Congenital hearing loss is the most common neonatal sensory disorder and it is crucial to diagnose hearing loss as soon as possible after birth in order to facilitate rapid treatment. Universal standards of infant hearing healthcare dictate that infant hearing screening should be completed by one month of age and abnormal screening tests should be followed with definitive audiological testing by three months of age. Obtaining diagnostic testing can be complicated by limited access to care in rural areas, breakdowns in communication, lack of parental support, and poor coordination of care. There is no established method to address appointment non-adherence in newborn hearing testing. Patient navigation (PN), which uses trained healthcare workers to educate patients and facilitate adherence to healthcare, is an evidence-based approach that has had widespread success in facilitating timely care in other healthcare settings but has not been studied in infant hearing testing. The objective of this dissertation is to 1) assess the effect of patient navigation on care delivery in healthcare inequity settings, 2) assess the efficacy of a PN intervention to decrease non-adherence to recommended infant audiological testing after failed newborn hearing screening, and 3) develop a method to implement patient navigation into the state hearing screening program.
The original concept and development of PN stems from the findings of the American Cancer Society National Hearings on Cancer in the Poor in 1989, which revealed a host of barriers that underserved populations face in receiving timely and appropriate, care. Cancer treatment centers have utilized patient navigators (PNs) to address these barriers in the delivery of cancer care. In order to consider the potential of applying patient navigation in promoting timely infant hearing healthcare, a systematic review was performed to systematically assess the efficacy of patient navigation to improve diagnosis and treatment of diseases affecting medically underserved populations. Specific outcomes assessed in the review included the effect of PN on timing of definitive diagnosis and effect on initiation of treatment. The search strategy produced 1,428 articles and 16 were included for review. In the Oncology field, timing of initial contact with a patient navigator after diagnostic or screening testing was correlated to the effectiveness of the navigator intervention. The majority of the studies reported significantly shorter time intervals to diagnosis and to treatment with patient navigation. This review provided evidence to justify a PN efficacy trial in infant hearing healthcare.
To investigate the efficacy of PN to decrease non-adherence to recommended infant audiological testing after failed newborn hearing screening, a randomized controlled trial was conducted in sixty-one guardian-infant dyads. All infants had abnormal newborn hearing screening and were recruited within the first week after birth. Dyads were randomized into a PN study arm or standard of care arm. PN was found to be efficacious as the percentage of participants with follow-up non-adherence was significantly lower in the PN arm compared with the standard of care arm (7.4% versus 38.2%, p=0.005). The timing of initial follow-up was significantly lower in the PN arm compared with the standard of care arm (67.9 days versus 105.9 days, p=0.010). Based on this efficacy data, the next objective of the research was to scale up PN to maximize public health impact by combining an effectiveness trial with implementation research. A hybrid effectiveness/implementation study was designed to investigate patient navigation within the state-funded EHDI (early hearing detection and intervention) system. Using a stepped wedge design this trial investigates the 1) effectiveness of PN to decrease non-adherence to hearing testing, 2) implementation factors using the Consolidated Framework of Implementation Research (CFIR), and 3) cost-effectiveness and sustainability of a PN program within a state-supported EHDI system
