Practice and challenges of newborn hearing screening: Analysis of a five-year database in Italy

Practice and challenges of newborn hearing screening: Analysis of a five-year database in Italy | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Practice and challenges of newborn hearing screening: Analysis of a five-year database in Italy Davide Coraci, Marta Fantoni, Eleonora Tonon, Raffaella Marchi, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-9305306/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 4 You are reading this latest preprint version Abstract Early identification and treatment of hearing impairments are essential for children’s development. International guidelines recommend a stepwise approach to conduct hearing screening in newborns. However, while the majority of countries worldwide implemented universal newborn hearing screening, inconsistencies remain in procedures and data management. In particular, Level 3 of the screening pathway—comprising diagnostic confirmation and therapeutic management—has received limited attention in the literature, despite its central role in determining program effectiveness and patient outcomes. This study investigates the clinical and organizational aspects of Level 3 within the neonatal hearing screening program of the Friuli-Venezia Giulia Region in Italy, analyzing data from 106 children enrolled between 2019 and 2023. The analysis considers the regional protocol, the roles of birthing centers, pediatricians, hospitals, and the Regional Center for Pediatric Hearing Loss Care, and subdivides Level 3 into four Phases (A–D) reflecting both organizational and diagnostic functions. By examining patient flow, false positives, loss to follow-up/documentation, and management practices, the study highlights how organizational factors—particularly the coordination between local and specialized facilities—produce “cascade” outcomes directly affecting diagnostic timelines and treatment initiation. Findings provide critical insights into weaknesses of the current system and propose directions for improving program efficiency, accuracy, and overall quality of care. universal hearing screening congenital hearing impairments hearing loss early identification pediatric audiology at-risk children Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Figure 6 Background Early diagnosis and treatment of congenital hearing impairment are fundamental for the development of perceptual and cognitive abilities, language, and overall social well-being. Nowadays, in many countries around the world, early intervention is made possible through established newborn hearing screening programs (Hyde, 2005). These programs follow the guidelines of the Joint Committee on Infant Hearing (JCIH, 2019), which define the key milestones and optimal timeline for the screening and management of suspected hearing loss in children. Specifically, the JCIH (2019) recommends that screening programs include the following steps: an initial objective hearing screening and re-screening to be completed within the first month of life for all newborns; a comprehensive audiological evaluation by no later than 2 months of age for infants who did not pass the initial screening; confirmation of diagnosis and initiation of early intervention and treatment no later than 3 months of age; and, finally, the implementation of an individualized audiological follow-up pathway for at-risk children. These guidelines update the 1-3-6 benchmark recommended in JCIH (2007). In the case of Italy—the case study of this article—newborn hearing screening is mandatory and provided free of charge to all newborns. Even prior to 2017—the year of the most recent updates to national healthcare programs (Ministerial Decree "Definition and Updating of the Essential Levels of Care," Art. 38)—the Italian clinical and scientific community was attentive and prepared to adapt its practices into large-scale, multidisciplinary, and multi-professional healthcare initiatives such as newborn hearing screening. However, the newborn hearing screening programs currently implemented across Italian regions are not without criticism. For example, in 2021, a report by the Italian Society of Otorhinolaryngology and Cervico-Facial Surgery (Orzan et al. 2022) highlights that the procedures and workflows of screening programs are not always consistent at the national, inter-regional, and sometimes even intra-regional levels. Additionally, there is a lack of systematic data analysis that could serve as process indicators for monitoring and improving the quality, accuracy, and time-efficiency of these programs (Holster et al. 2009; Walker et al. 2014; Orzan et al. 2016). In particular, despite the existing literature on hearing screening programs (Kumar, Mohapatra 2011; Lim et al. 2012; Kanji et al. 2018; Marinho et al. 2020), limited attention is generally given to the later stages of these programs—stages in which the impact on the overall quality and effectiveness of the screening process can be appreciated not only for clinical and diagnostic elements, but also for organizational factors (Wen and Huang, 2023). While several publications have assessed the performance of the initial phases of hearing screening in Italy (Molini et al., 2016; Malesci et al., 2022), the subsequent stage, which involves diagnostic confirmation and therapeutic management by a specialized facility, remains underexplored in the scientific literature. However, assessing this final step of the hearing screening program is mandatory. It is at this stage that the most critical challenges often arise, as it is where the diagnosis is confirmed, and treatment planning begins. Furthermore, evaluating this phase provides valuable insights into patient management, such as estimating the rates of false positives, lost to follow-up (LF), and lost documentation (LD; Feresin et al. 2019; Orzan et al. 2021; Razak et al. 2021), and highlights how clinical and organizational factors, including the coordination between local centers and specialized facilities, influence the overall effectiveness of the screening program. The aim of this article is to examine the main clinical and organizational aspects involved in the final step of the hearing screening pathway, with the goal of identifying key management weaknesses, evaluating their cascade effects on diagnostic timelines and treatment initiation, and proposing potential improvements for future screening strategies. The article focuses on the Friuli-Venezia Giulia (FVG) 2019-2023 Database (see Methods for details) of clinical records of 106 children who accessed the last phase of the neonatal hearing screening program, i.e., did not pass examinations at birthing centers nor the audiological evaluation, in the Italian Region Friuli-Venezia Giulia between 2019 and 2023. FVG is a region in which the program for early identification of childhood hearing loss was formally established in 2012 (Feresin et al. 2019). In particular, the regional protocol for early identification of childhood hearing loss in FVG defines the roles of the different centers involved in the program and the procedures to follow, based on JCIH recommendations (Figure 1(a)). These include the different birthing centers in the region, performing the hearing screening test within the first month of life (Level 1), three main hospitals (Center 1, Center 2, and Center 3), conducting a complete audiological evaluation (Level 2), and the Regional Center for Pediatric Hearing Loss Care (Center 2), responsible for the final audiological and etiological diagnosis (Level 3), treatment, and follow-up of children with permanent hearing loss. The dataset allows us to further analyze patients based on the different subsequent Phases 3A, 3B, 3C, and 3D (Figure 1(b)) they encounter during Level 3. This subdivision permits discrimination between the impact of clinical and organizational factors on the procedure as a whole, given the specific function each phase has. For instance, Phases 3A and 3B have primary organizational relevance, but a limited role from a diagnostic point of view, as they respectively concern individuals who failed Level 2 with suspected sensorineural or mixed hearing loss and individuals that correctly referred to Level 3 at the Regional Center for Pediatric Hearing Loss Care. Instead, Phases 3C and 3D, respectively regarding patients effectively arriving and being evaluated at the regional center and patients with confirmed hearing losses that entered the diagnostic process, have clear diagnostic importance. From the analysis of the pathway followed by patients suspected of hearing loss, we are then able to assess the coverage of the screening hearing program from identification to diagnosis in FVG, to examine the effective sensitivity and specificity of diagnostic tests, and, especially, to assess the often overlooked impact of management and organizational factors on the efficiency of the program, formulating potential solutions to address observed issues. Methods Database The FVG 2019-2023 Database includes reports for 106 patients who, between 2019 and 2023, were suspected of having hearing loss and referred to Level 3 of the neonatal hearing screening procedure in the Friuli-Venezia Giulia Region, Italy. Specifically, the database contains information on the patients’ history across the previous levels of screening, the outcomes of the different audiological examinations they underwent, the diagnosis of hearing impairment, and the subsequent treatment. Moreover, it records the cases of subjects who were dismissed from the program as having normal hearing conditions, as well as those whose evaluations were interrupted or whose documentation was lost (lost to follow-up or lost documentation), thereby providing important details about the overall efficiency of the screening process. The data were manually extracted from reports available to the personnel of the Institute for Maternal and Child Health IRCCS Burlo Garofolo Trieste, based on entries in a dedicated platform and regular reports from all other regional centers involved in Levels 1 and 2 of the program. Data on the number of births in the FVG region (Table S1; see Supplementary Material) were also available to the Burlo Garofolo Institute, which serves as the FVG regional center administering births. Overall, the neonatal hearing screening program in FVG is structured across three levels of monitoring for hearing impairments and involves four main stakeholders: Ten birthing centers (BC) in the region, responsible for performing the initial hearing screening test (Level 1) within the first month of life. Family pediatricians, responsible for ongoing hearing surveillance up to the child’s third year of life. Pediatric audiology services located in the region’s three main hospitals and birthing centers (Centers 1, 2, and 3), responsible for conducting comprehensive audiological evaluations (Level 2) for newborns who fail the initial screening or are referred by a pediatrician, and for referring confirmed cases to the Regional Center for Pediatric Hearing Loss Care. The Regional Center for Pediatric Hearing Loss Care, the only one in the FVG region, located at the Burlo Garofolo Institute, responsible for the final audiological and etiological diagnosis, treatment, and follow-up of children with hearing loss (Level 3). The specific activities and responsibilities of the various operational levels of the Friuli Venezia Giulia program are shown in Figure 1 and described in detail as follows. During Level 1, newborns are screened at the BC by trained nurses using a two-step procedure. The first test is the automated transient evoked otoacoustic emissions (A-TEOAE), which can be repeated up to two times. If the newborn fails this test, the screening is followed by the automated auditory brainstem response (A-ABR). Both tests are administered to infants considered at risk (see JCIH 2019) within 1 month from birth. The regional health system in FVG has complied with JCIH criteria since the program’s inception. Coverage has consistently exceeded 95%, while the referral rate has remained below 3% since the first year of the program’s formal implementation (Orzan et al. 2021). Family pediatricians are responsible for postnatal hearing surveillance during routine child visits at 1, 3, 6, 9, 12, 18, and 36 months of age. Their tasks include verifying the completion of newborn hearing screening, monitoring age-appropriate auditory and language milestones, and tracking risk indicators for hearing loss. Children who fail the newborn screening in one or both ears, those lost to or who did not complete the screening process, or those who initially pass but present a congenital or postnatal risk factor as defined by JCIH (2019), are referred to Level 2. At this stage, they undergo a comprehensive audiological evaluation at one of the three pediatric audiology units located in the region’s major hospitals, referred to in this study as Centers 1, 2, and 3. Comprehensive audiological evaluations are performed by expert audiologists—ideally within a single session—and include both objective and subjective tests: otoscopy, diagnostic OAE, tympanometry, ipsilateral acoustic reflexes, and air-conduction ABR to determine hearing thresholds. Children who fail the Level 2 audiological evaluation are referred to Level 3 for further assessment, diagnosis, and, when necessary, intervention and treatment. The Regional Center for Pediatric Hearing Loss Care, located at the Burlo Garofolo Institute, is the only facility in the FVG region responsible for conducting examinations at this final stage of the screening program. For instance, with regard to the additional evaluations and examinations carried out during the screening program, the database shows that the diagnosis of permanent hearing loss was based on a genetic test in 12 patients, and computed tomography or magnetic resonance imaging in 41 cases, to assess the presence of alterations at the level of the inner ear or cerebral abnormalities. Among those undertaking neuroimaging assessment, 22 show a cerebral alteration, and 2 patients also report an alteration in the inner ear. The database analyzed in this study contains detailed information about patients referred to Level 3, allowing us to assess the program’s effective coverage and efficiency along the pathway from identification to diagnosis. Specifically, we examined the number of patients progressing through the subsequent phases of Level 3: Phase 3A: individuals who failed the second level with a type 3 outcome. Phase 3B: individuals correctly referred to the third (diagnostic) level. Phase 3C: individuals who actually presented for evaluation. Phase 3D: confirmed cases of hearing loss that entered the diagnostic process. Statistical analyses Statistical analyses were conducted in Python using non-parametric permutation tests, due to the limited sample sizes of patient groups. For each analysis, a test statistic (e.g., χ²) was computed on the observed data. Observations were then randomly permuted 10,000 times to generate a null distribution of the statistic. P-values were computed by comparing the observed statistic to the null distribution. For significant t tests, the effect size (d’Cohen; Cousineau and Goulet-Pelletier 2021) and the confidence intervals are reported. Confidence intervals were computed using the bootstrap method with N=1000 bootstrap replicas. All the codes are available at: https://osf.io/5jeby/overview?view_only=d4d53b57f8384489befd32c0c4b525df . Sensitivity and specificity of diagnostic tests We further assess how permanent hearing loss is diagnosed by conducting an analysis of the effective sensitivity and specificity of diagnostic tests (A-TEOAE and A-ABR) employed during the early step of the screening program and how their results are aggregated (Böttcher et al. 2025). The effective sensitivity and specificity of diagnostic tests employed during Level 1 of the hearing screening program were computed based on the following confusion matrices. Table 2 . Confusion matrix of A-TEOAE test results. Table 3 . Confusion matrix of A-ABR test results Table 2 compares A-TEOAE results with respect to total births in the FVG region and IP diagnosis. Table 3 reports data for A-ABR results. (A-TEOAE or A-ABR results can be either “Refer,” i.e., positive, or “Pass,” i.e., negative. IP diagnosis can be present, i.e., 1, or absent, i.e., 0. TP= True Positive; FP=False Positive; FN=False Negative; TN=True Negative). The effective sensitivity ( Se ) and specificity ( Sp ) of the two tests are then computed as follows: Se=TP / (TP + FN) Sp =TN / (TN + FP) Effective sensitivity ( Se ) and specificity ( Sp ) are then used to compute the aggregated estimates Se OR and Sp OR based on the OR operator. In particular, the effective sensitivity and specificity of A-TEOAE, i.e., Se( A-TEOAE )= p(A-TEOAE+|IP=1) Sp( A-TEOAE )= p(A-TEOAE–|IP=0) and of A-ABR, i.e., Se( A-ABR )= p(A-ABR+|IP=1) Sp( A-ABR )= p(A-ABR–|IP=0) were computed. Then, to assess the overall sensitivity ( Se OR ) and specificity ( Sp OR ) of Level 1 screening, aggregated estimates can be computed by relying on the OR operator as follows (Böttcher et al. 2025): Se OR = Sp (A-TEOAE)+((1-Se(A-TEOAE))*Se(A-ABR) Sp OR = Sp (A-TEOAE)*Sp(A-ABR). Results 1.1 Overall screening procedure during Level 3 (Descriptive) The records of 106 children who accessed Level 3 of the neonatal hearing screening program in FVG between 2019 and 2023 were analyzed through Phases 3A, 3B, 3C and 3D, until the final diagnosis, i.e., normal hearing condition (NORM), temporary (conductive) hearing loss subsequently solved (TT), and permanent (sensorineural, conductive or mixed) hearing loss (IP). Table 1 below reports the number of patients in the FVG region accessing Level 3, arranged by year, Phase, and final diagnosis (either temporary conducive hearing loss or permanent). Aggregated data are reported in a flowchart (Figure 2) below. Table 1. Number of patients in the FVG region accessing Level 3 of the screening program between 2019 and 2023 and diagnosed with either TT or IP. Among 106 patients accessing Level 3, only 65 were actually diagnosed as IP, while 10 patients resulted in TT and 6 NORM (See Supplementary materials). Across the different Phases, 28 records were classified as losses, specifically either lost documentation (LD), i.e., patients whose records are missing, or loss to follow-up (LF), i.e., patients enrolled in the program who are no longer in contact with the centers. Moreover, 3 patients (indicated as “In”) accessed Phase 3C directly, having them previously wrongly dismissed from the program. Figure 2 shows mixed results. Indeed, while about 8 patients out of 10 correctly end the program with a definitive diagnosis and etiology, rates of LD and LF, as well as the presence of “In” patients reintroduced in the program, represent non-transcurable information when the efficiency of the screening procedure as a whole is evaluated. Further insights about losses can be obtained by looking at the specific influence of organizational aspects on the screening program. In this respect, data grouped by the different hospitals, i.e., Center 1, 2, and 3, in charge of audiological assessment during Level 2, are relevant. Indeed, as shown in Figure 3, while IP, TT, and NORM are comparable between the three centers, it is worth noticing that all LD come from either Center 1 or 3, that is, centers other than the Regional Center for Pediatric Hearing Loss Care (Center 2) that treat patients during Level 2 and communicate referrals to the regional hub. Such data suggest a management issue when patients are referred from these centers to Center 2 that needs further investigation. 1.2 Overall screening procedure during Level 3 (Statistical analysis) Criticisms about the management of referrals, i.e., the high rate of losses, can be investigated in light of the specific functions that Phases of the program have. Indeed, the early Phases 3A and 3B have mainly organizational and management functions, as substantially related to the correct communication between the centers involved in the program, while Phases 3C and 3D have a clear clinical and diagnostic impact, as involving audiological evaluation, diagnosis, and treatment of patients. Therefore, variations in the number of suspected hearing losses are not expected during Phases 3A and 3B and, if present, might be interpreted as cues of organizational and management weaknesses in the program. On the contrary, variations in the number of patients can be expected during Phases 3C and 3D, e.g., concerning the identification of false positives, given the clinical evaluations children undergo in these cases. A straightforward way to evaluate the efficiency of the procedure and the influence of clinical and organizational Phases consists of estimating the incidence of hearing loss at each Phase. Given the total births in FVG during the five-year period 2019–2023 are 39,112, the overall incidence of hearing loss across the three Centers varies as follows: 2.71‰ (Phase 3A), 2.12‰ (Phase 3B), 2.15‰ (Phase 3C), 1.92‰ (Phase 3D). Then, the final incidences of temporary (TT) and permanent (IP) hearing impairments are respectively 0.26‰, and 1.66‰–results that, in the case of permanent hearing loss, are in line with the prevalence of the condition in Italy. These results are in contrast with expectations about the screening program since the incidence varies during all Level 3 Phases. However, while variations are expected only during clinically-relevant Phases 3C and 3D, changes in the number of suspected hearing losses are observed during Phases 3A and 3B, that is, phases with primary organizational functions; these variations are due to the number of LF and LD only (See Supplementary Materials). In particular, the difference in the number of LF and LD across centers is significative and depends on the particular Level 2 Center is further confirmed by the results of a chi-squared test for independence (based on permutation design, 10,000 permutations) conducted on patients classified as losses (i.e., LD or LF) or no-losses (i.e., IP, TT, NORM) and the particular center (Center 1, 2 or 3). The test result allows us to reject the null hypothesis of independence between the Level 2 centers and their loss/no-loss classification during Level 3 (observed chi-square (χ²) = 11.56, DF=2, p-value=.003), indicating a clear relation between the rate of losses and the specific hospital that administered patients during Level 2. 2.1 Permanent and temporary hearing loss (Descriptive) Among the patients who accessed Level 3 in FVG between 2019 and 2023 and received a final diagnosis, 65 were classified as having a permanent hearing impairment (IP), 10 as temporary conductive hearing loss, and 6 as normal hearing subjects. In particular, IP and TT diagnoses were performed during Phase 3D, while normal hearing patients were identified after examinations occurred at Phase 3C (Figure 2). Available information about these patients allows us to investigate the timing of their diagnosis as well as provide details about their clinical conditions. Overall, the majority of patients included in the dataset that accessed Level 3 failed to pass both automated transient evoked otoacoustic emissions (A-TEOAE) and automated auditory brainstem response (A-ABR) examination during Level 1, present JCIH risk factors (JCIH 2019; Beswick et al. 2012), and show a grade of hearing loss (WHO 2021) from mild to moderate in the case of NORM and TT and from mild to profound for IPs, with 47 out of 65 bilaterally. In particular, regarding the JCIH risk factors (Figure 4; see also Supplementary Materials, Section 2), we observe that their presence often led to a refer outcome during Level 1 screening, even though A-TEOAE and A-ABR result negative. Specifically, within the current database, the majority (58%) of NORM, TT, and IP patients presented with at least one risk factor (17% multifactorial), while 10% of them had a history of preterm birth. When NORMs and TTs are taken into account, 63% (10 out of 16) of them show at least one risk factor (the most frequent being intensive care of more than 5 days). For IPs, the percentage of patients presenting at least one risk factor decreases to 57% (37 out of 65). Among them, risk factors that occur the most are neonatal intensive care of more than 5 days (code 2 in Fig. 4), family history of hearing loss (code 1), presence of syndromes associated with atypical hearing thresholds (code 9), and particular birth conditions, such as craniofacial malformations and temporal bone abnormalities (code 8). Another important aspect to consider when assessing the overall efficacy of the screening program is the time required to conclude the entire process, based on specific recommendations such as the 1-3-6 benchmark (JCIH 2007, 2019). Figures 5a-b report the time interval between birth, the different Phases of Level 3, and prosthesis implantation, both for IPs and TTs. While the protocol of the FVG region adheres to the 1-3-6 recommendations of JCIH (2007), results indicate a suboptimal timeline on average and difficulties in meeting the 1-2-3 benchmark (JCIH 2019). Indeed, IPs and TTs reach Phase 3A after 6.4 months from birth on average, while Phase 3D occurs after 12 months on average. For what specifically concerns IP's timeline from birth to implantation, 44% of the patients received audiological assessment and accessed Level 3 of the program within 3 months, as recommended by JCIH guidelines (average 6.3 months), with Phase 3D occurring on average after 11.9 months and implantation after 19 months. All these results are, however, due to a portion of cases achieving Phase 3D and implantation very late (>30 months), while the majority of patients actually receive diagnosis and implantation between 12 to 18 months from birth. Timeline concerns might be associated with different factors. Here, we investigated whether a difference between the timelines of patients diagnosed with temporary and permanent hearing loss exists and, if so, whether this difference is related to specific organizational and management aspects, e.g., difficult early discrimination, false positives, producing cascade effects on further steps of the program. 2.1 Permanent and temporary hearing loss (Statistical analysis) The issues in the communication and transfer of data between centers investigated in previous sections can be associated not only with a higher risk of losses but also with delays and time-related inefficiencies. To investigate whether a difference between the timeline associated with permanent and temporary hearing loss is significant and what stages of the screening program have major relevance, we conducted two one-tailed Student’s t-tests on the time intervals occurring between birth and different Level 3 Phases for patients diagnosed with permanent and temporary hearing loss. In light of the results reported in Fig. 5a, in the first test, we evaluated the hypothesis that the interval occurring between birth and Phase 3A is, on average, greater for TTs than IPs. Given the limited data available, a one-tailed t-test on the time intervals for the two groups was conducted based on a permutation design (10,000 permutations). The test results allows us to reject the null hypothesis that there is no significant difference between the birth to Phase 3A time intervals of TTs and IPs (t(73)=1.68, p-value=.048; 95% CI: [-1.42, 2.53]; Cohen's d=0.57; 95% CI= [-0.11, 1.25]) and, in particular, to conclude that such a time interval is larger in the case of TTs (TT’s mean interval: 304 days; IP’s mean interval: 174 days). This result demonstrates that time concerns were already involved in the early steps of the screening program, before entering the main Phases of Level 3. To assess whether Level 3 is also affected in terms of time, a second one-tailed Welch t-test was conducted on the time interval between Phase 3A and Phase 3D, corresponding to the final, diagnostic stage of the program. Again, we hypothesized that the time interval was greater for TTs as compared with IPs, and due to the limited number of data, we relied on a permutation design (10,000 rep.). Test results do not allow us to reject the null hypothesis (t(73)=0.93; p-value=0.12; 95% CI: [-3.53, 1.54]). So, we can conclude that there is no statistically significant difference in the time intervals associated with IPs and TTs when the gap between Phase 3A and Phase 3D is considered. Therefore, whether a difference in the timeline between temporary and permanent hearing loss exists and is significant, it is in the early steps of the screening procedure, i.e., Levels 1 and 2, with no clear impact of specific stages encountered during Level 3. Another practical aspect worth considering concerns how early in the program a reliable discrimination of the pathological conditions of interest, e.g., temporary or permanent hearing loss, is expected. Indeed, a high number of false positives hard to identify early on might cause inefficiencies in the management, thus leading to errors and delays. In this respect, it is worth assessing whether particular examination strategies during Levels 1 and 2 of the screening program might affect an early and correct discrimination of the two conditions or, for instance, increase the number of false positives, making their identification harder and impacting the timeline. Therefore, a central issue regards the particular diagnostic tests employed for early screening during Level 1. At this stage, the adopted protocol requires screening patients based on two objective tests, i.e., A-TEOAE and A-ABR, and then assessing the presence of potential risk factors. Both tests can provide a negative result (pass) or a positive one (refer), and according to the FVG protocol, A-ABR testing is performed subsequently to A-TEOAE, if the result is refer. The two tests are administered in series, and newborns access Level 2 for audiologic assessment when either (1) both tests result refer or (2) A-TEOAE results refer bilaterally, and A-ABR test results pass. Instead, if both test results are pass, but one or more risk factors are present, the patient undergoes an audiologic assessment. Therefore, the particular strategy implemented to aggregate multiple or repeated test results (Cebul et al. 1982; Politser 1982; Fanshawe et al. 2024) and decide whether to refer a patient to Level 2 is particularly relevant for an early and correct discrimination of the conditions of interest, as it might increase the risk of false positive referrals. Based on the decision three behind Level 1 (Figure 6a), the current strategy to aggregate A-TEOAE and A-ABR tests seems to follow an “all heuristic” or “conjunctive positivity criterion,” based on the Boolean aggregator AND (Böttcher et al. 2025). According to this rule, both tests should result refer, for the outcome of the screening Level 1 to be referred to Level 2 (Figure 6b). The main advantage of such a strategy is to enhance the specificity (or true negative rate) of the aggregated test, when compared to the specificity of the single ones, and to reduce the risk of accepting the hypothesis that the patient is affected by the disease, when in fact the condition is absent (type I error). Therefore, aggregating results of multiple tests via AND operator represents the best strategy to minimize the risk of false positives as compared with other aggregation rules, e.g., OR, or the consideration of a single test result (Böttcher et al. 2025). However, the FVG 2019-2023 Database shows that the effective strategy to aggregate results of diagnostic tests performed during Level 1 follows an “any heuristic” or “disjunctive positivity criterion” based on the Boolean aggregator OR. Indeed, the 106 patients arriving at Level 3 generally underwent both tests, even when the A-ABR was not strictly recommended by the FVG protocol, given that a pass result of A-TEOAE or risk factors for which A-ABR is suggested (e.g., intensive care) were absent. Moreover, the dataset includes a few patients who accessed Level 3, even though they passed all the Level 1 screening tests and showed no risk factors. This observation highlights the need to evaluate how results of screening tests are employed during the early step of the program to make decisions (Lin et al. 2007, Benito-Orejas et al. 2008) and, in particular, assessing the effect of using the “any heuristic” rather than the “all heuristic” as an aggregation strategy for detecting permanent hearing losses. Indeed, in the case of the OR strategy, for a patient to be referred to Level 2, it is sufficient that one of the two administered test results is refer, as illustrated in Figure 6b. This strategy enhances the sensitivity (or true positive rate) of the aggregated examination; that is, the sensitivity of the two tests when considered together is always higher than the sensitivity of each of the two tests taken alone, thus reducing the false negative rate, which could lead to delayed diagnosis of hearing loss (Acke et al., 2022), and type II error. However, the main disadvantage of the OR aggregation strategy is that, when compared to single tests, the aggregated examination is less specific, thus increasing the false positive rate and the risk of incurring in type I error (Böttcher et al. 2025). Here, we can confirm this by computing the actual sensitivities and specificities of A-TEOAE, i.e., 0.91 and 0.99, and of A-ABR, i.e., 0.92 and 0.99–in line with previous studies (Sheng et al., 2021; Neumann & Indermark, 2012), and then aggregate them via OR operator. The aggregated estimates, i.e., Se OR and Sp OR , of Level 1 screening show very high sensitivity and specificity, i.e., 0.99 and 0.98 (see Methods for details). In particular, the OR aggregation strategy increases sensitivity overall, but reduces specificity (from 0.99 for both tests to 0.98 for the aggregated case), even if very slightly. This in fact, increases the risk of having false positives and then the need to manage a higher number of patients during the program, with potential consequences on the organization and timing. Discussion Universal newborn hearing screening (UNHS) is widely recognized as one of the most effective public health interventions in pediatric audiology. Over the years, the Joint Committee on Infant Hearing (JCIH) has refined its recommendations, evolving from the 1-3-6 rule to the more 1-2-3 guideline, emphasizing earlier identification and intervention to optimize language, cognitive, and social outcomes in children with permanent hearing loss. This change points to early identification and intervention, which should be associated with better language, cognitive, and social outcomes in children with permanent hearing loss ( JCIH, 2019 ) . In this study, we aimed to identify the effectiveness of the actual screening protocol with a regional analysis of the final stage of the neonatal hearing screening pathway in Friuli-Venezia Giulia (FVG), highlighting how organizational factors influence the real-world effectiveness of an otherwise well-established program. The incidence of permanent hearing loss in FVG is 1.66‰ and aligns with data from high-income countries, where prevalence typically ranges from 1 to 3 per 1,000 live births. This confirms that the regional program successfully identifies a population consistent with epidemiological expectations and suggests adequate coverage of the target cohort. Nonetheless, the high proportion of patients lost to follow-up between Levels 2 and 3 reflects a challenge widely described in the international literature. In particular, between 2019 and 2023, 106 children accessed Level 3 of the neonatal hearing screening program in the FVG Region in Italy. Level 3 is the final stage of the program, involving diagnosis, treatment, and follow-up of hearing losses at the Regional Center for Pediatric Hearing Loss Care (Center 2) in FVG. The analysis of children’s reports from the identification and diagnosis of hearing impairments to the prosthesis implantation allows assessing the coverage and efficiency of the procedure as a whole. Indeed, while the program has been efficiently implemented for more than ten years and sees coordinated and proficient participation of different actors, different management and organizational weaknesses are observed, being related to the number of losses, communication between centers, delays in the treatment of cases, and strategies to aggregate results of early screening tests. First, at the end of the program, 65 of the 106 patients entering Level 3 were effectively diagnosed with a permanent hearing loss, being sensorineural, conductive, or mixed, resulting in an incidence of 1,66‰ in the FVG population. Among patients accessing Level 3, however, 28 records have been classified as losses (LDs or LFs). This high number of losses is mainly observed between Phases 3A and 3B, when patients who have undergone audiological evaluation (Level 2) are referred to Center 2 for diagnosis, treatment, and follow-up. Given that these phases have a clear organizational function and no clinical relevance, the number of losses is a sign of a management weakness concerning these program stages. Second, the assessment of the program's timeline across the different stages highlights that only a percentage of patients are diagnosed and treated according to the 1-3-6 benchmark recommended by JCIH ( 2007 ), and that the program does not meet the more recent 1-2-3 guidelines proposed by JCIH ( 2019 ). Such a discrepancy might have different reasons, for instance, the choice of the specific reference time points, i.e., Phases, of the process. However, the statistical analysis conducted on the time gap of permanent and temporary hearing loss between birth, Phase 3A, and Phase 3D, reveals that the difference between the time interval in the case of permanent and temporary hearing losses is significant when the birth-Phase 3A interval is considered, but not when the birth-Phase 3D interval is analyzed. These results suggest that the suboptimal timing is not associated with delays specific to Level 3, but rather reflects the management of patients in previous steps. Third, the risk of false positives is partly determined by the diagnostic tests used in Level 1 and their intrinsic quality; in addition, the method applied to aggregate multiple results is highly impactful. During Level 1, newborns are screened with two tests (A-TEOAE and A-ABR) and assessed for risk factors. Besides the quality of these diagnostic tests, which generally show high sensitivity and specificity, variations across instruments have been reported, and the timing of neonatal hearing screening has been shown to significantly affect the false positive referral rate (Vonk et al., 2026 ). Available evidence also indicates that a potential reason for a high number of false positives is the specific rule for aggregating test results. Indeed, if the screening program implements the “any heuristic” based on OR Boolean operator the sensitivity increases, but the risk of incurring in type I error and false positives is enhanced. Results reveal that the observed decrease in specificity due to OR aggregation is very slight. However, this strategy necessarily determines an increase in the false positives and of the number of patients to treat. Moreover, when a cohort of approximately 39,000 newborns, as in FVG between 2019 and 2023, is taken into account, even a modest increase in false positives might have a detrimental effect on the management of suspected hearing losses, reducing the program efficiency. Therefore, “any heuristics” cannot minimize the risk of false positives, potentially causing not only a delayed patient dismissal from the program, but also time-related inefficiencies in the management of patients with permanent hearing loss. These issues underscore the need for evidence-based aggregation strategies, along with ongoing evaluation of screening protocols, to optimize specificity without compromising sensitivity. The effectiveness of a hearing screening program cannot be judged solely on clinical performance; it must also be evaluated in relation to the organization and management of the healthcare system in which the program operates. Indeed, organizational and structural factors, such as coordination among screening levels, efficient communication pathways, data monitoring systems, and standardized referral protocols, are crucial for quality, scalability, and sustainability (Yoshinaga-Itano et al., 2021 ; Orzan et al., 2022 ). Even when screening technologies exhibit high sensitivity and specificity, weaknesses in program organization can undermine their effectiveness by introducing delays, increasing losses to follow-up, and reducing overall coverage of the target population. Data from the final stages of the universal newborn hearing screening program in the Italian FVG Region highlight several systemic challenges, especially in the organizational domain. Newborn screening is a multi-step process requiring coordination, timely data transmission, and systematic monitoring. Without robust structures, even clinically sound programs risk inefficiencies, lower coverage, and delays. Each stage of this pathway relies on timely information exchange, accurate documentation, and effective patient tracking across institutions. Without robust organizational structures, even clinically well-designed programs risk inefficiencies, reduced coverage, and delays in diagnosis and intervention. In particular, the lack of centralized monitoring systems and clear data-sharing mechanisms can lead to higher rates of loss to follow-up and delayed diagnosis, even when initial screening coverage is high (Shulman et al., 2010 ). In line with recent public health perspectives, strengthening digital integration and shared data infrastructures appears critical. Centralized tracking systems that allow real-time monitoring of each child’s pathway have been shown to reduce delays and improve coverage. Automated notifications, standardized reporting formats, and interoperable electronic health records can facilitate continuity between maternity wards, second-level services, and tertiary referral centers. Such measures would likely enhance compliance with international benchmarks and reduce errors and delays, ensuring more effective and equitable programs. Conclusion The UNHS program in Friuli Venezia Giulia effectively identifies children with permanent hearing loss at expected prevalence rates, but organizational challenges, such as losses to follow-up, suboptimal timing, and inefficient aggregation of screening results, limit its full effectiveness. These findings highlight that clinical performance alone does not ensure program success. Strengthening coordination between care levels, implementing centralized digital tracking, and standardizing data sharing could reduce delays, improve coverage, and optimize early intervention. Combining high-quality screening tools with robust program management is essential to maximize outcomes and ensure timely, equitable care for children with hearing loss. Abbreviations A-TEOAE automated transient evoked otoacoustic emissions A-ABR automated auditory brainstem response LF lost to follow-up LD lost documentation TP True Positive FP False Positive FN False Negative TN True Negative Se Effective sensitivity Sp Effective specificity NORM Normal hearing condition TT temporary (conductive) hearing loss subsequently solved IP permanent (sensorineural, conductive or mixed) hearing loss BC birthing centers FVG Friuli-Venezia Giulia JCIH Joint Committee on Infant Hearing Declarations Ethics approval and consent to participate The study was conducted in accordance with the Declaration of Helsinki and approved by the Institutional Review Board of the Institute for Maternal and Child Health-IRCCS Burlo Garofolo, Trieste, Italy (protocol code IRB BURLO 08/2020, approved on 1 December 2022). Consent for publication All necessary participant consent has been obtained and the appropriate institutional forms have been archived, and any participant identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals. Availability of data and materials All the data and codes used in the analysis are available at: https://osf.io/5jeby/overview?view_only=d4d53b57f8384489befd32c0c4b525df . The raw FVG Dataset is available upon request. Competing interests The authors declare that they have no competing interests. Funding This work was supported by the Italian Ministry of Health, through the contribution given to the Institute for Maternal and Child Health IRCCS Burlo Garofolo, Trieste - Italy. Authors' contributions DC: Conceptualization, Analyses, Writing; MF: Conceptualization, Writing; ET: Data collection; Writing; RT: Data Collection; Writing; LR: Conceptualization; Funding; Writing; Data Collection; EO: Conceptualization, Writing. Acknowledgements Importantly, the first author, Dr. Davide Coraci, conducted the study and prepared the manuscript in 2025 while employed at the Institute for Maternal and Child Health IRCCS Burlo Garofolo in Trieste, Italy. References Acke, F. R. E., De Vriese, C., Van Hoecke, H., & De Leenheer, E. M. R. (2021). Twelve years of neonatal hearing screening: audiological and etiological results. European Archives of Oto-Rhino-Laryngology , 279 (7), 3371–3378. https://doi.org/10.1007/s00405-021-07060-5 Benito-Orejas, J. I., Ramírez, B., Morais, D., Almaraz, A., & Fernández-Calvo, J. L. (2008). 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A study of confidence intervals for Cohen’s dp in within-subject designs with new proposals. The Quantitative Methods for Psychology, 17 (1), 51–75. https://doi.org/10.20982/tqmp.17.1.p051 Fanshawe TR, Nicholson BD, Perera R, Oke JL. A review of methods for the analysis of diagnostic tests performed in sequence. Diagnostic and Prognostic Research. 2024; 8(1):8. https://doi.org/10. 1186/s41512-024-00175-3 PMID: 39223640 Feresin, A., Ghiselli, S., Marchi, R., Staffa, P., Monasta, L., & Orzan, E. (2019). Who misses the newborn hearing screening? Five years’ experience in Friuli-Venezia Giulia Region (Italy). International Journal of Pediatric Otorhinolaryngology , 124 , 193-199. Holster, Ingrid L., Lambertus J. Hoeve, Marian H. Wieringa, Rose MS Willis-Lorrier, and Henriette HW de Gier. "Evaluation of hearing loss after failed neonatal hearing screening." The Journal of pediatrics 155, no. 5 (2009): 646-650. Hyde, M. L. (2005). Newborn hearing screening programs: overview. 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Epub 2016 Feb 29. PMID: 27054385; PMCID: PMC4825067. Neumann, K., Indermark, A. (2012). Validation of a new TEOAE-AABR device for newborn hearing screening. International journal of audiology , 51 (8), 570-575. Orzan, E., Tinelli Bonadonna, E., Consolino, P., Cutler, J. M., Di Berardino, F., Forli, F., Gallo, L., Merico, A., Viola, A. 2022, Screening uditivi nel corso della vita: una fotografia del panorama italiano, Acta Otorhinolaryngologica Italica, 16 (1), 2-12. Orzan, E., Pizzamiglio, G., Marchi, R., Muzzi, E., Monasta, L., Torelli, L., & Feresin, A. (2021). Modeling Postnatal Hearing Case Finding Within the Italian National Health System. Frontiers in pediatrics , 9 , 564662. Orzan, E., Ruta, F., Bolzonello, P., Marchi, R., Ceschin, F., & Ciciriello, E. (2016). Childhood hearing surveillance activity in Italy: preliminary recommendations. Acta Otorhinolaryngologica Italica , 36 (1), 15. Politser, P. 1982. Reliability, decision rules, and the value of repeated tests. Medical Decision Making 2(1), pp. 47–69. https://doi.org/10.1177/0272989X8200200108 PMID: 7169931 Razak, A., Fard, D., Hubbell, R., Cohen, M., Hartman-Joshi, K., & Levi, J. R. (2021). Loss to follow-up after newborn hearing screening: Analysis of risk factors at a Massachusetts urban safety-net hospital. Ear and Hearing , 42 (1), 173-179. Sheng, H., Zhou, Q., Wang, Q., Yu, Y., Liu, L., Liang, M., Zhou, X., Wu, H., Tang, X., Huang, Z. (2021) Comparison of Two-Step Transient Evoked Otoacoustic Emissions and One-Step Automated Auditory Brainstem Response for Universal Newborn Hearing Screening Programs in Remote Areas of China. Front. Pediatr. 9:655625. doi: 10.3389/tped.2021.655625 Shulman S, Besculides M, Saltzman A, Ireys H, White KR, Forsman I. Evaluation of the universal newborn hearing screening and intervention program. Pediatrics. 2010 Aug;126 Suppl 1:S19-27. doi: 10.1542/peds.2010-0354F. PMID: 20679316. Vonk, L., Van Dommelen, P., Eekhout, I., Uilenburg, N. N., Verkerk, P. H., & Van Der Ploeg, C. P. B. (2026). Optimal timing for neonatal hearing screening in Well-Babies. International Journal of Neonatal Screening , 12 (1), 7. https://doi.org/10.3390/ijns12010007 Walker, E. A., Holte, L., Spratford, M., Oleson, J., Welhaven, A., Harrison, M. 2014. Timeliness of service delivery for children with later-identified mild-to-severe hearing loss. Am J Audiol. 23, pp. 116–28. doi: 10.1044/1059-0889(2013/13-0031) Wen, C., Huang, L. H. (2023). Newborn hearing screening program in China: a narrative review of the issues in screening and management. Frontiers in Pediatrics , 11 , 1222324. WHO (2021). World report on hearing. Geneva: World Health Organization; 2021. Licence: CC BY-NC-SA 3.0 IGO. Yoshinaga-Itano, C., Manchaiah, V., & Hunnicutt, C. (2021). Outcomes of Universal Newborn Screening Programs: Systematic review. Journal of Clinical Medicine , 10 (13), 2784. https://doi.org/10.3390/jcm10132784 Supplementary Files SupplementaryMaterials.docx Cite Share Download PDF Status: Under Review Version 1 posted Reviewers agreed at journal 16 Apr, 2026 Reviewers invited by journal 15 Apr, 2026 Editor assigned by journal 13 Apr, 2026 First submitted to journal 03 Apr, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-9305306","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":623633387,"identity":"a1649ca4-a5d3-44e3-950f-69d7dea4fbc0","order_by":0,"name":"Davide Coraci","email":"","orcid":"","institution":"IUSS: Scuola Universitaria Superiore Pavia","correspondingAuthor":false,"prefix":"","firstName":"Davide","middleName":"","lastName":"Coraci","suffix":""},{"id":623633388,"identity":"054c3a38-3ae2-4436-a7e8-68706cac3ff5","order_by":1,"name":"Marta Fantoni","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABJ0lEQVRIie2QsUrDQBjHvyOQLgHXE7R5AuFCIDoovsodwvUVOoimHMTFBwhY7CtkqggOnwRuirh26JAscXGwW4YOpo1YMbe4Odxvuf/9+X7cxwFYLP+XYXfwMQIMtpF+NcZxEgOEAO5moGgVpw24UbaN0fmhkORbga4xPHN08/JWNsD8Y1/psrpfigfloLN6Ohn6M4VQNT0lKkbB5BZY8Ji4IybmtZjmLgesach0GwyLRShJ7MGaZNqLqJjnInU8BohUZG4bTMprTSZrYOedMt0p17Nk78OoLCRRHjDRKfFO4aA9449Fi5rcHTB2kWkpKdd1mDouxwJp0DYMuTQsJmH1PmZnWZ7r/eZyeZgO1HM5xivfV3lVNac9pYP9umMvWCwWi+VPfALugG+9V3+hKQAAAABJRU5ErkJggg==","orcid":"https://orcid.org/0000-0003-0155-880X","institution":"IRCCS materno infantile Burlo Garofolo","correspondingAuthor":true,"prefix":"","firstName":"Marta","middleName":"","lastName":"Fantoni","suffix":""},{"id":623633389,"identity":"830cce0f-a13f-4869-839c-e2b2ec6bf0c4","order_by":2,"name":"Eleonora Tonon","email":"","orcid":"","institution":"IRCCS materno infantile Burlo Garofolo","correspondingAuthor":false,"prefix":"","firstName":"Eleonora","middleName":"","lastName":"Tonon","suffix":""},{"id":623633390,"identity":"7df03aec-dd4a-4e5d-bc9e-5d27c5fa13c2","order_by":3,"name":"Raffaella Marchi","email":"","orcid":"","institution":"IRCCS materno infantile Burlo Garofolo","correspondingAuthor":false,"prefix":"","firstName":"Raffaella","middleName":"","lastName":"Marchi","suffix":""},{"id":623633391,"identity":"4b95c9c2-f7db-458c-afb9-0eb37462444c","order_by":4,"name":"Luca Ronfani","email":"","orcid":"","institution":"IRCCS materno infantile Burlo Garofolo","correspondingAuthor":false,"prefix":"","firstName":"Luca","middleName":"","lastName":"Ronfani","suffix":""},{"id":623633392,"identity":"adeff6ac-3be9-43a0-8ed0-985486b42364","order_by":5,"name":"Eva Orzan","email":"","orcid":"","institution":"IRCCS materno infantile Burlo Garofolo","correspondingAuthor":false,"prefix":"","firstName":"Eva","middleName":"","lastName":"Orzan","suffix":""}],"badges":[],"createdAt":"2026-04-02 16:02:19","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-9305306/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-9305306/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":107634492,"identity":"bfb0703c-74c1-436a-a2a1-21492faff461","added_by":"auto","created_at":"2026-04-23 12:22:31","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":107543,"visible":true,"origin":"","legend":"\u003cp\u003e(a) Levels 1, 2, and 3 in the neonatal hearing screening program in the FVG region. (b) Details about the Level 3 Phases.\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-9305306/v1/7b4b99be188aa3a04f71fccc.png"},{"id":107634494,"identity":"822f78cf-bdda-44d4-bff9-540f4d7f1408","added_by":"auto","created_at":"2026-04-23 12:22:31","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":58420,"visible":true,"origin":"","legend":"\u003cp\u003eFlowchart of Level 3 showing aggregated data (2019–2023).\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-9305306/v1/91a70c867c3362135f6302bd.png"},{"id":107634495,"identity":"38b3c732-d199-49ef-834f-2de6b44a50d4","added_by":"auto","created_at":"2026-04-23 12:22:31","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":29811,"visible":true,"origin":"","legend":"\u003cp\u003eOutcomes (IP, TT, NORM, LD, and LF) are divided by Level 2 Centers (2019–2023).\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-9305306/v1/e5250e1dbb659481198415b4.png"},{"id":107706243,"identity":"9de2e9b6-4cbf-4138-a860-c600442bfe6e","added_by":"auto","created_at":"2026-04-24 09:17:44","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":35540,"visible":true,"origin":"","legend":"\u003cp\u003ePresence of JCIH risk factors in the different groups, i.e., IP, TT, and NORM. The list of JCIH risk factors corresponding to each code is reported in Supplementary Materials (Section 2).\u003c/p\u003e","description":"","filename":"4.png","url":"https://assets-eu.researchsquare.com/files/rs-9305306/v1/3639fde61fc8c07f73143fdb.png"},{"id":107634497,"identity":"d4877cff-e409-4136-b9de-120ee29e1d84","added_by":"auto","created_at":"2026-04-23 12:22:31","extension":"png","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":184091,"visible":true,"origin":"","legend":"\u003cp\u003e(a) Time interval between birth and Phases 3A and 3D for IP and TT patients. (b) Time interval including prosthesis implantation for IP patients.\u003c/p\u003e","description":"","filename":"5.png","url":"https://assets-eu.researchsquare.com/files/rs-9305306/v1/e103ea6e33da132417164f76.png"},{"id":107706022,"identity":"6d055abf-7dd5-4174-afda-1fb4c66ac6fb","added_by":"auto","created_at":"2026-04-24 09:17:09","extension":"png","order_by":6,"title":"Figure 6","display":"","copyAsset":false,"role":"figure","size":68909,"visible":true,"origin":"","legend":"\u003cp\u003e(a) Decision three of Level 1 of the screening program in FVG based on results of A-TEOAE and A-ABR and the presence of risk factors. (b) Outcomes of AND and OR operators when two input results are aggregated, both in series and parallel testing (in the context of screening, plus and minus signs stand for refer and pass, respectively).\u003c/p\u003e","description":"","filename":"6.png","url":"https://assets-eu.researchsquare.com/files/rs-9305306/v1/e343014ad765caeae462b233.png"},{"id":108181050,"identity":"fe7191d3-1cfa-4128-978d-b52db8a57e02","added_by":"auto","created_at":"2026-04-30 08:56:40","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":735113,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-9305306/v1/c0d4c65f-13ee-40cb-b43c-c05e8c7ab832.pdf"},{"id":107706970,"identity":"74674321-88d9-4605-9462-911583800a06","added_by":"auto","created_at":"2026-04-24 09:19:10","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":97153,"visible":true,"origin":"","legend":"","description":"","filename":"SupplementaryMaterials.docx","url":"https://assets-eu.researchsquare.com/files/rs-9305306/v1/6a72dc96ef9ffeb0b143e08b.docx"}],"financialInterests":"","formattedTitle":"Practice and challenges of newborn hearing screening: Analysis of a five-year database in Italy","fulltext":[{"header":"Background","content":"\u003cp\u003eEarly diagnosis and treatment of congenital hearing impairment are fundamental for the development of perceptual and cognitive abilities, language, and overall social well-being. Nowadays, in many countries around the world, early intervention is made possible through established newborn hearing screening programs (Hyde, 2005). These programs follow the guidelines of the Joint Committee on Infant Hearing (JCIH, 2019), which define the key milestones and optimal timeline for the screening and management of suspected hearing loss in children. Specifically, the JCIH (2019) recommends that screening programs include the following steps: an initial objective hearing screening and re-screening to be completed within the first month of life for all newborns; a comprehensive audiological evaluation by no later than 2 months of age for infants who did not pass the initial screening; confirmation of diagnosis and initiation of early intervention and treatment no later than 3 months of age; and, finally, the implementation of an individualized audiological follow-up pathway for at-risk children. These guidelines update the 1-3-6 benchmark recommended in JCIH (2007).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIn the case of Italy—the case study of this article—newborn hearing screening is mandatory and provided free of charge to all newborns. Even prior to 2017—the year of the most recent updates to national healthcare programs (Ministerial Decree \u003cem\u003e\"Definition and Updating of the Essential Levels of Care,\"\u003c/em\u003e Art. 38)—the Italian clinical and scientific community was attentive and prepared to adapt its practices into large-scale, multidisciplinary, and multi-professional healthcare initiatives such as newborn hearing screening. However, the newborn hearing screening programs currently implemented across Italian regions are not without criticism. For example, in 2021, a report by the Italian Society of Otorhinolaryngology and Cervico-Facial Surgery (Orzan et al. 2022) highlights that the procedures and workflows of screening programs are not always consistent at the national, inter-regional, and sometimes even intra-regional levels. Additionally, there is a lack of systematic data analysis that could serve as process indicators for monitoring and improving the quality, accuracy, \u0026nbsp;and time-efficiency of these programs (Holster et al. 2009; Walker et al. 2014; Orzan et al. 2016).\u003c/p\u003e\n\u003cp\u003eIn particular, despite the existing literature on hearing screening programs (Kumar, Mohapatra 2011;\u0026nbsp;Lim et al. 2012; Kanji et al. 2018; Marinho et al. 2020), limited attention is generally given to the later stages of these programs—stages in which the impact on the overall quality and effectiveness of the screening process can be appreciated not only for clinical and diagnostic elements, but also for organizational factors (Wen and Huang, 2023). While several publications have assessed the performance of the initial phases of hearing screening in Italy (Molini et al., 2016; Malesci et al., 2022), the subsequent stage, which involves diagnostic confirmation and therapeutic management by a specialized facility, remains underexplored in the scientific literature.\u003c/p\u003e\n\u003cp\u003eHowever, assessing this final step of the hearing screening program is mandatory. It is at this stage that the most critical challenges often arise, as it is where the diagnosis is confirmed, and treatment planning begins. Furthermore, evaluating this phase provides valuable insights into patient management, such as estimating the rates of false positives, lost to follow-up (LF), and lost documentation (LD; Feresin et al. 2019; Orzan et al. 2021; Razak et al. 2021), and highlights how clinical and organizational factors, including the coordination between local centers and specialized facilities, influence the overall effectiveness of the screening program.\u003c/p\u003e\n\u003cp\u003eThe aim of this article is to examine the main clinical and organizational aspects involved in the final step of the hearing screening pathway, with the goal of identifying key management weaknesses, evaluating their cascade effects on diagnostic timelines and treatment initiation, and proposing potential improvements for future screening strategies.\u003c/p\u003e\n\u003cp\u003eThe article focuses on the Friuli-Venezia Giulia (FVG) 2019-2023 Database (see Methods for details) of clinical records of 106 children who accessed the last phase of the neonatal hearing screening program, i.e., did not pass examinations at birthing centers nor the audiological evaluation, in the Italian Region Friuli-Venezia Giulia between 2019 and 2023.\u003c/p\u003e\n\u003cp\u003eFVG is a region in which the program for early identification of childhood hearing loss was formally established in 2012 (Feresin et al. 2019). In particular, the regional protocol for early identification of childhood hearing loss in FVG defines the roles of the different centers involved in the program and the procedures to follow, based on JCIH recommendations (Figure 1(a)). These include the different birthing centers in the region, performing the hearing screening test within the first month of life (Level 1), three main hospitals (Center 1, Center 2, and Center 3), conducting a complete audiological evaluation (Level 2), and the Regional Center for Pediatric Hearing Loss Care (Center 2), responsible for the final audiological and etiological diagnosis (Level 3), treatment, and follow-up of children with permanent hearing loss.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe dataset allows us to further analyze patients based on the different subsequent Phases 3A, 3B, 3C, and 3D (Figure 1(b)) they encounter during Level 3. This subdivision permits discrimination between the impact of clinical and organizational factors on the procedure as a whole, given the specific function each phase has. For instance, Phases 3A and 3B have primary organizational relevance, but a limited role from a diagnostic point of view, as they respectively concern individuals who failed Level 2 with suspected sensorineural or mixed hearing loss and individuals that correctly referred to Level 3 at the\u0026nbsp;Regional\u0026nbsp;Center for\u0026nbsp;Pediatric Hearing Loss Care. Instead, Phases 3C and 3D,\u0026nbsp;respectively regarding patients effectively\u0026nbsp;arriving\u0026nbsp;and\u0026nbsp;being evaluated at the regional center and patients with confirmed hearing losses that entered the diagnostic process, have clear diagnostic importance.\u0026nbsp;From the analysis of the pathway followed by patients suspected of hearing loss, we are then able to assess the\u0026nbsp;coverage of the screening hearing program from identification to diagnosis in FVG, to examine the effective sensitivity and specificity of diagnostic tests, and, especially, to assess the often overlooked impact of management and organizational factors on the efficiency of the program, formulating potential solutions to address observed issues.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003e\u003cem\u003eDatabase\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe FVG 2019-2023 Database includes reports for 106 patients who, between 2019 and 2023, were suspected of having hearing loss and referred to Level 3 of the neonatal hearing screening procedure in the Friuli-Venezia Giulia Region, Italy. Specifically, the database contains information on the patients’ history across the previous levels of screening, the outcomes of the different audiological examinations they underwent, the diagnosis of hearing impairment, and the subsequent treatment. Moreover, it records the cases of subjects who were dismissed from the program as having normal hearing conditions, as well as those whose evaluations were interrupted or whose documentation was lost (lost to follow-up or lost documentation), thereby providing important details about the overall efficiency of the screening process.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe data were manually extracted from reports available to the personnel of the Institute for Maternal and Child Health IRCCS Burlo Garofolo Trieste, based on entries in a dedicated platform and regular reports from all other regional centers involved in Levels 1 and 2 of the program. Data on the number of births in the FVG region (Table S1; see Supplementary Material) were also available to the Burlo Garofolo Institute, which serves as the FVG regional center administering births.\u003c/p\u003e\n\u003cp\u003eOverall, the neonatal hearing screening program in FVG is structured across three levels of monitoring for hearing impairments and involves four main stakeholders:\u003c/p\u003e\n\u003col start=\"1\" type=\"1\"\u003e\n \u003cli\u003eTen birthing centers (BC) in the region, responsible for performing the initial hearing screening test (Level 1) within the first month of life.\u003c/li\u003e\n \u003cli\u003eFamily pediatricians, responsible for ongoing hearing surveillance up to the child’s third year of life.\u003c/li\u003e\n \u003cli\u003ePediatric audiology services\u0026nbsp;located in the region’s three main hospitals and birthing centers (Centers 1, 2, and 3), responsible for conducting comprehensive audiological evaluations (Level 2) for newborns who fail the initial screening or are referred by a pediatrician, and for referring confirmed cases to the Regional Center for Pediatric Hearing Loss Care.\u003c/li\u003e\n \u003cli\u003eThe Regional Center for Pediatric Hearing Loss Care, the only one in the FVG region, located at the Burlo Garofolo Institute, responsible for the final audiological and etiological diagnosis, treatment, and follow-up of children with hearing loss (Level 3).\u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\u003eThe specific activities and responsibilities of the various operational levels of the Friuli Venezia Giulia program are shown in\u0026nbsp;Figure 1\u0026nbsp;and described in detail as follows.\u003c/p\u003e\n\u003cp\u003eDuring\u0026nbsp;Level 1, newborns are screened at the BC by trained nurses using a two-step procedure. The first test is the automated transient evoked otoacoustic emissions (A-TEOAE), which can be repeated up to two times. If the newborn fails this test, the screening is followed by the automated auditory brainstem response (A-ABR). Both tests are administered to infants considered at risk (see JCIH 2019) within 1 month from birth. The regional health system in FVG has complied with JCIH criteria since the program’s inception. Coverage has consistently exceeded\u0026nbsp;95%, while the referral rate has remained below\u0026nbsp;3%\u0026nbsp;since the first year of the program’s formal implementation (Orzan et al. 2021).\u003c/p\u003e\n\u003cp\u003eFamily pediatricians are responsible for postnatal hearing surveillance during routine child visits at\u0026nbsp;1, 3, 6, 9, 12, 18, and 36 months of age. Their tasks include verifying the completion of newborn hearing screening, monitoring age-appropriate auditory and language milestones, and tracking risk indicators for hearing loss.\u003c/p\u003e\n\u003cp\u003eChildren who fail the newborn screening in one or both ears, those lost to or who did not complete the screening process, or those who initially pass but present a congenital or postnatal risk factor as defined by JCIH (2019), are referred to Level 2.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAt this stage, they undergo a comprehensive audiological evaluation at one of the three pediatric audiology units located in the region’s major hospitals, referred to in this study as\u0026nbsp;Centers 1, 2, and 3. Comprehensive audiological evaluations are performed by expert audiologists—ideally within a single session—and include both objective and subjective tests: otoscopy, diagnostic OAE, tympanometry, ipsilateral acoustic reflexes, and air-conduction ABR to determine hearing thresholds.\u003c/p\u003e\n\u003cp\u003eChildren who fail the Level 2 audiological evaluation are referred to\u0026nbsp;Level 3\u0026nbsp;for further assessment, diagnosis, and, when necessary, intervention and treatment. The\u0026nbsp;Regional Center for Pediatric Hearing Loss Care, located at the\u0026nbsp;Burlo Garofolo Institute, is the only facility in the FVG region responsible for conducting examinations at this final stage of the screening program.\u003c/p\u003e\n\u003cp\u003eFor instance, with regard to the additional evaluations and examinations carried out during the screening program, the database shows that the diagnosis of permanent hearing loss was based on a genetic test in 12 patients, and computed tomography or magnetic resonance imaging in 41 cases, to assess the presence of alterations at the level of the inner ear or cerebral abnormalities. Among those undertaking neuroimaging assessment, 22 show a cerebral alteration, and 2 patients also report an alteration in the inner ear.\u003c/p\u003e\n\u003cp\u003eThe database analyzed in this study contains detailed information about patients referred to Level 3, allowing us to assess the program’s effective coverage and efficiency along the pathway from identification to diagnosis. Specifically, we examined the number of patients progressing through the subsequent phases of Level 3:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003ePhase 3A: individuals who failed the second level with a type 3 outcome.\u003c/p\u003e\n\u003cp\u003ePhase 3B: individuals correctly referred to the third (diagnostic) level.\u003c/p\u003e\n\u003cp\u003ePhase 3C: individuals who actually presented for evaluation.\u003c/p\u003e\n\u003cp\u003ePhase 3D: confirmed cases of hearing loss that entered the diagnostic process.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eStatistical analyses\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eStatistical analyses were conducted in Python using non-parametric permutation tests, due to the limited sample sizes of patient groups. For each analysis, a test statistic (e.g., χ²) was computed on the observed data. Observations were then randomly permuted 10,000 times to generate a null distribution of the statistic. P-values were computed by comparing the observed statistic to the null distribution. For significant t tests, the effect size (d’Cohen; Cousineau and Goulet-Pelletier 2021) and the confidence intervals are reported. Confidence intervals were computed using the bootstrap method with N=1000 bootstrap replicas.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAll the codes are available at:\u003c/p\u003e\n\u003cp\u003e\u003cu\u003ehttps://osf.io/5jeby/overview?view_only=d4d53b57f8384489befd32c0c4b525df\u003c/u\u003e.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eSensitivity and specificity of diagnostic tests\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eWe further assess how permanent hearing loss is diagnosed by conducting an analysis of the effective sensitivity and specificity of diagnostic tests (A-TEOAE and A-ABR) employed during the early step of the screening program and how their results are aggregated (Böttcher et al. 2025).\u003c/p\u003e\n\u003cp\u003eThe effective sensitivity and specificity of diagnostic tests employed during Level 1 of the hearing screening program were computed based on the following confusion matrices.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2\u003c/strong\u003e. Confusion matrix of A-TEOAE test results.\u003c/p\u003e\n\u003cp\u003e\u003cimg width=\"643\" height=\"101\" 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\" v:shapes=\"image9.png\" alt=\"image\"\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 3\u003c/strong\u003e. Confusion matrix of A-ABR test results\u003c/p\u003e\n\u003cp\u003e\u003cimg width=\"643\" height=\"101\" src=\"data:image/png;base64,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\" v:shapes=\"image1.png\" alt=\"image\"\u003e\u003c/p\u003e\n\u003cp\u003eTable 2 compares A-TEOAE results with respect to total births in the FVG region and IP diagnosis. Table 3 reports data for A-ABR results. (A-TEOAE or A-ABR results can be either “Refer,” i.e., positive, or “Pass,” i.e., negative. IP diagnosis can be present, i.e., 1, or absent, i.e., 0. TP= True Positive; FP=False Positive; FN=False Negative; TN=True Negative).\u003c/p\u003e\n\u003cp\u003eThe effective sensitivity (\u003cem\u003eSe\u003c/em\u003e) and specificity (\u003cem\u003eSp\u003c/em\u003e) of the two tests are then computed as follows:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eSe=TP / (TP + FN)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eSp\u003c/em\u003e=TN / (TN + FP)\u003c/p\u003e\n\u003cp\u003eEffective sensitivity (\u003cem\u003eSe\u003c/em\u003e) and specificity (\u003cem\u003eSp\u003c/em\u003e) are then used to compute the aggregated estimates \u003cem\u003eSe\u003csub\u003eOR\u003c/sub\u003e\u003c/em\u003e and \u003cem\u003eSp\u003csub\u003eOR\u003c/sub\u003e\u003c/em\u003e based on the OR operator. In particular, the effective sensitivity and specificity of A-TEOAE, i.e.,\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eSe(\u003c/em\u003eA-TEOAE\u003cem\u003e)=\u003c/em\u003ep(A-TEOAE+|IP=1)\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eSp(\u003c/em\u003eA-TEOAE\u003cem\u003e)=\u0026nbsp;\u003c/em\u003ep(A-TEOAE–|IP=0)\u003c/p\u003e\n\u003cp\u003eand of A-ABR, i.e.,\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eSe(\u003c/em\u003eA-ABR\u003cem\u003e)=\u003c/em\u003ep(A-ABR+|IP=1)\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eSp(\u003c/em\u003eA-ABR\u003cem\u003e)=\u0026nbsp;\u003c/em\u003ep(A-ABR–|IP=0)\u003c/p\u003e\n\u003cp\u003ewere computed. Then, to assess the overall sensitivity (\u003cem\u003eSe\u003csub\u003eOR\u003c/sub\u003e\u003c/em\u003e) and specificity (\u003cem\u003eSp\u003csub\u003eOR\u003c/sub\u003e\u003c/em\u003e) of Level 1 screening, aggregated estimates can be computed by relying on the OR operator as follows (Böttcher et al. 2025):\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eSe\u003csub\u003eOR\u003c/sub\u003e\u003c/em\u003e= \u003cem\u003eSp\u003c/em\u003e(A-TEOAE)+((1-Se(A-TEOAE))*Se(A-ABR)\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eSp\u003csub\u003eOR\u003c/sub\u003e\u003c/em\u003e=\u003cem\u003eSp\u003c/em\u003e(A-TEOAE)*Sp(A-ABR).\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003e\u003cem\u003e1.1 Overall screening procedure during Level 3 (Descriptive)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe records of 106 children who accessed Level 3 of the neonatal hearing screening program in FVG between 2019 and 2023 were analyzed through Phases 3A, 3B, 3C and 3D, until the final diagnosis, i.e., normal hearing condition (NORM), temporary (conductive) hearing loss subsequently solved (TT), and permanent (sensorineural, conductive or mixed) hearing loss (IP). \u0026nbsp;Table 1 below reports the number of patients in the FVG region accessing Level 3, arranged by year, Phase, and final diagnosis (either temporary conducive hearing loss or permanent). Aggregated data are reported in a flowchart (Figure 2) below.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 1.\u0026nbsp;\u003c/strong\u003eNumber of patients in the FVG region accessing Level 3 of the screening program between 2019 and 2023 and diagnosed with either TT or IP.\u003c/p\u003e\n\u003cp\u003e\u003cimg 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\"\u003e\u003c/p\u003e\n\u003cp\u003eAmong 106 patients accessing Level 3, only 65 were actually diagnosed as IP, while 10 patients resulted in TT and 6 NORM (See Supplementary materials). Across the different Phases, 28 records were classified as losses, specifically either lost documentation (LD), i.e., patients whose records are missing, or loss to follow-up (LF), i.e., patients enrolled in the program who are no longer in contact with the centers. Moreover, 3 patients (indicated as \u0026ldquo;In\u0026rdquo;) accessed Phase 3C directly, having them previously wrongly dismissed from the program.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eFigure 2 shows mixed results. Indeed, while about 8 patients out of 10 correctly end the program with a definitive diagnosis and etiology, rates of LD and LF, as well as the presence of \u0026ldquo;In\u0026rdquo; patients reintroduced in the program, represent non-transcurable information when the efficiency of the screening procedure as a whole is evaluated.\u003c/p\u003e\n\u003cp\u003eFurther insights about losses can be obtained by looking at the specific influence of organizational aspects on the screening program. In this respect, data grouped by the different hospitals, i.e., Center 1, 2, and 3, in charge of audiological assessment during Level 2, are relevant. Indeed, as shown in Figure 3, while IP, TT, and NORM are comparable between the three centers, it is worth noticing that all LD come from either Center 1 or 3, that is, centers other than the Regional Center for Pediatric Hearing Loss Care (Center 2) that treat patients during Level 2 and communicate referrals to the regional hub. Such data suggest a management issue when patients are referred from these centers to Center 2 that needs further investigation.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e1.2 Overall screening procedure during Level 3 (Statistical analysis)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eCriticisms about the management of referrals, i.e., the high rate of losses, can be investigated in light of the specific functions that Phases of the program have. Indeed, the early Phases 3A and 3B have mainly organizational and management functions, as substantially related to the correct communication between the centers involved in the program, while Phases 3C and 3D have a clear clinical and diagnostic impact, as involving audiological evaluation, diagnosis, and treatment of patients.\u003c/p\u003e\n\u003cp\u003eTherefore, variations in the number of suspected hearing losses are not expected during Phases 3A and 3B and, if present, might be interpreted as cues of organizational and management weaknesses in the program. On the contrary, variations in the number of patients can be expected during Phases 3C and 3D, e.g., concerning the identification of false positives, given the clinical evaluations children undergo in these cases.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eA straightforward way to evaluate the efficiency of the procedure and the influence of clinical and organizational Phases consists of estimating the incidence of hearing loss at each Phase. Given the total births in FVG during the five-year period 2019\u0026ndash;2023 are 39,112, the overall incidence of hearing loss across the three Centers varies as follows: 2.71\u0026permil; (Phase 3A), 2.12\u0026permil; (Phase 3B), 2.15\u0026permil; (Phase 3C), 1.92\u0026permil; (Phase 3D). Then, the final incidences of temporary (TT) and permanent (IP)\u0026nbsp;hearing impairments are respectively 0.26\u0026permil;, and 1.66\u0026permil;\u0026ndash;results that, in the case of permanent hearing loss, \u0026nbsp;are in line with the prevalence of the condition in Italy.\u003c/p\u003e\n\u003cp\u003eThese results are in contrast with expectations about the screening program since the incidence varies during all Level 3 Phases. However, while variations are expected only during clinically-relevant Phases 3C and 3D, changes in the number of suspected hearing losses are observed during Phases 3A and 3B, that is, phases with primary organizational functions; these variations are due to the number of LF and LD only (See Supplementary Materials).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIn particular, the difference in the number of LF and LD across centers is significative and depends on the particular Level 2 Center is further confirmed by the results of a chi-squared test for independence (based on permutation design, 10,000 permutations) conducted on patients classified as losses (i.e., LD or LF) or no-losses (i.e., IP, TT, NORM) and the particular center (Center 1, 2 or 3). The test result allows us to reject the null hypothesis of independence between the Level 2 centers and their loss/no-loss classification during Level 3 (observed chi-square (\u0026chi;\u0026sup2;) = 11.56, DF=2, p-value=.003), indicating a clear relation between the rate of losses and the specific hospital that administered patients during Level 2.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e2.1 Permanent and temporary hearing loss (Descriptive)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eAmong the patients who accessed Level 3 in FVG between 2019 and 2023 and received a final diagnosis, 65 were classified as having a permanent hearing impairment (IP), 10 as temporary conductive hearing loss, and 6 as normal hearing subjects. In particular, IP and TT diagnoses were performed during Phase 3D, while normal hearing patients were identified after examinations occurred at Phase 3C (Figure 2).\u003c/p\u003e\n\u003cp\u003eAvailable information about these patients allows us to investigate the timing of their diagnosis as well as provide details about their clinical conditions. Overall, the majority of patients included in the dataset that accessed Level 3 failed to pass both automated transient evoked otoacoustic emissions (A-TEOAE) and automated auditory brainstem response (A-ABR) examination during Level 1, present JCIH risk factors (JCIH 2019; Beswick et al. 2012), and show a grade of hearing loss (WHO 2021) from mild to moderate in the case of NORM and TT and from mild to profound for IPs, with 47 out of 65 bilaterally. In particular, regarding the JCIH risk factors (Figure 4; see also Supplementary Materials, Section 2), we observe that their presence often led to a refer outcome during Level 1 screening, even though A-TEOAE and A-ABR result negative. Specifically, within the current database, the majority (58%) of NORM, TT, and IP patients presented with at least one risk factor (17% multifactorial), while 10% of them had a history of preterm birth. When NORMs and TTs are taken into account, 63% (10 out of 16) of them show at least one risk factor (the most frequent being intensive care of more than 5 days). For IPs, the percentage of patients presenting at least one risk factor decreases to 57% (37 out of 65). Among them, risk factors that occur the most are neonatal intensive care of more than 5 days (code 2 in Fig. 4), family history of hearing loss (code 1), presence of syndromes associated with atypical hearing thresholds (code 9), and particular birth conditions, such as craniofacial malformations and temporal bone abnormalities (code 8).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAnother important aspect to consider when assessing the overall efficacy of the screening program is the time required to conclude the entire process, based on specific recommendations such as the 1-3-6 benchmark (JCIH 2007, 2019).\u003c/p\u003e\n\u003cp\u003eFigures 5a-b report the time interval between birth, the different Phases of Level 3, and prosthesis implantation, both for IPs and TTs. While the protocol of the FVG region adheres to the 1-3-6 recommendations of JCIH (2007), results indicate a suboptimal timeline on average and difficulties in meeting the 1-2-3 benchmark (JCIH 2019). Indeed, IPs and TTs reach Phase 3A after 6.4 months from birth on average, while Phase 3D occurs after 12 months on average. For what specifically concerns IP\u0026apos;s timeline from birth to implantation, 44% of the patients received audiological assessment and accessed Level 3 of the program within 3 months, as recommended by JCIH guidelines (average 6.3 months), with Phase 3D occurring on average after 11.9 months and implantation after 19 months. All these results are, however, due to a portion of cases achieving Phase 3D and implantation very late (\u0026gt;30 months), while the majority of patients actually receive diagnosis and implantation between 12 to 18 months from birth.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTimeline concerns might be associated with different factors. Here, we investigated whether a difference between the timelines of patients diagnosed with temporary and permanent hearing loss exists and, if so, whether this difference is related to specific organizational and management aspects, e.g., difficult early discrimination, false positives, producing cascade effects on further steps of the program.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e2.1 Permanent and temporary hearing loss (Statistical analysis)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe issues in the communication and transfer of data between centers investigated in previous sections can be associated not only with a higher risk of losses but also with delays and time-related inefficiencies.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTo investigate whether a difference between the timeline associated with permanent and temporary hearing loss is significant and what stages of the screening program have major relevance, we conducted two one-tailed Student\u0026rsquo;s t-tests on the time intervals occurring between birth and different Level 3 Phases for patients diagnosed with permanent and temporary hearing loss.\u003c/p\u003e\n\u003cp\u003eIn light of the results reported in Fig. 5a, in the first test, we evaluated the hypothesis that the interval occurring between birth and Phase 3A is, on average, greater for TTs than IPs. Given the limited data available, a one-tailed t-test on the time intervals for the two groups was conducted based on a permutation design (10,000 permutations). The test results allows us to reject the null hypothesis that there is no significant difference between the birth to Phase 3A time intervals of TTs and IPs (t(73)=1.68, p-value=.048; 95% CI: [-1.42, 2.53]; Cohen\u0026apos;s d=0.57; 95% CI= [-0.11, 1.25]) and, in particular, to conclude that such a time interval is larger in the case of TTs (TT\u0026rsquo;s mean interval: 304 days; IP\u0026rsquo;s mean interval: 174 days). This result demonstrates that time concerns were already involved in the early steps of the screening program, before entering the main Phases of Level 3.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTo assess whether Level 3 is also affected in terms of time, a second one-tailed Welch t-test was conducted on the time interval between Phase 3A and Phase 3D, corresponding to the final, diagnostic stage of the program. Again, we hypothesized that the time interval was greater for TTs as compared with IPs, and due to the limited number of data, we relied on a permutation design (10,000 rep.).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTest results do not allow us to reject the null hypothesis (t(73)=0.93;\u0026nbsp;p-value=0.12; 95% CI: [-3.53, 1.54]). So, we can conclude that there is no statistically significant difference in the time intervals associated with IPs and TTs when the gap between Phase 3A and Phase 3D is considered.\u003c/p\u003e\n\u003cp\u003eTherefore, whether a difference in the timeline between temporary and permanent hearing loss exists and is significant, it is in the early steps of the screening procedure, i.e., Levels 1 and 2, with no clear impact of specific stages encountered during Level 3.\u003c/p\u003e\n\u003cp\u003eAnother practical aspect worth considering concerns how early in the program a reliable discrimination of the pathological conditions of interest, e.g., temporary or permanent hearing loss, is expected. Indeed, a high number of false positives hard to identify early on might cause inefficiencies in the management, thus leading to errors and delays.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIn this respect, it is worth assessing whether particular examination strategies during Levels 1 and 2 of the screening program might affect an early and correct discrimination of the two conditions or, for instance, increase the number of false positives, making their identification harder and impacting the timeline. Therefore, a central issue regards the particular diagnostic tests employed for early screening during Level 1. At this stage, the adopted protocol requires screening patients based on two objective tests, i.e., A-TEOAE and A-ABR, and then assessing the presence of potential risk factors. Both tests can provide a negative result (pass) or a positive one (refer), and according to the FVG protocol, A-ABR testing is performed subsequently to A-TEOAE, if the result is refer. The two tests are administered in series, and newborns access Level 2 for audiologic assessment when either (1) both tests result refer or (2) A-TEOAE results refer bilaterally, and A-ABR test results pass. Instead, if both test results are pass, but one or more risk factors are present, the patient undergoes an audiologic assessment.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTherefore, the particular strategy implemented to aggregate multiple or repeated test results (Cebul et al. 1982; Politser 1982; Fanshawe et al. 2024) and decide whether to refer a patient to Level 2 is particularly relevant for an early and correct discrimination of the conditions of interest, as it might increase the risk of false positive referrals.\u003c/p\u003e\n\u003cp\u003eBased on the decision three behind Level 1 (Figure 6a), the current strategy to aggregate A-TEOAE and A-ABR tests seems to follow an \u0026ldquo;all heuristic\u0026rdquo; or \u0026ldquo;conjunctive positivity criterion,\u0026rdquo; based on the Boolean aggregator AND (B\u0026ouml;ttcher et al. 2025). According to this rule, both tests should result refer, for the outcome of the screening Level 1 to be referred to Level 2 (Figure 6b). The main advantage of such a strategy is to enhance the specificity (or true negative rate) of the aggregated test, when compared to the specificity of the single ones, and to reduce the risk of accepting the hypothesis that the patient is affected by the disease, when in fact the condition is absent (type I error). Therefore, aggregating results of multiple tests via AND operator represents the best strategy to minimize the risk of false positives as compared with other aggregation rules, e.g., OR, or the consideration of a single test result (B\u0026ouml;ttcher et al. 2025).\u003c/p\u003e\n\u003cp\u003eHowever, the FVG 2019-2023 Database shows that the effective strategy to aggregate results of diagnostic tests performed during Level 1 follows an \u0026ldquo;any heuristic\u0026rdquo; or \u0026nbsp; \u0026ldquo;disjunctive positivity criterion\u0026rdquo; based on the Boolean aggregator OR. Indeed, the 106 patients arriving at Level 3 generally underwent both tests, even when the A-ABR was not strictly recommended by the FVG protocol, given that a pass result of A-TEOAE or risk factors for which A-ABR is suggested (e.g., intensive care) were absent. Moreover, the dataset includes a few patients who accessed Level 3, even though they passed all the Level 1 screening tests and showed no risk factors.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThis observation highlights the need to evaluate how results of screening tests are employed during the early step of the program to make decisions (Lin et al. 2007, Benito-Orejas et al. 2008)\u0026nbsp;and, in particular, assessing the effect of using the \u0026ldquo;any heuristic\u0026rdquo; rather than the \u0026ldquo;all heuristic\u0026rdquo; as an aggregation strategy for detecting permanent hearing losses. Indeed, in the case of the OR strategy, for a patient to be referred to Level 2, it is sufficient that one of the two administered test results is refer, as illustrated in Figure 6b. This strategy enhances the sensitivity (or true positive rate) of the aggregated examination; that is, the sensitivity of the two tests when considered together is always higher than the sensitivity of each of the two tests taken alone, thus reducing the false negative rate, which could lead to delayed diagnosis of hearing loss (Acke et al., 2022), and type II error. However, the main disadvantage of the OR aggregation strategy is that, when compared to single tests, the aggregated examination is less specific, thus increasing the false positive rate and the risk of incurring in type I error (B\u0026ouml;ttcher et al. 2025).\u003c/p\u003e\n\u003cp\u003eHere, we can confirm this by computing the actual sensitivities and specificities of A-TEOAE, i.e., 0.91 and 0.99, and of A-ABR, i.e., 0.92 and 0.99\u0026ndash;in line with previous studies (Sheng et al., 2021; Neumann \u0026amp; Indermark, 2012), and then aggregate them via OR operator. The aggregated estimates, i.e., \u003cem\u003eSe\u003csub\u003eOR\u003c/sub\u003e\u003c/em\u003e and \u003cem\u003eSp\u003csub\u003eOR\u003c/sub\u003e\u003c/em\u003e, of Level 1 screening show very high sensitivity and specificity, i.e., 0.99 and 0.98 (see Methods for details). In particular, the OR aggregation strategy increases sensitivity overall, but reduces specificity (from 0.99 for both tests to 0.98 for the aggregated case), even if very slightly. This in fact, increases the risk of having false positives and then the need to manage a higher number of patients during the program, with potential consequences on the organization and timing.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eUniversal newborn hearing screening (UNHS) is widely recognized as one of the most effective public health interventions in pediatric audiology. Over the years, the Joint Committee on Infant Hearing (JCIH) has refined its recommendations, evolving from the 1-3-6 rule to the more 1-2-3 guideline, emphasizing earlier identification and intervention to optimize language, cognitive, and social outcomes in children with permanent hearing loss. This change points to early identification and intervention, which should be associated with better language, cognitive, and social outcomes in children with permanent hearing loss \u003cb\u003e(\u003c/b\u003eJCIH, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e2019\u003c/span\u003e\u003cb\u003e)\u003c/b\u003e.\u003c/p\u003e \u003cp\u003eIn this study, we aimed to identify the effectiveness of the actual screening protocol with a regional analysis of the final stage of the neonatal hearing screening pathway in Friuli-Venezia Giulia (FVG), highlighting how organizational factors influence the real-world effectiveness of an otherwise well-established program. The incidence of permanent hearing loss in FVG is 1.66\u0026permil; and aligns with data from high-income countries, where prevalence typically ranges from 1 to 3 per 1,000 live births. This confirms that the regional program successfully identifies a population consistent with epidemiological expectations and suggests adequate coverage of the target cohort. Nonetheless, the high proportion of patients lost to follow-up between Levels 2 and 3 reflects a challenge widely described in the international literature.\u003c/p\u003e \u003cp\u003eIn particular, between 2019 and 2023, 106 children accessed Level 3 of the neonatal hearing screening program in the FVG Region in Italy. Level 3 is the final stage of the program, involving diagnosis, treatment, and follow-up of hearing losses at the Regional Center for Pediatric Hearing Loss Care (Center 2) in FVG. The analysis of children\u0026rsquo;s reports from the identification and diagnosis of hearing impairments to the prosthesis implantation allows assessing the coverage and efficiency of the procedure as a whole. Indeed, while the program has been efficiently implemented for more than ten years and sees coordinated and proficient participation of different actors, different management and organizational weaknesses are observed, being related to the number of losses, communication between centers, delays in the treatment of cases, and strategies to aggregate results of early screening tests.\u003c/p\u003e \u003cp\u003eFirst, at the end of the program, 65 of the 106 patients entering Level 3 were effectively diagnosed with a permanent hearing loss, being sensorineural, conductive, or mixed, resulting in an incidence of 1,66\u0026permil; in the FVG population. Among patients accessing Level 3, however, 28 records have been classified as losses (LDs or LFs). This high number of losses is mainly observed between Phases 3A and 3B, when patients who have undergone audiological evaluation (Level 2) are referred to Center 2 for diagnosis, treatment, and follow-up. Given that these phases have a clear organizational function and no clinical relevance, the number of losses is a sign of a management weakness concerning these program stages.\u003c/p\u003e \u003cp\u003eSecond, the assessment of the program's timeline across the different stages highlights that only a percentage of patients are diagnosed and treated according to the 1-3-6 benchmark recommended by JCIH (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e2007\u003c/span\u003e), and that the program does not meet the more recent 1-2-3 guidelines proposed by JCIH (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e2019\u003c/span\u003e). Such a discrepancy might have different reasons, for instance, the choice of the specific reference time points, i.e., Phases, of the process. However, the statistical analysis conducted on the time gap of permanent and temporary hearing loss between birth, Phase 3A, and Phase 3D, reveals that the difference between the time interval in the case of permanent and temporary hearing losses is significant when the birth-Phase 3A interval is considered, but not when the birth-Phase 3D interval is analyzed. These results suggest that the suboptimal timing is not associated with delays specific to Level 3, but rather reflects the management of patients in previous steps.\u003c/p\u003e \u003cp\u003eThird, the risk of false positives is partly determined by the diagnostic tests used in Level 1 and their intrinsic quality; in addition, the method applied to aggregate multiple results is highly impactful. During Level 1, newborns are screened with two tests (A-TEOAE and A-ABR) and assessed for risk factors. Besides the quality of these diagnostic tests, which generally show high sensitivity and specificity, variations across instruments have been reported, and the timing of neonatal hearing screening has been shown to significantly affect the false positive referral rate (Vonk et al., \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e2026\u003c/span\u003e). Available evidence also indicates that a potential reason for a high number of false positives is the specific rule for aggregating test results. Indeed, if the screening program implements the \u0026ldquo;any heuristic\u0026rdquo; based on OR Boolean operator the sensitivity increases, but the risk of incurring in type I error and false positives is enhanced. Results reveal that the observed decrease in specificity due to OR aggregation is very slight. However, this strategy necessarily determines an increase in the false positives and of the number of patients to treat. Moreover, when a cohort of approximately 39,000 newborns, as in FVG between 2019 and 2023, is taken into account, even a modest increase in false positives might have a detrimental effect on the management of suspected hearing losses, reducing the program efficiency. Therefore, \u0026ldquo;any heuristics\u0026rdquo; cannot minimize the risk of false positives, potentially causing not only a delayed patient dismissal from the program, but also time-related inefficiencies in the management of patients with permanent hearing loss. These issues underscore the need for evidence-based aggregation strategies, along with ongoing evaluation of screening protocols, to optimize specificity without compromising sensitivity.\u003c/p\u003e \u003cp\u003eThe effectiveness of a hearing screening program cannot be judged solely on clinical performance; it must also be evaluated in relation to the organization and management of the healthcare system in which the program operates. Indeed, organizational and structural factors, such as coordination among screening levels, efficient communication pathways, data monitoring systems, and standardized referral protocols, are crucial for quality, scalability, and sustainability (Yoshinaga-Itano et al., \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e2021\u003c/span\u003e; Orzan et al., \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). Even when screening technologies exhibit high sensitivity and specificity, weaknesses in program organization can undermine their effectiveness by introducing delays, increasing losses to follow-up, and reducing overall coverage of the target population. Data from the final stages of the universal newborn hearing screening program in the Italian FVG Region highlight several systemic challenges, especially in the organizational domain. Newborn screening is a multi-step process requiring coordination, timely data transmission, and systematic monitoring. Without robust structures, even clinically sound programs risk inefficiencies, lower coverage, and delays. Each stage of this pathway relies on timely information exchange, accurate documentation, and effective patient tracking across institutions. Without robust organizational structures, even clinically well-designed programs risk inefficiencies, reduced coverage, and delays in diagnosis and intervention. In particular, the lack of centralized monitoring systems and clear data-sharing mechanisms can lead to higher rates of loss to follow-up and delayed diagnosis, even when initial screening coverage is high (Shulman et al., \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e2010\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIn line with recent public health perspectives, strengthening digital integration and shared data infrastructures appears critical. Centralized tracking systems that allow real-time monitoring of each child\u0026rsquo;s pathway have been shown to reduce delays and improve coverage. Automated notifications, standardized reporting formats, and interoperable electronic health records can facilitate continuity between maternity wards, second-level services, and tertiary referral centers. Such measures would likely enhance compliance with international benchmarks and reduce errors and delays, ensuring more effective and equitable programs.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThe UNHS program in Friuli Venezia Giulia effectively identifies children with permanent hearing loss at expected prevalence rates, but organizational challenges, such as losses to follow-up, suboptimal timing, and inefficient aggregation of screening results, limit its full effectiveness. These findings highlight that clinical performance alone does not ensure program success. Strengthening coordination between care levels, implementing centralized digital tracking, and standardizing data sharing could reduce delays, improve coverage, and optimize early intervention. Combining high-quality screening tools with robust program management is essential to maximize outcomes and ensure timely, equitable care for children with hearing loss.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eA-TEOAE\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eautomated transient evoked otoacoustic emissions\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eA-ABR\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eautomated auditory brainstem response\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eLF\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003elost to follow-up\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eLD\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003elost documentation\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eTP\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eTrue Positive\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eFP\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eFalse Positive\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eFN\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eFalse Negative\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eTN\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eTrue Negative\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cem\u003eSe\u003c/em\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eEffective sensitivity\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cem\u003eSp\u003c/em\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eEffective specificity\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eNORM\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eNormal hearing condition\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eTT\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003etemporary (conductive) hearing loss subsequently solved\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eIP\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003epermanent (sensorineural, conductive or mixed) hearing loss\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eBC\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ebirthing centers\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eFVG\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eFriuli-Venezia Giulia\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eJCIH\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eJoint Committee on Infant Hearing\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003col start=\"1\" type=\"1\"\u003e\n \u003cli\u003eEthics approval and consent to participate\u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\u003eThe study was conducted in accordance with the Declaration of Helsinki and approved by the Institutional Review Board of the Institute for Maternal and Child Health-IRCCS Burlo Garofolo, Trieste, Italy (protocol code IRB BURLO 08/2020, approved on 1 December 2022).\u003c/p\u003e\n\u003col start=\"2\" type=\"1\"\u003e\n \u003cli\u003eConsent for publication\u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\u003eAll necessary participant consent has been obtained and the appropriate institutional forms have been archived, and any participant identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals.\u003c/p\u003e\n\u003col start=\"3\" type=\"1\"\u003e\n \u003cli\u003eAvailability of data and materials\u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\u003eAll the data and codes used in the analysis are available at:\u003cu\u003ehttps://osf.io/5jeby/overview?view_only=d4d53b57f8384489befd32c0c4b525df\u003c/u\u003e. The raw FVG Dataset is available upon request.\u003c/p\u003e\n\u003col start=\"4\" type=\"1\"\u003e\n \u003cli\u003eCompeting interests\u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003col start=\"5\" type=\"1\"\u003e\n \u003cli\u003eFunding\u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\u003eThis work was supported by the Italian Ministry of Health, through the contribution given to the Institute for Maternal and Child Health IRCCS Burlo Garofolo, Trieste - Italy.\u0026nbsp;\u003c/p\u003e\n\u003col start=\"6\" type=\"1\"\u003e\n \u003cli\u003eAuthors' contributions\u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\u003eDC: Conceptualization, Analyses, Writing; MF: Conceptualization, Writing; ET: Data collection; Writing; RT: Data Collection; Writing; LR: Conceptualization; Funding; Writing; Data Collection; EO: Conceptualization, Writing.\u003c/p\u003e\n\u003col start=\"7\" type=\"1\"\u003e\n \u003cli\u003eAcknowledgements\u0026nbsp;\u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\u003eImportantly, the first author, Dr. Davide Coraci, conducted the study and prepared the manuscript in 2025 while employed at the Institute for Maternal and Child Health IRCCS Burlo Garofolo in Trieste, Italy.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eAcke, F. R. E., De Vriese, C., Van Hoecke, H., \u0026amp; De Leenheer, E. M. R. (2021). Twelve years of neonatal hearing screening: audiological and etiological results. \u003cem\u003eEuropean Archives of\u0026nbsp;\u003c/em\u003e\u003cem\u003eOto-Rhino-Laryngology\u003c/em\u003e, \u003cem\u003e279\u003c/em\u003e(7), 3371\u0026ndash;3378. https://doi.org/10.1007/s00405-021-07060-5\u003c/li\u003e\n \u003cli\u003eBenito-Orejas, J. I., Ram\u0026iacute;rez, B., Morais, D., Almaraz, A., \u0026amp; Fern\u0026aacute;ndez-Calvo, J. L. (2008). Comparison of two-step transient evoked otoacoustic emissions (TEOAE) and automated auditory brainstem response (AABR) for universal newborn hearing screening programs. \u003cem\u003eInternational journal of pediatric otorhinolaryngology\u003c/em\u003e, \u003cem\u003e72\u003c/em\u003e(8), 1193-1201.\u003c/li\u003e\n \u003cli\u003eBeswick R et al. 2012. Monitoring for postnatal hearing loss using risk factors: a systematic literature review. Ear \u0026amp; Hearing 2012; 33 (6): 747-756.\u003c/li\u003e\n \u003cli\u003eB\u0026ouml;ttcher L, D\u0026rsquo;Orsogna MR, Chou T (2025) Aggregating multiple test results to improve medical decision-making. PLoS Comput Biol 21(1): e1012749.\u0026nbsp;\u003cu\u003ehttps://doi.org/10.1371/journal.pcbi.1012749\u003c/u\u003e\u003c/li\u003e\n \u003cli\u003eCebul RD, Hershey JC, et al. Using multiple tests: series and parallel approaches. Clinics in Laboratory Medicine. 1982; 2(4):871\u0026ndash;890.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eCollins, A., Beswick, R., Driscoll, C., \u0026amp; Kei, J. (2019).\u0026nbsp;Conductive Hearing Loss Within Universal Newborn Hearing Screening Programs: A Systematic Review. \u003cem\u003eJournal of Hearing Science\u003c/em\u003e, \u003cem\u003e9\u003c/em\u003e(3).\u003c/li\u003e\n \u003cli\u003eCousineau, D., Goulet-Pelletie, J.-C. (2021). 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Wieringa, Rose MS Willis-Lorrier, and Henriette HW de Gier. \u0026quot;Evaluation of hearing loss after failed neonatal hearing screening.\u0026quot;\u0026nbsp;\u003cem\u003eThe Journal of pediatrics\u003c/em\u003e 155, no. 5 (2009): 646-650.\u003c/li\u003e\n \u003cli\u003eHyde, M. L. (2005). Newborn hearing screening programs: overview.\u0026nbsp;\u003cem\u003eJournal of Otolaryngology\u003c/em\u003e,\u0026nbsp;\u003cem\u003e34\u003c/em\u003e.\u003c/li\u003e\n \u003cli\u003eJCIH (2019). Year 2019 Position Statement: Principles and Guidelines for Early Hearing Detection and Intervention Programs. \u003cem\u003eJournal of Early Hearing Detection and Intervention,\u0026nbsp;\u003c/em\u003e4(2), 1-44. \u003cu\u003ehttps://doi.org/10.15142/fptk-b748\u003c/u\u003e\u003c/li\u003e\n \u003cli\u003eJCIH (2007). Year 2007 position statement: Principles and guidelines for Early Hearing Detection and Intervention programs. \u003cem\u003ePediatrics, 120\u003c/em\u003e(4), 898\u0026ndash;921. https://doi.org/10.1542/peds.2007-2333\u003c/li\u003e\n \u003cli\u003eKanji, A., Khoza-Shangase, K., \u0026amp; Moroe, N. (2018). Newborn hearing screening protocols and their outcomes: A systematic review.\u0026nbsp;\u003cem\u003eInternational journal of pediatric otorhinolaryngology\u003c/em\u003e,\u0026nbsp;\u003cem\u003e115\u003c/em\u003e, 104-109.\u003c/li\u003e\n \u003cli\u003eKumar, S., \u0026amp; Mohapatra, B. (2011). Status of newborn hearing screening program in India.\u0026nbsp;\u003cem\u003eInternational journal of pediatric otorhinolaryngology\u003c/em\u003e,\u0026nbsp;\u003cem\u003e75\u003c/em\u003e(1), 20-26.\u003c/li\u003e\n \u003cli\u003eLim, H. W., Kim, E. A. R., \u0026amp; Chung, J. W. (2012). Audiological follow-up results after newborn hearing screening program.\u0026nbsp;\u003cem\u003eClinical and experimental otorhinolaryngology\u003c/em\u003e,\u0026nbsp;\u003cem\u003e5\u003c/em\u003e(2), 57-61.\u003c/li\u003e\n \u003cli\u003eLin, H. C., Shu, M. T., Lee, K. S., Lin, H. Y., \u0026amp; Lin, G. (2007). Reducing false positives in newborn hearing screening program: how and why.\u0026nbsp;\u003cem\u003eOtology \u0026amp; Neurotology\u003c/em\u003e,\u0026nbsp;\u003cem\u003e28\u003c/em\u003e(6), 788-792.\u003c/li\u003e\n \u003cli\u003eMalesci, R., Del Vecchio, V., Bruzzese, D., Burattini, E., Auletta, G., Errichiello, M., Fetoni, A. R., Franz\u0026egrave;, A., Laria, C., Toscano, F., Caso, A., Marciano, E. 2022, Performance and characteristics of the Newborn Hearing Screening Program in Campania region (Italy) between 2013 and 2019. Eur Arch Otorhinolaryngol. 279(3):1221-1231. doi: 10.1007/s00405-021-06748-y.\u003c/li\u003e\n \u003cli\u003eMarinho, A. C. A., Pereira, E. C. D. S., Torres, K. K. C., Miranda, A. M., \u0026amp; Ledesma, A. L. L. (2020). Evaluation of newborn hearing screening program.\u0026nbsp;\u003cem\u003eRevista de Sa\u0026uacute;de P\u0026uacute;blica\u003c/em\u003e,\u0026nbsp;\u003cem\u003e54\u003c/em\u003e, 44.\u003c/li\u003e\n \u003cli\u003eMolini E, Cristi MC, Lapenna R, Calzolaro L, Muzzi E, Ciciriello E, Della Volpe A, Orzan E, Ricci G. 2016, Improving regional universal newborn hearing screening programmes in Italy. Acta Otorhinolaryngol Ital. 36(1):10-4. doi: 10.14639/0392-100X-1072. Epub 2016 Feb 29. PMID: 27054385; PMCID: PMC4825067.\u003c/li\u003e\n \u003cli\u003eNeumann, K., Indermark, A. (2012). Validation of a new TEOAE-AABR device for newborn hearing screening.\u0026nbsp;\u003cem\u003eInternational journal of audiology\u003c/em\u003e, \u003cem\u003e51\u003c/em\u003e(8), 570-575.\u003c/li\u003e\n \u003cli\u003eOrzan, E., Tinelli Bonadonna, E., Consolino, P., Cutler, J. M., Di Berardino, F., Forli, F., Gallo, L., Merico, A., Viola, A. 2022, Screening uditivi nel corso della vita: una fotografia del panorama italiano, \u003cem\u003eActa Otorhinolaryngologica Italica,\u003c/em\u003e \u003cem\u003e16\u003c/em\u003e(1), 2-12.\u003c/li\u003e\n \u003cli\u003eOrzan, E., Pizzamiglio, G., Marchi, R., Muzzi, E., Monasta, L., Torelli, L., \u0026amp; Feresin, A. (2021). Modeling Postnatal Hearing Case Finding Within the Italian National Health System.\u0026nbsp;\u003cem\u003eFrontiers in pediatrics\u003c/em\u003e,\u0026nbsp;\u003cem\u003e9\u003c/em\u003e, 564662.\u003c/li\u003e\n \u003cli\u003eOrzan, E., Ruta, F., Bolzonello, P., Marchi, R., Ceschin, F., \u0026amp; Ciciriello, E. (2016). Childhood hearing surveillance activity in Italy: preliminary recommendations.\u0026nbsp;\u003cem\u003eActa Otorhinolaryngologica Italica\u003c/em\u003e,\u0026nbsp;\u003cem\u003e36\u003c/em\u003e(1), 15.\u003c/li\u003e\n \u003cli\u003ePolitser, P. 1982. Reliability, decision rules, and the value of repeated tests. Medical Decision Making 2(1), pp. 47\u0026ndash;69.\u0026nbsp;https://doi.org/10.1177/0272989X8200200108\u0026nbsp;PMID: 7169931\u003c/li\u003e\n \u003cli\u003eRazak, A., Fard, D., Hubbell, R., Cohen, M., Hartman-Joshi, K., \u0026amp; Levi, J. R. (2021). Loss to follow-up after newborn hearing screening: Analysis of risk factors at a Massachusetts urban safety-net hospital. \u003cem\u003eEar and Hearing\u003c/em\u003e, \u003cem\u003e42\u003c/em\u003e(1), 173-179.\u003c/li\u003e\n \u003cli\u003eSheng, H., Zhou, Q., Wang, Q., Yu, Y., Liu, L., Liang, M., Zhou, X., Wu, H., Tang, X., Huang, Z. (2021) Comparison of Two-Step Transient Evoked Otoacoustic Emissions and One-Step Automated Auditory Brainstem Response for Universal Newborn Hearing Screening Programs in Remote Areas of China. Front. Pediatr. 9:655625. doi: 10.3389/tped.2021.655625\u003c/li\u003e\n \u003cli\u003eShulman S, Besculides M, Saltzman A, Ireys H, White KR, Forsman I. Evaluation of the universal newborn hearing screening and intervention program. Pediatrics. 2010 Aug;126 Suppl 1:S19-27. doi: 10.1542/peds.2010-0354F. PMID: 20679316.\u003c/li\u003e\n \u003cli\u003eVonk, L., Van Dommelen, P., Eekhout, I., Uilenburg, N. N., Verkerk, P. H., \u0026amp; Van Der Ploeg, C. P. B. (2026). Optimal timing for neonatal hearing screening in Well-Babies. \u003cem\u003eInternational Journal of Neonatal Screening\u003c/em\u003e, \u003cem\u003e12\u003c/em\u003e(1), 7. https://doi.org/10.3390/ijns12010007\u003c/li\u003e\n \u003cli\u003eWalker, E. A., Holte, L., Spratford, M., Oleson, J., Welhaven, A., Harrison, M. 2014. Timeliness of service delivery for children with later-identified mild-to-severe hearing loss. \u003cem\u003eAm J Audiol.\u003c/em\u003e 23, pp. 116\u0026ndash;28. doi: 10.1044/1059-0889(2013/13-0031)\u003c/li\u003e\n \u003cli\u003eWen, C., Huang, L. H. (2023). Newborn hearing screening program in China: a narrative review of the issues in screening and management.\u0026nbsp;\u003cem\u003eFrontiers in Pediatrics\u003c/em\u003e,\u0026nbsp;\u003cem\u003e11\u003c/em\u003e, 1222324.\u003c/li\u003e\n \u003cli\u003eWHO (2021). World report on hearing. Geneva: World Health Organization; 2021. Licence: CC BY-NC-SA 3.0\u0026nbsp;IGO.\u003c/li\u003e\n \u003cli\u003eYoshinaga-Itano, C., Manchaiah, V., \u0026amp; Hunnicutt, C. (2021). Outcomes of Universal Newborn Screening Programs: Systematic review. \u003cem\u003eJournal of Clinical Medicine\u003c/em\u003e, \u003cem\u003e10\u003c/em\u003e(13), 2784. https://doi.org/10.3390/jcm10132784\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"italian-journal-of-pediatrics","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"itjp","sideBox":"Learn more about [Italian Journal of Pediatrics](http://ijponline.biomedcentral.com)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/ITJP/default.aspx","title":"Italian Journal of Pediatrics","twitterHandle":"@BioMedCentral","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"universal hearing screening, congenital hearing impairments, hearing loss, early identification, pediatric audiology, at-risk children","lastPublishedDoi":"10.21203/rs.3.rs-9305306/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-9305306/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eEarly identification and treatment of hearing impairments are essential for children\u0026rsquo;s development. International guidelines recommend a stepwise approach to conduct hearing screening in newborns. However, while the majority of countries worldwide implemented universal newborn hearing screening, inconsistencies remain in procedures and data management.\u003c/p\u003e \u003cp\u003eIn particular, Level 3 of the screening pathway\u0026mdash;comprising diagnostic confirmation and therapeutic management\u0026mdash;has received limited attention in the literature, despite its central role in determining program effectiveness and patient outcomes.\u003c/p\u003e \u003cp\u003eThis study investigates the clinical and organizational aspects of Level 3 within the neonatal hearing screening program of the Friuli-Venezia Giulia Region in Italy, analyzing data from 106 children enrolled between 2019 and 2023. The analysis considers the regional protocol, the roles of birthing centers, pediatricians, hospitals, and the Regional Center for Pediatric Hearing Loss Care, and subdivides Level 3 into four Phases (A\u0026ndash;D) reflecting both organizational and diagnostic functions. By examining patient flow, false positives, loss to follow-up/documentation, and management practices, the study highlights how organizational factors\u0026mdash;particularly the coordination between local and specialized facilities\u0026mdash;produce \u0026ldquo;cascade\u0026rdquo; outcomes directly affecting diagnostic timelines and treatment initiation.\u003c/p\u003e \u003cp\u003e Findings provide critical insights into weaknesses of the current system and propose directions for improving program efficiency, accuracy, and overall quality of care.\u003c/p\u003e","manuscriptTitle":"Practice and challenges of newborn hearing screening: Analysis of a five-year database in Italy","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-04-23 12:22:26","doi":"10.21203/rs.3.rs-9305306/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"reviewerAgreed","content":"","date":"2026-04-16T17:40:45+00:00","index":0,"fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-04-15T12:16:23+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-04-14T03:23:00+00:00","index":"","fulltext":""},{"type":"submitted","content":"Italian Journal of Pediatrics","date":"2026-04-03T11:03:56+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"italian-journal-of-pediatrics","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"itjp","sideBox":"Learn more about [Italian Journal of Pediatrics](http://ijponline.biomedcentral.com)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/ITJP/default.aspx","title":"Italian Journal of Pediatrics","twitterHandle":"@BioMedCentral","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"4cae91cd-5793-4260-840e-7d70171f2118","owner":[],"postedDate":"April 23rd, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-04-23T12:22:26+00:00","versionOfRecord":[],"versionCreatedAt":"2026-04-23 12:22:26","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-9305306","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-9305306","identity":"rs-9305306","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}