Quality measures of two-stage newborn hearing screening: systematic review and meta-analysis.

Introduction: Newborn screening for hearing impairment (NHS) is a crucial public health issue worldwide. Often, a two-stage screening with two different testing approaches is used. We aimed to investigate the optimal screening algorithm, based on data from the literature published in the last 30 years. A particular focus of the study was to synthesize the existing evidence on two-stage newborn hearing screening regarding the refer rate (RFR), the percentage of children that did not pass the second test or were lost after the first test. Methods: We searched MEDLINE and Scopus for studies on two-stage NHS using transient evoked otoacoustic emissions (TEOAE) or automated auditory brainstem response (AABR). All studies on newborns who received their first test as an inpatient and a second test up to 1 month later were eligible. Random effects meta-analysis was performed to estimate RFR. Risk of bias was assessed using QUADAS-II. The unfunded study was registered in PROSPERO (CRD42023403091, available at https://www.crd.york.ac.uk/PROSPERO/view/CRD42023403091). Results: Eighty-five study protocols, including over 1,120,000 newborns, met the inclusion criteria. Certainty in the evidence was rated as moderate. Discussion: Strategies that did not involve changes to the screening method had a lower RFR. AABR-AABR: RFR = 1.3% [95% confidence interval (CI): 0.9, 1.8%], TEOAE-TEOAE: RFR = 2.7% (CI: 2.2, 3.2%), TEOAE-AABR: RFR = 3.9% (CI: 2.9, 5.1%), AABR-TEOAE: 5.9% (CI: 5.0, 6.9%). Consequently, where feasible, changing the screening method at the second screening should be avoided in order to minimize the number of follow-up examinations.