Objectives: Early detection of neonatal hearing impairment moderates the negative
effects on speech and language development. Universal neonatal hearing screening protocols
vary in tests used, timing of testing and the number of stages of screening. This
study estimated the cost-effectiveness of various protocols in the preparation of
implementation of neonatal hearing screening in Albania. Design: A micro-simulation
model was developed using input on demography, natural history of neonatal hearing
impairment, screening characteristics and treatment. Parameter values were derived
from a review of the literature and expert opinion. We simulated multiple protocols
using otoacoustic emissions (OAE) and automated auditory brainstem response (aABR),
varying the test type, timing and number of stages. Cost-effectiveness was analyzed
over a life-time horizon. Results: The two best protocols for well infants were OAE
followed by aABR (i.e., two-stage OAE-aABR) testing in the maternity ward and single-aABR
testing. Incremental cost-effectiveness ratios were euro4181 and euro78,077 per quality-adjusted
life-year gained, respectively. Single-aABR screening led to more cases being detected
compared to a two-stage screening program. However, it also resulted in higher referral
rates, which increased the total costs of diagnostics. Multi-staged screening decreased
referral rates but may increase the number of missed cases due to false-negative test
results and nonattendance. Conclusions: Only the 2-stage OAE-aABR (maternity ward)
protocol was below the willingness-to-pay threshold of euro10,413 for Albania, as
suggested by the World Health Organization, and was found to be cost-effective. This
study is among the few to assess neonatal hearing screening programs over a life-time
horizon and the first to predict the cost-effectiveness of multiple screening scenarios.
