrals associated with SES programmes or if referrals occur more quickly with SES programmes.

Conclusions:

A SES programme using the PTS or HC screener is unlikely to be effective in increasing the identified number of cases with hearing impairment and lowering the average age at identification and is therefore unlikely to represent good value for money. This finding is, however, critically dependent on the results of the observational study comparing Nottingham and Cambridge, which has limitations. The following are suggested: systematic reviews of the accuracy of devices used to measure hearing at school entry; characterisation and measurement of the cost-effectiveness of different approaches to the ad-hoc referral system; examination of programme specificity as opposed to test specificity; further observational comparative studies of different programmes; and opportunistic trials of withdrawal of SES programmes.

Trial registration:

Current Controlled Trials ISRCTN61668996.

Funding:

This project was funded by the NIHR Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 20, No. 36. See the NIHR Journals Library website for further project information.

Article history

The research reported in this issue of the journal was funded by the HTA programme as project number 10/63/03. The contractual start date was in August 2012. The draft report began editorial review in March 2015 and was accepted for publication in November 2015. The authors have been wholly responsible for all data collection, analysis and interpretation, and for writing up their work. The HTA editors and publisher have tried to ensure the accuracy of the authors’ report and would like to thank the reviewers for their constructive comments on the draft document. However, they do not accept liability for damages or losses arising from material published in this report.

Declared competing interests of authors

Dr Fortnum and Professor Taylor were co-authors on the previous Health Technology Assessment (HTA) publication reporting evaluation of the school entry hearing screen [Bamford J, Fortnum H, Bristow K, Smith J, Vamvakas G, Davies L, et al. Current practice, accuracy, effectiveness and cost-effectiveness of the school entry hearing screen. Health Technol Assess 2007;11(32)]. Professor Taylor is chairperson of the National Institute for Health Research (NIHR) Health Services and Delivery Research researcher-led panel, March 2014–February 2016 (appointment extended to February 2018), and a member from 2013. He is also a member of NIHR Priority Research Advisory Methodology Group (PRAMG), August 2015–present, is a core member of NIHR HTA Themed Call Board, 2012–present and is a member of the core group of methodological experts for the NIHR Programme Grants for Applied Research programme, 2013–present.