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Acquisition of hearing aids and assistive listening devices among the pediatric hearing-impaired population
International Journal of Pediatric Otorhinolaryngology 52 (2000) 247 – 251 www.elsevier.com/locate/ijporl
Acquisition of hearing aids and assistive listening devices among the pediatric hearing-impaired population Fannie S. Leake *, Jerome W. Thompson, Erin Simms, James Bailey, Rose Mary S. Stocks, Anne M. Murphy Pediatric Otolaryngology, The Uni6ersity of Tennessee Memphis, 777 Washington A6enue Suite P110, Memphis, TN 38105, USA Received 13 March 1999; received in revised form 31 January 2000; accepted 2 February 2000
Abstract Sufficient access to health care is of concern to the indigent population in the US and to their health care providers. This study was undertaken to elucidate the rate of the follow-up among lower socioeconomic hearing-impaired pediatric patients who had received a recommendation for hearing aids and/or assistive listening devices. Our question was, would the families’ financial situation have a negative effect on the acquisition of hearing aids and assistive listening devices? Fifty patients, age 0–18 years, who had been seen in our clinic over 2 years were evaluated via a telephone survey. The survey consisted of seven questions, including whether or not the devices or aids were obtained, what type was purchased, where the device was being used, and the child’s apparent performance with the device. Eighty-two percent of our patients were on TennCare, a state mandated Medicaid HMO system. Two-thirds of these TennCare patients are at or below the poverty level and the remaining one-third is either disabled or uninsurable according to the Aid for Dependent Children (AFDC) with indeterminate income. In addition the TennCare organization did not cover hearing amplification equipment for these children. The study showed that the majority of the patients did follow-up as recommended. Furthermore, this equipment is easily obtainable for the pediatric indigent population due to financial resources available in the community outside the mandated Medicaid system. © 2000 Elsevier Science Ireland Ltd. All rights reserved. Keywords: Indigent; Non-indigent; Hearing aids
1. Introduction The only developing country without a healthcare policy is the US. What the US has is a limited national health insurance system [1]. Therefore, providing sufficient healthcare for the
* Corresponding author.
poor, especially poor children, in our society is an escalating problem. Access to financial resources for medical care is either not always available or easily available, even with the advent of policies such as neighborhood health centers and Medicaid [2]. For children who live in poverty, there are fewer physician contacts, and they are not as likely to receive routine preventive care when needed [3].
0165-5876/00/$ - see front matter © 2000 Elsevier Science Ireland Ltd. All rights reserved. PII: S 0 1 6 5 - 5 8 7 6 ( 0 0 ) 0 0 2 9 4 - 9
248
F.S. Leake et al. / Int. J. Pediatr. Otorhinolaryngol. 52 (2000) 247–251
To be classified as medically indigent (M.I.) in Tennessee the patient must be either uninsured or under-insured [4]. We found that the majority of the hearing-impaired children in our clinic met the criteria to be medically indigent. Our clinic is a private, non-profit facility, and is staffed by the University of Tennessee, Memphis Physicians. We see private, state insured, as well as uninsured patients. A large percentage of the hearing-impaired children in our clinic are TennCare recipients. TennCare is a state mandated and funded medical insurance. It was developed to control the rapid rising cost of the state’s already existing Medicaid program, and to extend health insurance coverage to most Tennesseans who did not have access to government or employer sponsored health insurance [5]. Although TennCare provides access to physician services, the insurance will not pay for hearing aids. Our goal is to refer indigent patients to attentive appropriate sources that will provide funding for these devices. This is frequently difficult and time consuming for both parents and medical staff, and places a burden on both. Therefore, the opportunity for the child to not get hearing aids is higher for this population. Due to the lack of research in this area, little is known about the acquisition and use of hearing aids for this population.
2. Objective The objective of this study was to determine if our indigent patients followed-up with their referrals to obtain and use hearing aids as recommended, or did their compromised financial situation have a negative impact.
3. Methods The primary objective of providing and/or obtaining hearing aids is to diminish the handicapping effect of hearing impairment. Assessing the benefits of hearing aids can be done in many different ways [6]. The study wanted to know if our patients received their hearing aids as recommended, and if so, were they benefiting from
them. The best and most expedient way to obtain this information was by administering a questionnaire through a telephone survey. Between August 1997 and July 1998 we conducted a telephone survey of fifty patients, ranging in age from 0–18 years. These patients were the first 50 patients that were diagnosed with hearing losses in our clinic from January 1995 through July 1997. The average age of the first time diagnosis was 2 years (Table 5). The degree of hearing loss for each patient can be found in Table 4. All of the hearing losses were sensorineural, with the exception of two who had mixed hearing losses. These patients were not only candidates for hearing aids due to the severity of their hearing loss, but also due to significant language delays and poor school performance. The questionnaire (Table 3) consisted of seven questions, including whether or not the hearing aids were received, what type of device was obtained, whether or not the devices were being used, and whether or not the patient’s performance in school, awareness of sound, speech and vocabulary improved, as reported by the parents. We also asked whether or not the patient was enrolled in a therapeutic program, i.e. auditory and speech training. The adult member of the household was questioned, as well as the referred clinical evaluator of each patient. The questionnaire was only administered during the day, and the average length of time was 15 min per call. We were successful in reaching most of our patients, and the clinical evaluator on the first initial contact. 4. Data analysis A statistical evaluation of the frequency of follow-up can be found in Table 1. Out of fifty patients, 41 (82%) followed-up with their referrals as recommended, four (8%) did not (for explanation, see Table 2). Five (10%) had unilateral hearing losses; therefore, no referrals were made for hearing aids at the time of diagnosis. Four (8%) of these patients with a unilateral hearing loss were indigent and one was classified as non-indigent. The average age of first time diagnosis was 6 years.
F.S. Leake et al. / Int. J. Pediatr. Otorhinolaryngol. 52 (2000) 247–251
The patients were counseled on the effects of unilateral hearing loss and how the problem should be managed. The following recommendations were made to the parent and teacher: (1) Front row seating; (2) Seating directly in front of the teacher; (3) Before giving oral instructions, obtain the student’s attention; (4) Speak clearly and concisely; (5) Give written instructions to Accompany oral instructions whenever possible; (6) Yearly hearing test in order to monitor the hearing in the good ear; (7) Notify all persons who come in contact with the child of the child’s hearing loss; and (8) If appropriate, use an FM system in the classroom and/or a CROS hearing aid if learning problems occur. According to Keller et al. [7] unilateral hearing loss can be a risk factor for the production of developmental problems.
5. Results Out of the 50 patients with hearing impairments contacted, 40 (80%) were medically indigent and 10 (20%) were non-indigent. Nine (18%) of the non-indigent patients received hearing aids, with the exception of one that had a unilateral hearing loss, and a hearing aid was not recommended at the time of diagnosis. Twenty-six (52%) of the medically indigent patients received Table 1 Percentage of patients who did/did not follow-up with their referrals as recommendeda Followed-up (%)
Did not follow-up (%)
No referral made (%)
41 (82)
4 (8)
5 (10)
32 (64) Indigent 9 (18) Non-indigent a
Number of patients: 50.
Table 2 Explanation of why referrals were not followed Unable to reach
4 (8%)
249
hearing aids. Of those who did not , four (8%) of the patients had unilateral hearing loss, we were unable to contact four patients (8%), one patient (2%) was having PE tube surgery, two (4%) were having an ABR test performed, two (4%) were currently in the process and one (2%) was waiting on a repeat audiogram. Our clinic made no recommendations for the type of hearing aid to be fitted. We left it up to the outside clinic evaluator. Thirty-four patients (68%) were fitted with behind-the-ear (BTE) hearing aids and one (2%) received a cochlear implant. It took on the average 1 month for the non-indigent patients to receive their hearing aids as compared to the indigent patients, where the average length of time that it took to receive hearing aids was 3 months. Thirty-one (62%) of the hearing-impaired patients were enrolled in an aural habilitation/rehabilitation program. Twenty-three (46%) were indigent and eight (16%) were non-indigent. Of the indigent patients who were not enrolled, one (2%) was mainstreamed, one (2%) refused to wear the hearing aids and one (2%) lost the hearing aids. For the non-indigent patient who was not enrolled therapy was not necessary. Of the indigent patients, 17 (34%) of them are presently wearing their hearing aids at home and/ or pre-school/school, five patients (10%) are only wearing the devices at school, two (2%) are only wearing them at home, one (2%) will not wear the hearing aid and one patient (2%) lost his/her hearing aid. All nine (18%) of the non-indigent patients, who received hearing aids, were either wearing their hearing aids at home and/or preschool/school. There were 20 (40%) school age children in the study. Out of 20 school age children, 15 (30%) were indigent and five (10%) were non-indigent. Eleven of the indigent patients (22%) showed improvement in their school work, three patients (6%) showed no improvement, and for one patient (2%) lost his/her hearing aid. Out of the five non-indigent school age children, one patient’s (2%) school work did improve, and for four patients (8%) no improvement was needed. Fifteen (30%) of the patients needed improvement in their speech, vocabulary, and awareness
250
F.S. Leake et al. / Int. J. Pediatr. Otorhinolaryngol. 52 (2000) 247–251
Table 3 Questionnairea
Table 3 (Continued)
Total number of patients Indigent patients Non-indigent patients
50 41 (82) 9 (18)
Question 1: Were hearing aids recei6ed? Received hearing aids: Indigent patients Non-indigent Did not receive Not recommended
26 9 10 5
(52) (18) (20) (10)
Question 2: If hearing aids were not recei6ed, why not? Pending PE tube surgery 1 (2) Pending 2nd ABR results 2 (4) Currently in the process 2 (4) Will repeat audiogram 1 (2) Unable to contact 4 (8) Question 3: What type of hearing aids were recei6ed? Behind the ear (BTE) 34 (68) Cochlear implant 1 (2) Question 4: Is the patient enrolled in an aural habilitation/rehabilitation program. If not, why? Enrolled Indigent Non-indigent Mainstreamed Not necessary non-indigent Will not wear hearing aids indigent Lost hearing aids indigent
27 23 8 1 1 1 1
(54) (46) (16) (2) (2) (2) (2)
Question 5: Where are the hearing aids being worn? Home only indigent 2 (4) Preschool/school only indigent 5 (10) Both settings 22 (44) Indigent 17 (34) Non-indigent 9 (18) Will not wear indigent 1 (2) Lost hearing aids indigent 1 (2) Question 6: Did the patients performance in school impro6e (if age appropriate) after hearing aids were recei6ed? School age children 20 (40) Indigent 15 (30) Non-indigent 5 (10) School work improved 12 (24) Indigent 11 (22) Non-indigent 1 (2) Did not improve indigent 3 (6) No improvement needed non-indigent 4 (8) Lost hearing aids indigent 1 (2) Question 7: Did the patients 6ocabulary, speech, and awareness of sound, etc. impro6e after hearing aid placement? Needed improvement 15 (30) Indigent 13 (26)
Non-indigent Showed improvement Indigent Non-indigent Showed no improvement Non-indigent Indigent Refused to wear aids indigent a
2 10 9 1 4 1 3 1
(4) (20) (18) (2) (8) (2) (6) (2)
Values in parentheses are percent.
of sound. Thirteen (26%) were indigent and two (4%) were non-indigent. Nine (18%) of the indigent patients showed improvement, three (6%) showed no improvement and one (2%) refused to wear the hearing aid. One (2%) non-indigent patient showed improvement and one (2%) did not (Table 3).
6. Conclusion In conclusion, the study found that the majority of our medically indigent hearing-impaired patients did follow-up with their referral for hearing aids as recommended, and are enrolled in a therapeutic program. Their financial situation did not have a negative impact. It is to be noted that all nine (18%) of the non-indigent children who were referred for hearing aids received them, as compared to only 26 (52%) out of 40 (80%) of the indigent children. But the reasons that the indigent patients did not receive hearing aids was not due to the lack of follow-up. Four patients (8%) had unilateral hearing losses hearing aids were not recommended at the time of diagnosis, we could not reach four patients (8%), two patients (4%) were waiting to have an ABR test repeated, one patient (2%) was having PE tube surgery, two patients (4%) were currently in the process of receiving hearing aids and one patient (2%) was waiting on a repeat audiogram. This study showed that once provided with the opportunity to have hearing aids, this population takes advantage and has a high utilization rate. This is money well spent. Fortunately, in the state of Tennessee, financial resources are available to offer assistance to poor children in need of hear-
F.S. Leake et al. / Int. J. Pediatr. Otorhinolaryngol. 52 (2000) 247–251 Table 4 Degree of hearing loss per patient No. of patients (%)
Right
Left
1 1 1 2 1 1
Severe Severe Profound Moderate
Profound Mild Severe Mild
(2) (2) (2) (4) (2) (2)
Bilateral
Mild Mild to profound Mild to moderate Moderate to severe Severe Moderate Profound
1 (2) 1 (2) 16 (32) 12 (24) 7 (14) Unilateral hearing loss 3 (6) Normal 1 (2) Profound 1 (2) Normal
.
Profound Normal Moderate
Table 5 Percent of patients by age Age
No. of patients (%)
0 1 2 3 4 5 6 7 8 12 13
6 6 13 1 4 3 5 3 7 1 1
(12) (12) (26) (2) (8) (6) (10) (6) (14) (2) (2)
ing aids. Tennessee Infant Parent Services (TIPS), Children’s Special Services (CSS) and the Lions Club are the primary organizations. Their funding comes from either the state government (Maternal Child Health Grant) or private donations. Due to the availability of these programs, financial barriers for the uninsured and/or under-insured hearing impaired children in need of hearing aids are significantly lessened, at least within the state of Tennessee.
251
The study also concluded that there is not a significant difference in the attitudes about obtaining hearing aids, whether the patient is indigent or non-indigent. Care givers of both populations are interested in their children obtaining these devices. The length of time it takes to receive hearing aids between the two populations is the only variant. It took, on the average, 3 months for the indigent patient to receive a hearing aid and only 1 month for the non-indigent patient to receive a hearing aid. TennCare patients are required to get a referral from their primary care physicians for a hearing aid before one can be administered. This process can be time consuming and results in delaying the child amplification until this process is complete. The average age of first time diagnosis was 2 years of age. Hopefully, with the advent of newborn hearing screening programs in hospitals in Tennessee, this late diagnosis of hearing losses will eventually be lessened. All of our hearing-impaired patients are advised to return to us for routine otological, audiological and hearing aid assessment. Our goal is to retain these patients until they are 18 years of age.
References [1] A.J. Cebrun, The role of managed care: The national and Tennessee experiences, J. Health Care Poor Undeserved 8 (3) (1997) 384 – 387. [2] B.L. Wolfe, Children’s utilization of medical care, Med. Care 18 (12) (1980) 1196 – 1207. [3] P. Newacheek, D. Hughes, J. Stoddard, Children’s access to primary care: differences by race, income, and insurance status, Pediatrics 97 (1) (1996) 26 – 32. [4] A. Hubbell, H. Wautzlan, L. Ducker, B. Alan, G. Heide, Financial barriers to medical care: a prospective study in a university affiliated community clinic, Am. J. Med. Sci. 297 (3) (1989) 158 – 162. [5] D.M. Mirvis, C.F. Chang, C.J. Hall, G.T. Zaar, W.B. Applegate, TennCare — health system reform for Tennessee, J. Am. Med. Assoc. 274 (15) (1995) 1235 – 1241. [6] D.N. Brooks, The effect of attitude on benefit obtained from hearing aids, Br. J. Audiol. 23 (1) (1989) 3 – 11. [7] W.D. Keller, R.S. Bundy, Effects of unilateral hearing loss upon educational achievement, Child Care Health Dev. 6 (2) (1980) 93 – 100.
Acquisition of hearing aids and assistive listening devices among the pediatric hearing-impaired population Fannie S. Leake *, Jerome W. Thompson, Erin Simms, James Bailey, Rose Mary S. Stocks, Anne M. Murphy Pediatric Otolaryngology, The Uni6ersity of Tennessee Memphis, 777 Washington A6enue Suite P110, Memphis, TN 38105, USA Received 13 March 1999; received in revised form 31 January 2000; accepted 2 February 2000
Abstract Sufficient access to health care is of concern to the indigent population in the US and to their health care providers. This study was undertaken to elucidate the rate of the follow-up among lower socioeconomic hearing-impaired pediatric patients who had received a recommendation for hearing aids and/or assistive listening devices. Our question was, would the families’ financial situation have a negative effect on the acquisition of hearing aids and assistive listening devices? Fifty patients, age 0–18 years, who had been seen in our clinic over 2 years were evaluated via a telephone survey. The survey consisted of seven questions, including whether or not the devices or aids were obtained, what type was purchased, where the device was being used, and the child’s apparent performance with the device. Eighty-two percent of our patients were on TennCare, a state mandated Medicaid HMO system. Two-thirds of these TennCare patients are at or below the poverty level and the remaining one-third is either disabled or uninsurable according to the Aid for Dependent Children (AFDC) with indeterminate income. In addition the TennCare organization did not cover hearing amplification equipment for these children. The study showed that the majority of the patients did follow-up as recommended. Furthermore, this equipment is easily obtainable for the pediatric indigent population due to financial resources available in the community outside the mandated Medicaid system. © 2000 Elsevier Science Ireland Ltd. All rights reserved. Keywords: Indigent; Non-indigent; Hearing aids
1. Introduction The only developing country without a healthcare policy is the US. What the US has is a limited national health insurance system [1]. Therefore, providing sufficient healthcare for the
* Corresponding author.
poor, especially poor children, in our society is an escalating problem. Access to financial resources for medical care is either not always available or easily available, even with the advent of policies such as neighborhood health centers and Medicaid [2]. For children who live in poverty, there are fewer physician contacts, and they are not as likely to receive routine preventive care when needed [3].
0165-5876/00/$ - see front matter © 2000 Elsevier Science Ireland Ltd. All rights reserved. PII: S 0 1 6 5 - 5 8 7 6 ( 0 0 ) 0 0 2 9 4 - 9
248
F.S. Leake et al. / Int. J. Pediatr. Otorhinolaryngol. 52 (2000) 247–251
To be classified as medically indigent (M.I.) in Tennessee the patient must be either uninsured or under-insured [4]. We found that the majority of the hearing-impaired children in our clinic met the criteria to be medically indigent. Our clinic is a private, non-profit facility, and is staffed by the University of Tennessee, Memphis Physicians. We see private, state insured, as well as uninsured patients. A large percentage of the hearing-impaired children in our clinic are TennCare recipients. TennCare is a state mandated and funded medical insurance. It was developed to control the rapid rising cost of the state’s already existing Medicaid program, and to extend health insurance coverage to most Tennesseans who did not have access to government or employer sponsored health insurance [5]. Although TennCare provides access to physician services, the insurance will not pay for hearing aids. Our goal is to refer indigent patients to attentive appropriate sources that will provide funding for these devices. This is frequently difficult and time consuming for both parents and medical staff, and places a burden on both. Therefore, the opportunity for the child to not get hearing aids is higher for this population. Due to the lack of research in this area, little is known about the acquisition and use of hearing aids for this population.
2. Objective The objective of this study was to determine if our indigent patients followed-up with their referrals to obtain and use hearing aids as recommended, or did their compromised financial situation have a negative impact.
3. Methods The primary objective of providing and/or obtaining hearing aids is to diminish the handicapping effect of hearing impairment. Assessing the benefits of hearing aids can be done in many different ways [6]. The study wanted to know if our patients received their hearing aids as recommended, and if so, were they benefiting from
them. The best and most expedient way to obtain this information was by administering a questionnaire through a telephone survey. Between August 1997 and July 1998 we conducted a telephone survey of fifty patients, ranging in age from 0–18 years. These patients were the first 50 patients that were diagnosed with hearing losses in our clinic from January 1995 through July 1997. The average age of the first time diagnosis was 2 years (Table 5). The degree of hearing loss for each patient can be found in Table 4. All of the hearing losses were sensorineural, with the exception of two who had mixed hearing losses. These patients were not only candidates for hearing aids due to the severity of their hearing loss, but also due to significant language delays and poor school performance. The questionnaire (Table 3) consisted of seven questions, including whether or not the hearing aids were received, what type of device was obtained, whether or not the devices were being used, and whether or not the patient’s performance in school, awareness of sound, speech and vocabulary improved, as reported by the parents. We also asked whether or not the patient was enrolled in a therapeutic program, i.e. auditory and speech training. The adult member of the household was questioned, as well as the referred clinical evaluator of each patient. The questionnaire was only administered during the day, and the average length of time was 15 min per call. We were successful in reaching most of our patients, and the clinical evaluator on the first initial contact. 4. Data analysis A statistical evaluation of the frequency of follow-up can be found in Table 1. Out of fifty patients, 41 (82%) followed-up with their referrals as recommended, four (8%) did not (for explanation, see Table 2). Five (10%) had unilateral hearing losses; therefore, no referrals were made for hearing aids at the time of diagnosis. Four (8%) of these patients with a unilateral hearing loss were indigent and one was classified as non-indigent. The average age of first time diagnosis was 6 years.
F.S. Leake et al. / Int. J. Pediatr. Otorhinolaryngol. 52 (2000) 247–251
The patients were counseled on the effects of unilateral hearing loss and how the problem should be managed. The following recommendations were made to the parent and teacher: (1) Front row seating; (2) Seating directly in front of the teacher; (3) Before giving oral instructions, obtain the student’s attention; (4) Speak clearly and concisely; (5) Give written instructions to Accompany oral instructions whenever possible; (6) Yearly hearing test in order to monitor the hearing in the good ear; (7) Notify all persons who come in contact with the child of the child’s hearing loss; and (8) If appropriate, use an FM system in the classroom and/or a CROS hearing aid if learning problems occur. According to Keller et al. [7] unilateral hearing loss can be a risk factor for the production of developmental problems.
5. Results Out of the 50 patients with hearing impairments contacted, 40 (80%) were medically indigent and 10 (20%) were non-indigent. Nine (18%) of the non-indigent patients received hearing aids, with the exception of one that had a unilateral hearing loss, and a hearing aid was not recommended at the time of diagnosis. Twenty-six (52%) of the medically indigent patients received Table 1 Percentage of patients who did/did not follow-up with their referrals as recommendeda Followed-up (%)
Did not follow-up (%)
No referral made (%)
41 (82)
4 (8)
5 (10)
32 (64) Indigent 9 (18) Non-indigent a
Number of patients: 50.
Table 2 Explanation of why referrals were not followed Unable to reach
4 (8%)
249
hearing aids. Of those who did not , four (8%) of the patients had unilateral hearing loss, we were unable to contact four patients (8%), one patient (2%) was having PE tube surgery, two (4%) were having an ABR test performed, two (4%) were currently in the process and one (2%) was waiting on a repeat audiogram. Our clinic made no recommendations for the type of hearing aid to be fitted. We left it up to the outside clinic evaluator. Thirty-four patients (68%) were fitted with behind-the-ear (BTE) hearing aids and one (2%) received a cochlear implant. It took on the average 1 month for the non-indigent patients to receive their hearing aids as compared to the indigent patients, where the average length of time that it took to receive hearing aids was 3 months. Thirty-one (62%) of the hearing-impaired patients were enrolled in an aural habilitation/rehabilitation program. Twenty-three (46%) were indigent and eight (16%) were non-indigent. Of the indigent patients who were not enrolled, one (2%) was mainstreamed, one (2%) refused to wear the hearing aids and one (2%) lost the hearing aids. For the non-indigent patient who was not enrolled therapy was not necessary. Of the indigent patients, 17 (34%) of them are presently wearing their hearing aids at home and/ or pre-school/school, five patients (10%) are only wearing the devices at school, two (2%) are only wearing them at home, one (2%) will not wear the hearing aid and one patient (2%) lost his/her hearing aid. All nine (18%) of the non-indigent patients, who received hearing aids, were either wearing their hearing aids at home and/or preschool/school. There were 20 (40%) school age children in the study. Out of 20 school age children, 15 (30%) were indigent and five (10%) were non-indigent. Eleven of the indigent patients (22%) showed improvement in their school work, three patients (6%) showed no improvement, and for one patient (2%) lost his/her hearing aid. Out of the five non-indigent school age children, one patient’s (2%) school work did improve, and for four patients (8%) no improvement was needed. Fifteen (30%) of the patients needed improvement in their speech, vocabulary, and awareness
250
F.S. Leake et al. / Int. J. Pediatr. Otorhinolaryngol. 52 (2000) 247–251
Table 3 Questionnairea
Table 3 (Continued)
Total number of patients Indigent patients Non-indigent patients
50 41 (82) 9 (18)
Question 1: Were hearing aids recei6ed? Received hearing aids: Indigent patients Non-indigent Did not receive Not recommended
26 9 10 5
(52) (18) (20) (10)
Question 2: If hearing aids were not recei6ed, why not? Pending PE tube surgery 1 (2) Pending 2nd ABR results 2 (4) Currently in the process 2 (4) Will repeat audiogram 1 (2) Unable to contact 4 (8) Question 3: What type of hearing aids were recei6ed? Behind the ear (BTE) 34 (68) Cochlear implant 1 (2) Question 4: Is the patient enrolled in an aural habilitation/rehabilitation program. If not, why? Enrolled Indigent Non-indigent Mainstreamed Not necessary non-indigent Will not wear hearing aids indigent Lost hearing aids indigent
27 23 8 1 1 1 1
(54) (46) (16) (2) (2) (2) (2)
Question 5: Where are the hearing aids being worn? Home only indigent 2 (4) Preschool/school only indigent 5 (10) Both settings 22 (44) Indigent 17 (34) Non-indigent 9 (18) Will not wear indigent 1 (2) Lost hearing aids indigent 1 (2) Question 6: Did the patients performance in school impro6e (if age appropriate) after hearing aids were recei6ed? School age children 20 (40) Indigent 15 (30) Non-indigent 5 (10) School work improved 12 (24) Indigent 11 (22) Non-indigent 1 (2) Did not improve indigent 3 (6) No improvement needed non-indigent 4 (8) Lost hearing aids indigent 1 (2) Question 7: Did the patients 6ocabulary, speech, and awareness of sound, etc. impro6e after hearing aid placement? Needed improvement 15 (30) Indigent 13 (26)
Non-indigent Showed improvement Indigent Non-indigent Showed no improvement Non-indigent Indigent Refused to wear aids indigent a
2 10 9 1 4 1 3 1
(4) (20) (18) (2) (8) (2) (6) (2)
Values in parentheses are percent.
of sound. Thirteen (26%) were indigent and two (4%) were non-indigent. Nine (18%) of the indigent patients showed improvement, three (6%) showed no improvement and one (2%) refused to wear the hearing aid. One (2%) non-indigent patient showed improvement and one (2%) did not (Table 3).
6. Conclusion In conclusion, the study found that the majority of our medically indigent hearing-impaired patients did follow-up with their referral for hearing aids as recommended, and are enrolled in a therapeutic program. Their financial situation did not have a negative impact. It is to be noted that all nine (18%) of the non-indigent children who were referred for hearing aids received them, as compared to only 26 (52%) out of 40 (80%) of the indigent children. But the reasons that the indigent patients did not receive hearing aids was not due to the lack of follow-up. Four patients (8%) had unilateral hearing losses hearing aids were not recommended at the time of diagnosis, we could not reach four patients (8%), two patients (4%) were waiting to have an ABR test repeated, one patient (2%) was having PE tube surgery, two patients (4%) were currently in the process of receiving hearing aids and one patient (2%) was waiting on a repeat audiogram. This study showed that once provided with the opportunity to have hearing aids, this population takes advantage and has a high utilization rate. This is money well spent. Fortunately, in the state of Tennessee, financial resources are available to offer assistance to poor children in need of hear-
F.S. Leake et al. / Int. J. Pediatr. Otorhinolaryngol. 52 (2000) 247–251 Table 4 Degree of hearing loss per patient No. of patients (%)
Right
Left
1 1 1 2 1 1
Severe Severe Profound Moderate
Profound Mild Severe Mild
(2) (2) (2) (4) (2) (2)
Bilateral
Mild Mild to profound Mild to moderate Moderate to severe Severe Moderate Profound
1 (2) 1 (2) 16 (32) 12 (24) 7 (14) Unilateral hearing loss 3 (6) Normal 1 (2) Profound 1 (2) Normal
.
Profound Normal Moderate
Table 5 Percent of patients by age Age
No. of patients (%)
0 1 2 3 4 5 6 7 8 12 13
6 6 13 1 4 3 5 3 7 1 1
(12) (12) (26) (2) (8) (6) (10) (6) (14) (2) (2)
ing aids. Tennessee Infant Parent Services (TIPS), Children’s Special Services (CSS) and the Lions Club are the primary organizations. Their funding comes from either the state government (Maternal Child Health Grant) or private donations. Due to the availability of these programs, financial barriers for the uninsured and/or under-insured hearing impaired children in need of hearing aids are significantly lessened, at least within the state of Tennessee.
251
The study also concluded that there is not a significant difference in the attitudes about obtaining hearing aids, whether the patient is indigent or non-indigent. Care givers of both populations are interested in their children obtaining these devices. The length of time it takes to receive hearing aids between the two populations is the only variant. It took, on the average, 3 months for the indigent patient to receive a hearing aid and only 1 month for the non-indigent patient to receive a hearing aid. TennCare patients are required to get a referral from their primary care physicians for a hearing aid before one can be administered. This process can be time consuming and results in delaying the child amplification until this process is complete. The average age of first time diagnosis was 2 years of age. Hopefully, with the advent of newborn hearing screening programs in hospitals in Tennessee, this late diagnosis of hearing losses will eventually be lessened. All of our hearing-impaired patients are advised to return to us for routine otological, audiological and hearing aid assessment. Our goal is to retain these patients until they are 18 years of age.
References [1] A.J. Cebrun, The role of managed care: The national and Tennessee experiences, J. Health Care Poor Undeserved 8 (3) (1997) 384 – 387. [2] B.L. Wolfe, Children’s utilization of medical care, Med. Care 18 (12) (1980) 1196 – 1207. [3] P. Newacheek, D. Hughes, J. Stoddard, Children’s access to primary care: differences by race, income, and insurance status, Pediatrics 97 (1) (1996) 26 – 32. [4] A. Hubbell, H. Wautzlan, L. Ducker, B. Alan, G. Heide, Financial barriers to medical care: a prospective study in a university affiliated community clinic, Am. J. Med. Sci. 297 (3) (1989) 158 – 162. [5] D.M. Mirvis, C.F. Chang, C.J. Hall, G.T. Zaar, W.B. Applegate, TennCare — health system reform for Tennessee, J. Am. Med. Assoc. 274 (15) (1995) 1235 – 1241. [6] D.N. Brooks, The effect of attitude on benefit obtained from hearing aids, Br. J. Audiol. 23 (1) (1989) 3 – 11. [7] W.D. Keller, R.S. Bundy, Effects of unilateral hearing loss upon educational achievement, Child Care Health Dev. 6 (2) (1980) 93 – 100.