title: Using benefit-cost ratio to select Universal Newborn Hearing Screening test criteria.
abstract: OBJECTIVE
  Current protocols presumably use criteria that are chosen on the basis of the sensitivity and specificity rates they produce. Such an approach emphasizes test performance but does not include societal implications of the benefit of early identification. The purpose of the present analysis was to evaluate an approach to selecting criteria for use in Universal Newborn Hearing Screening (UNHS) programs that uses benefit-cost ratio (BCR) to demonstrate an alternative method to audiologists, administrators, and others involved in UNHS protocol decisions.
  
  
  METHODS
  Existing data from more than 1200 ears were used to analyze BCR as a function of Distortion Product Otoacoustic Emission (DPOAE) level. These data were selected because both audiometric and DPOAE data were available on every ear. Although these data were not obtained in newborns, this compromise was necessary because audiometric outcomes (especially in infants with congenital hearing loss) in neonates are either lacking or limited in number. As such, it is important to note that the characteristics of responses from the group of subjects that formed the bases of the present analyses are different from those for neonates. This limits the extent to which actual criterion levels can be selected but should not affect the general approach of using BCR as a framework for considering UNHS criteria. Estimates of the prevalence of congenital hearing loss identified through UNHS in 37 states and U.S. territories in 2004 were used to calculate BCR. A range of estimates for the lifetime monetary benefits and yearly costs for UNHS were used, based on data available in the literature. Still, exact benefits and costs are difficult to know. Both one-step (DPOAE alone) and two-step (DPOAE followed by automated auditory brainstem response, AABR) screening paradigms were considered in the calculation of BCR. The influence of middle ear effusion was simulated by incorporating a range of expected DPOAE level reductions into an additional BCR analyses
  
  
  RESULTS
  Our calculations indicate that for a range of proposed benefit and cost estimates, the monetary benefits of both one-step (DPOAE alone) and two-step (DPOAE followed by AABR) NHS programs outweigh programmatic costs. Our calculations indicate that BCR is robust in that it can be applied regardless of the values that are assigned to benefit and cost. Maximum BCR was identified and remained stable regardless of these values; however, it was recognized that the use of maximum BCR could result in reduced test sensitivity and may not be optimal for use in UNHS programs. The inclusion of secondary AABR screening increases BCR but does not alter the DPOAE criterion level at which maximum BCR occurs. The model of middle ear effusion reduces overall DPOAE level, subsequently lowering the DPOAE criterion level at which maximum BCR was obtained
  
  
  CONCLUSIONS
  BCR is one of several alternative methods for choosing UNHS criteria, in which the evaluation of costs and benefits allows clinical and societal considerations to be incorporated into the pass/refer decision in a meaningful way. Although some of the benefits of early identification of hearing impairment cannot be estimated through a monetary analysis, such as improved psychosocial development and quality of life, this article provides an alternative to audiologists and administrators for selecting UNHS protocols that includes consideration of societal implications of UNHS screening criteria. BCR suggests that UNHS is a worthwhile investment for society as benefits always outweigh costs, at least for the estimations included in this article. Although the use of screening criteria that maximize BCR results in lower test sensitivity compared with other criteria, BCR may be used to select criteria that result in increased test sensitivity and still provide a high, although not maximal, BCR. Using BCR analysis provides a framework in which the societal implications of NHS protocols are considered and emphasizes the value of UNHS.
authors.affiliation: Boys Town National Research Hospital, Omaha, Nebraska, USA. heather.l.porter@vanderbilt.edu
authors.forename: Heather L
authors.initials: HL
authors.lastname: Porter
authors.forename: Stephen T
authors.initials: ST
authors.lastname: Neely
authors.forename: Michael P
authors.initials: MP
authors.lastname: Gorga
mesh_terms: D002657:Child Development; D017281:Cost of Illness; D003362:Cost-Benefit Analysis; D006319:Hearing Loss, Sensorineural / Q000151:congenital / Q000175:diagnosis* / Q000453:epidemiology; D006320:Hearing Tests / Q000191:economics* / Q000379:methods*; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D015997:Neonatal Screening / Q000191:economics* / Q000379:methods*; D010033:Otitis Media / Q000175:diagnosis / Q000453:epidemiology; D017084:Otoacoustic Emissions, Spontaneous; D015995:Prevalence; D012680:Sensitivity and Specificity; D014481:United States / Q000453:epidemiology