Graduation Year

2025

Document Type

Dissertation

Degree

Ph.D.

Degree Name

Doctor of Philosophy (Ph.D.)

Degree Granting Department

Public Health

Major Professor

Troy Quast, Ph.D.

Committee Member

Etienne Pracht, Ph.D.

Committee Member

Russell Kirby, Ph.D.

Committee Member

Michelle Arnold, Ph.D.

Keywords

Cost Effectiveness Analysis, Discharge Against Medical Advice, Hearing Aid Mandate, Loss to Follow Up, Newborn Hearing Screening, Sensory Impairment

Abstract

Hearing loss affects individuals across the age span and, if left untreated, can lead to developmental delays and health and well-being concerns. This dissertation applies econometric analyses to investigate factors influencing diagnostic outcomes in the neonatal intensive care unit (NICU), intervention enrollment rates among babies with permanent childhood hearing loss (PCHL), and utilization and hospitalization outcomes among adults with sensory impairment (SI). The first study evaluates the cost-effectiveness of automated auditory brainstem response (aABR) versus transient evoked otoacoustic emissions (TEOAE) for newborn hearing screenings in a Thailand hospital NICU. Decision tree modeling and economic evaluation suggested that although aABR is more costly, it demonstrated superior sensitivity and specificity compared to TEOAE. The incremental cost-effectiveness ratio (ICER) indicated that the aABR’s higher diagnostic accuracy may justify the increased expense for identifying hearing loss in high-risk populations. The second study examines the association of state mandates for pediatric hearing aid insurance coverage on early intervention (EI) enrollment rates. Analyses of state-year panel data for 31 states over 15 years revealed that insurance mandates alone do not significantly reduce loss-to-follow-up (LTFU) to EI enrollment, after adjusting for demographic and contextual variables. Ethnicity and annual birth volume were more strongly associated with LTFU, suggesting the importance of culturally and linguistically tailored strategies and necessary consideration for contextual factors in policy evaluation. In the third study, we used a case-control design with three years of Florida inpatient hospitalization data to explore the relationship between SI and discharge against medical advice (DAMA) among adults. Results indicated that adults with SI are more likely to be discharged by a provider than their peers without SI. Additional influences included demographic, clinical, and hospital factors. Notably, practices associated with teaching and not-for-profit hospitals and rehabilitation therapies were linked to reduced DAMA rates. This dissertation highlights the importance of prioritizing diagnostic accuracy, policy context, and individualized care in optimizing hearing health and healthcare outcomes for vulnerable populations. Our findings inform clinical practice, health policy, and future research aimed at reducing disparities and improving service delivery across the continuum of care for individuals of all ages with hearing loss.

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