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Factors Associated with
Lost to Follow-up in Massachusetts
Jessica MacNeil, MPH
Massachusetts Department of Public Health
March 26, 2007
Snapshot of Massachusetts 78,000 births annually 51 birth facilities 29 Department of Public Health Approved
Audiological Diagnostic Centers (ADCs) 62 Early Intervention (EI) Programs
All children with hearing loss are eligible for EI services
Massachusetts Statistics - 2005 99% screened 1% referred 20% diagnosed with hearing loss
33% of bilateral referrals 14% of unilateral referrals
71% referred to Early Intervention (EI)
Lost to Follow-up Diagnostic EvaluationMassachusetts, 2003-2005*
0%
2%
4%
6%
8%
10%
2003 2004 2005 2003-2005
Lost to Follow-up Diagnostic Evaluation Massachusetts vs. U.S., 2004
0%
10%
20%
30%
40%
50%
60%
MA US
Lost to Follow-up Early InterventionMassachusetts, 2003-2005*
0%
5%
10%
15%
20%
25%
30%
2003 2004 2005 2003-2005
Strategies to Success Strong Foundations
Law, regulations, guidelines
Strong Partnerships Hospitals, ADCs, Early Intervention, Advisory Committee,
Vital Records
Strong Systems Childhood Hearing Data System, EBC, data linkages
Strong Connections Outreach to families, bilingual staff, parent-to-parent support
Lost to Follow-up:Diagnostic Evaluation
Defining Lost to Follow-up:Diagnostic Evaluation 2003-2005 births Did not pass a newborn hearing screening Did not receive diagnostic results from ADCs Exclusions: parents declined follow-up/no
consent (n=72), deceased (n=13), non-residents/moved out of jurisdiction (n=82), sealed records (n=1)
Analytic sample size: 2,870
Follow-up by Infant Characteristics Birth weight
≥2,500 gm (N=2,462) 93% <2,500 gm (N=408) 91%
Laterality of hearing screening referral Bilateral (N=685) 92% Unilateral (N=2,185) 92%
Follow-up by Maternal Characteristics Race/Ethnicity
White (N=1,803) 94% Non-white (N=1,067) 90%*
Language English (N=2,418) 93% Other (N=452) 90%
Place of Birth 50 U.S. States (N=1,866) 93% Foreign-born (N=1,004) 92%
*factor associated with lower follow-up, p<.05
Follow-up by Maternal Characteristics
Age ≥20 years (N=2,657) 93% <20 years (N=213) 87%*
Education level ≥HS (N=2,403) 94% <HS (N=467) 83%*
*factor associated with lower follow-up, p<.05
Follow-up by Maternal Characteristics
Region of Residence Boston (N=545) 94% Western (N=106) 69%* Central (N=357) 94% Northeastern (N=266) 92% Metro West (N=1,064) 95% Southeastern (N=532) 89%*
*factor associated with lower follow-up, p<.05
Follow-up by Maternal Characteristics
Marital status Married (N=1,001) 96% Unmarried (N=1,866) 86%*
Parity 1 child (N=1,276) 94% 2 children (N=958) 93% 3+ children (N=630) 87%*
*factor associated with lower follow-up, p<.05
Follow-up by Maternal Characteristics
Insurance Private (N=1,812) 96% Public (N=1,055) 86%*
Employment status Mom & Dad employed (N=1,392) 96% Dad only employed (N=899) 91%* Mom only employed (N=177) 90%* Mom & Dad not employed (N=402) 85%*
*factor associated with lower follow-up, p<.05
Follow-up by Maternal Characteristics
Onset of Prenatal Care: Month 1-3 (N=2,241) 94% Month 4-6 (N=474) 88%* Month 6-9 (N=100) 89%
Smoked during pregnancy No (N=2,657) 93% Yes (N=213) 83%*
*factor associated with lower follow-up, p<.05
Factors Associated With No Follow-up: Univariate Analysis Non-white <20 years <HS education Residence in:
Western MA Southeastern MA
Unmarried 3+ children
Publicly Insured Unemployed:
Mom or Dad Both Parents
Later prenatal care 2nd trimester
Smoked during pregnancy
Factors Associated With No Follow-up: Logistic Regression <HS education aOR = 1.59 (1.14-2.23) Residence in:
Western MA aOR = 6.49 (3.66-11.50) Southeastern MA aOR = 2.61 (1.65-4.13)
Unmarried aOR = 2.19 (1.53-3.14) 3+ children aOR = 1.95 (1.43-2.65) Publicly insured aOR = 1.91 (1.31-2.77)
Lost to Follow-up: Early Intervention
Defining Lost to Follow-up:Early Intervention
2003-2005 births Diagnosed with hearing loss Not referred to EI services Data from Early Intervention Information
System through December 31, 2006 Exclusions: moved out of jurisdiction (n=7) Analytic sample size: 600
Follow-up by Infant Characteristics Birth weight
<2,500 gm (N=137) 89% ≥2,500 gm (N=463) 71%*
Laterality of hearing loss Bilateral (N=371) 84% Unilateral (N=229) 62%*
Degree of hearing loss Severe/profound (N=158) 89% Mild/moderate (N=423) 70%*
*factor associated with lower follow-up, p<.05
Follow-up by Maternal Characteristics Race/Ethnicity
White (N=400) 78% Non-white (N=200) 70%*
Language English (N=504) 76% Other (N=96) 70%
Place of Birth 50 U.S. States (N=410) 79% Foreign-born (N=190) 68%*
*factor associated with lower follow-up, p<.05
Follow-up by Maternal Characteristics
Age <20 years (N=52) 75% ≥20 years (N=548) 77%
Education level ≥HS (N=488) 77% <HS (N=112) 68%*
*factor associated with lower follow-up, p<.05
Follow-up by Maternal Characteristics
Region of Residence Boston (N=84) 64%* Western (N=41) 71%* Central (N=85) 84% Northeastern (N=73) 90% Metro West (N=208) 74%* Southeastern (N=109) 72%*
*factor associated with lower follow-up, p<.05
Follow-up by Maternal Characteristics
Marital status Married (N=410) 76% Unmarried (N=188) 74%
Parity 1 child (N=274) 75% 2 children (N=197) 77% 3+ children (N=129) 73%
Follow-up by Maternal Characteristics
Insurance Private (N=394) 76% Public (N=205) 74%
Employment status Mom & Dad employed (N=285) 76% Dad only employed (N=201) 77% Mom only employed (N=31) 71% Mom & Dad not employed (N=83) 72%
Follow-up by Maternal Characteristics
Onset of Prenatal Care: Month 1-3 (N=466) 76% Month 4-6 (N=101) 72% Month 6-9 (N=19) 68%
Smoked During Pregnancy No (N=558) 75% Yes (N=42) 83%
Factors Associated With No Follow-up: Univariate Analysis ≥2,500 gm Unilateral hearing loss Mild/moderate loss Non-white Foreign-born <HS education
Residence in: Boston Western MA Metro West Southeastern MA
Factors Associated With No Follow-up: Logistic Regression ≥2,500gm aOR = 3.70 (1.98-6.91) Unilateral loss aOR = 3.50 (2.31-5.31) Mild/moderate loss aOR = 3.30 (1.92-5.67) Foreign-born aOR = 1.92 (1.23-2.99)
From Data to Action Develop targeted outreach strategies based
on results of analysis Outreach efforts should focus on:
Diagnostic evaluation: Residents of Western and Southeastern MA Unmarried, 3+ children, publicly insured, <HS
education Early Intervention:
Unilateral and mild/moderate losses Foreign-born mothers, normal birth weight
From Data to Action Improve communication with hospitals and
diagnostic centers Educate providers on the importance of
follow-up Collaborate with other state programs and
support services to reach out to high-risk families
Conclusions In MA, 8% of infants referred for diagnostic
evaluation became lost to follow-up Risk factors: maternal characteristics
75% of children with hearing loss were referred to Early Intervention Risk factors: infant characteristics
Conclusions Overall, follow-up in MA is significantly
higher than the national average Continue to analyze data to determine
where to prioritize outreach efforts
Acknowledgements Janet Farrell, Program Director Chia-Ling Liu, Research Analyst Sarah Stone, Program Coordinator Martha deHahn, Parent Outreach Specialist Amarilys Triana, Lost to Follow-up
Specialist
Massachusetts Universal Newborn Hearing Screening Program
http://www.mass.gov/dph/fch/unhsp/index.htm
617-624-5959