Primary care hearing screening is of limited utility

Halloran DR, Hardin JM, Wall TC. Validity of pure-tone hearing screening at well-child visits. Arch Pediatr Adolesc Med 2009;163:158-63.

Question 

Among children, how sensitive and specific is pure-tone audiometry hearing screening in the primary care setting?

Design 

Prospective cohort study.

Setting 

Eight academic and private pediatric practices in Alabama.

Participants 

A subset of children from a convenience sample of 1061 children between 3 and 19 years of age were screened for hearing loss using pure-tone audiometry.

Intervention 

Formal audiologic evaluations (gold standard) for those children referred by their primary care physician (28 children) and for a random sample of children not referred (102 children).

Outcomes 

Audiologic evaluations.

Main Results 

A total of 28 children were referred to an audiologist for formal hearing testing after pure-tone audiometry screening during a well-child visit, at which 25 children did not pass the initial screening and 3 could not complete the screening. Of the 25 children, only 7 were evaluated by an audiologist, for a follow-up rate of 25%. One child was diagnosed as having hearing loss. Formal audiologic assessment was also performed on a random sample of 102 children who were not referred to the audiologist. For the random sample, hearing loss was identified in 2 of 76 (3%) children who passed and 1 of 16 (6%) children who did not pass pure tone audiometry screening. The sensitivity and specificity of pure-tone audiometry were 50% and 78%, respectively (positive likelihood ratio (LR) = 1.8, negative LR = 0.64).

Conclusions 

In light of the increasing burden on physicians to provide preventive care, this study calls into question the value of hearing screening using pure-tone audiometry during well-child visits given the poor test characteristics and lack of follow-up after referral.

Commentary 

Pure-tone audiometry screening is one of the many components of usual well-child care for which there is little underlying scientific evidence. This study finds that many children do not follow-up with an audiologist after an abnormal hearing screen and that the accuracy of audiometry compared with a formal audiologic evaluation is poor. The story may be even worse if the actual diagnoses, which were not presented in this report, were considered. For example, some of these children may have had serous otitis media, which would likely simply resolve over time. This study raises important healthcare delivery questions. For example, many states require repeated hearing screens as part of well-child care for Medicaid-enrolled children. This report suggests that such policies may be a significant waste of limited healthcare resources. It should be noted that in contrast to pure-tone audiometry, newborn hearing screening has led to dramatic improvements in the diagnosis of significant hearing loss. Unfortunately, there have also been barriers to the timely follow-up after an abnormal newborn hearing screen.