Continuity of Health Insurance Coverage for Children with Special Health Care Needs

Rurality and determinants of hearing healthcare in adult hearing aid recipients

OBJECTIVE

The objective of this study was to compare the timing of hearing aid (HA) acquisition between adults in rural and urban communities. We hypothesized that time of acquisition of HA after onset of hearing loss is greater in rural adults compared with urban adults. Secondary objectives included assessment of socioeconomic/educational status and impact of hearing loss and hearing rehabilitation of urban and rural HA recipients.

STUDY DESIGN

Cross-sectional questionnaire survey.

METHODS

We assessed demographics, timing of HA fitting from onset of hearing loss, and impact of hearing impairment in 336 adult HA recipients (273 urban, 63 rural) from a tertiary referral center. Amplification benefit was assessed using the International Outcome Inventory for Hearing Aids (IOI).

RESULTS

The time to HA acquisition was greater for rural participants compared to urban participants (19.1 vs. 25.7 years, P = 0.024) for those with untreated hearing loss for at least 8 years. Age at hearing loss onset was correlated with time to HA acquisition (P = -0.54, P < 0.001). Rural HA participants experienced longer commutes to hearing specialists (68 vs. 32 minutes, P < 0.001), were less likely to achieve a degree beyond high school (P < 0.001), and were more likely to possess Medicaid coverage (P = 0.012) compared to urban participants. Hearing impairment caused job performance difficulty in 60% of all participants.

CONCLUSION

Rural adults are at risk for delayed HA acquisition, which may be related to distance to hearing specialists. Further research is indicated to investigate barriers to care and expand access for vulnerable populations.

LEVEL OF EVIDENCE

4. Laryngoscope, 127:2362-2367, 2017.

The Role of Telemedicine in Auditory Rehabilitation: A Systematic Review

OBJECTIVE

The purpose of this study was to assess the feasibility and effectiveness of live telemedicine applications in hearing amplification and cochlear implantation.

DATA SOURCES AND STUDY SELECTION

A systematic search was performed in PubMed, MEDLINE, PsychINFO, CINALH, and Web of Science to identify peer-reviewed research. Inclusion criteria were titles containing words from the search terms 1) audiology, otolaryngology, and hearing impairment, 2) rehabilitative methods, and 3) telemedicine. Exclusion criteria were: 1) non-English articles, and 2) non-original research.

DATA EXTRACTION AND SYNTHESIS

Twelve eligible studies were identified. The studies employed a prospective design in nine of the articles and retrospective case series in three. The use of telemedicine for the provision of cochlear implant services was examined in eight of the articles and with hearing aids in four of the articles. The types of services include intraoperative cochlear implant telemetry; implant programming and assessment of electrode-specific measures and speech recognition after implantation. Hearing aid programming and remote gain assessments were also reported. Many studies assess patient and provider satisfaction along with encounter time comparison. The studies occurred from 2009 to 2014 and took place in seven countries.

CONCLUSIONS

This review examined the feasibility of remote telemedicine connection to provide in auditory rehabilitation services through hearing aids and cochlear implants. There are significant concerns regarding Internet bandwidth limitations for remote clinics. There is a paucity of research examining reimbursement and cost-effectiveness for services. Further prospective research investigating cost-effectiveness and bandwidth limitations is warranted to assess long-term sustainability of remote audiological rehabilitative service delivery.

Timing discrepancies of early intervention hearing services in urban and rural cochlear implant recipients

OBJECTIVE

The purpose of this study was to examine the timing of early intervention diagnostic and therapeutic services in cochlear implant recipients from rural and urban areas.

STUDY DESIGN

Retrospective case series review.

SETTING

Tertiary referral center.

PATIENTS

Cochlear implant recipients from a single comprehensive hearing institute born with severe congenital sensorineural hearing loss were examined. Timing of diagnostic and therapeutic services was examined.

INTERVENTION(S)

Diagnosis, amplification, and eventual cochlear implantation for all patients in the study.

MAIN OUTCOME MEASURE(S)

Time points of definitive diagnosis, amplification, and cochlear implantation for children from urban and rural regions were examined. Correlation analysis of distance to testing center and timing of services was also assessed.

RESULTS

Forty children born with congenital hearing loss were included in the study and were diagnosed at a median age of 13 weeks after birth. Children from rural regions obtained amplification at a median age of 47.7 weeks after birth, whereas urban children were amplified at 26 weeks after birth. Cochlear implantation was performed at a median age of 182 weeks after birth in those from rural areas and at 104 weeks after birth in urban-dwelling patients. A linear relationship was identified between distance to the implant center and timing of hearing aid amplification (r = 0.5, p = 0.033) and cochlear implantation (r = 0.5, p = 0.016).

CONCLUSION

Children residing outside of metro areas may be at higher risk of delayed rehabilitative services and cochlear implantation than those residing in urban areas that may be closer to tertiary care centers.

Assessment of Appalachian region pediatric hearing healthcare disparities and delays

OBJECTIVES/HYPOTHESIS

The purpose of this study was to examine the timing of diagnostic and therapeutic services in cochlear implant recipients from a rural Appalachian region with healthcare disparity.

STUDY DESIGN

Retrospective analysis.

METHODS

Cochlear implant recipients from a tertiary referral center born with severe congenital sensorineural hearing loss were examined. Rural status and Appalachian status of their county of origin were recorded. A log-rank test was used to examine differences in the distributions of time to definitive diagnosis of hearing loss, initial amplification fitting, and cochlear implantation in these children. Correlation analysis of the rural status of each county and the timing of services was assessed.

RESULTS

A total of 53 children born with congenital hearing loss were included in the study (36 from rural counties and 17 from urban/suburban counties). The distribution of weeks after birth to diagnosis (P=.006), amplification (P=.030), and cochlear implantation (P=.002) was delayed in rural children compared with urban children. An analysis factoring in the effect of implementation of mandatory infant hearing screening in 2000 demonstrated a similar delay in rural children for weeks to diagnosis (P=.028), amplification (P=.087), and cochlear implantation (P<.0001).

CONCLUSIONS

Children with severe hearing loss in very rural areas, such as Appalachia, may have significant delays in diagnostic and rehabilitative services. Further investigation is warranted to assess causative factors in delays of cochlear implantation and to develop interventions to promote timely diagnosis and care.

LEVEL OF EVIDENCE

3b.

Delays in diagnosis of congenital hearing loss in rural children

OBJECTIVE

To examine the incidence of pediatric congenital hearing loss and the timing of diagnosis in a rural region of hearing healthcare disparity.

STUDY DESIGN

Data from the Kentucky newborn hearing-screening program was accessed to determine the incidence of congenital hearing loss in Kentucky, both in the extremely rural region of Appalachia and non-Appalachian region of Kentucky. We also performed a retrospective review of records of children with congenital hearing loss at our institution to determine the timing of diagnostic testing.

RESULTS

In Kentucky, during 2009-2011, there were 6970 newborns who failed hearing screening; the incidence of newborn hearing loss was 1.71 per 1000 births (1.28/1000 in Appalachia and 1.87/1000 in non-Appalachia); 23.8% of Appalachian newborns compared with 17.3% of non-Appalachian children failed to obtain follow-up diagnostic testing. Children from Appalachia were significantly delayed in obtaining a final diagnosis of hearing loss compared with children from non-Appalachian regions (P = .04).

CONCLUSION

Congenital hearing loss in children from rural regions with hearing healthcare disparities is a common problem, and these children are at risk for a delay in the timing of diagnosis, which has the potential to limit language and social development. It is important to further assess the causative factors and develop interventions that can address this hearing healthcare disparity issue.

A Review of Diabetes Mellitus–Specific Family Assessment Instruments

Family dynamics and attributes are increasingly recognized as affecting management of diabetes mellitus (DM); however, little research has been done on the validity and usefulness of family assessment instruments (FAIs). This article reviewed the literature that employs DM-specific FAIs and evaluates whether the instruments comprehensively captured family attributes/processes and were robust enough to be useful in understanding the relationship between family attributes/issues and DM-related health care. Studies using eight instruments were identified through a search of literature published from 1982 to 2010 and were analyzed with criteria derived from the measurement and family literatures. The findings of this study revealed that DM-specific FAIs yield useful data about family-related phenomenon; however, some domains of DM-specific care, such as family dynamics/functioning, were not overtly measured. Suggestions for improving DM-specific FAIs are provided and a rationale for why DM-specific and non-DM-specific FAIs is needed to fully measure family issues related to family dynamics/attributes on DM patient care.

The impact of the public insurance expansions on children's use of preventive dental care

To determine if children eligible for coverage by the State Children's Health Insurance Program (SCHIP) and Medicaid Programs were more likely to receive preventive dental visits after implementation of the SCHIP policy, retrospective cross-sectional analysis was done from the 1996-2000 Medical Expenditure Panel Surveys (MEPS) data. We linked the individual level data from the MEPS to state-level information on program eligibility. Using logistic regression models that adjust for the complex survey design, the association between SCHIP implementation and receipt of preventive dental care was examined for children aged 3-18 with family incomes < or =200% of the Federal Poverty Line (FPL). Children who were eligible for SCHIP/Medicaid coverage in their respective states were more likely to have received preventive care three years after SCHIP implementation than children with similar eligibility profiles prior to SCHIP implementation. SCHIP has successfully increased the proportion of eligible children receiving preventive dental care among children in families with incomes less than or equal to 200% FPL. Our findings indicate, however, that SCHIP needed time to mature before detecting significant effects on national level.

The impact of health insurance gaps on access to care among children with asthma in the United States

BACKGROUND

Health insurance coverage is important to help assure children appropriate access to medical care and preventive services. Insurance gaps could be particularly problematic for children with asthma, since appropriate preventive care for these children depends on frequent, consistent contacts with health care providers.

OBJECTIVE

The aim of this study was to determine the association between insurance gaps and access to care among a nationally representative sample of children with asthma.

METHODS

The National Survey of Children's Health provided parent-report data for 8097 children with asthma. We identified children with continuous public or continuous private insurance and defined 3 groups with gaps in insurance coverage: those currently insured who had a lapse in coverage during the prior 12 months (gained insurance), those currently uninsured who had been insured at some time during the prior 12 months (lost insurance), and those with no health insurance at all during the prior 12 months (full-year uninsured).

RESULTS

Thirteen percent of children had coverage gaps (7% gained insurance, 4% lost insurance, and 2% were full-year uninsured). Many children with gaps in coverage had unmet needs for care (7.4%, 12.8%, and 15.1% among the gained insurance, lost insurance, and full-year uninsured groups, respectively). In multivariate models, we found significant associations between insurance gaps and every indicator of poor access to care among this population.

CONCLUSIONS

Many children with asthma have unmet health care needs and poor access to consistent primary care, and lack of continuous health insurance coverage may play an important role. Efforts are needed to ensure uninterrupted coverage for these children.

Evaluating loss to follow-up in newborn hearing screening in Massachusetts

OBJECTIVE

The purpose of this work was to examine loss to follow-up on the use of diagnostic or intervention services for Massachusetts infants and children screened or diagnosed with hearing loss and risk factors for becoming lost to follow-up.

METHODS

We used data from the Massachusetts Childhood Hearing Data System and Early Intervention Information System. We calculated the percent use of audiologic evaluation for Massachusetts infants born in 2002-2003 who did not pass hearing screening and Early Intervention services for those with hearing loss. We generated crude and adjusted relative risks, as well as confidence intervals, to estimate associations of maternal and infant factors with the use of audiologic evaluation and early intervention services. Factors evaluated included child's birth weight and hearing screening or diagnostic results and maternal age, race or ethnicity, marital status, smoking status during pregnancy, educational attainment, health insurance, and residence region.

RESULTS

In 2002-2003, 11% of Massachusetts children who did not pass hearing screening became lost to follow-up on the audiologic evaluation, and 25% of those with hearing loss did not receive early intervention services. Children were at higher risk of becoming lost to follow-up on audiologic evaluation if their mothers were nonwhite, covered by public insurance, smokers during pregnancy, or residing in western, northeastern, or southeastern Massachusetts compared with those in the Boston region. Of children with hearing loss, those with a unilateral or mild or moderate degree of hearing loss, normal birth weight, or living in the southeastern or Boston region were more likely to go without early intervention services.

CONCLUSIONS

Massachusetts has excellent follow-up rates overall. Our analyses allow the program to prioritize limited resources to subgroups of infants who are at high risk of becoming lost to follow-up.