Mobile health school screening and telemedicine referral to improve access to specialty care in rural Alaska: a cluster- randomised controlled trial

Susan D Emmett; Alyssa Platt; Elizabeth L Turner; Joseph J Gallo; Alain B Labrique; S Meade Inglis; Cole D Jenson; Heather E Parnell; Nae-Yuh Wang; Kelli L Hicks; Joseph R Egger; Peter F Halpin; Michael Yong; Jeromie Ballreich; Samantha Kleindienst Robler

doi:10.1016/S2214-109X(22)00184-X

Mobile health school screening and telemedicine referral to improve access to specialty care in rural Alaska: a cluster- randomised controlled trial

Lancet Glob Health. 2022 Jul;10(7):e1023-e1033. doi: 10.1016/S2214-109X(22)00184-X.

Authors

Affiliations

¹ Department of Head and Neck Surgery and Communication Science, Duke University School of Medicine, Duke University, Durham, NC, USA; Duke Global Health Institute, Duke University, Durham, NC, USA; Center for Health Policy and Inequalities Research, Duke University, Durham, NC, USA. Electronic address: sdemmett@uams.edu.
² Duke Global Health Institute, Duke University, Durham, NC, USA; Department of Biostatistics and Bioinformatics, Duke University, Durham, NC, USA.
³ Mixed Methods Research Training Program, Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.
⁴ Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.
⁵ Duke Global Health Institute, Duke University, Durham, NC, USA; Center for Health Policy and Inequalities Research, Duke University, Durham, NC, USA.
⁶ Department of Audiology, Norton Sound Health Corporation, Nome, AK, USA.
⁷ Department of Biostatistics, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA; Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA; Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
⁸ Department of Otolaryngology-Head and Neck Surgery, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
⁹ Duke Global Health Institute, Duke University, Durham, NC, USA.
¹⁰ School of Education, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
¹¹ Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA; BC Rotary Hearing and Balance Centre, Division of Otolaryngology-Head and Neck Surgery, Department of Surgery, University of British Columbia, Vancouver, BC, Canada.
¹² Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.
¹³ Department of Audiology, Norton Sound Health Corporation, Nome, AK, USA; Department of Population Health, Norton Sound Health Corporation, Nome, AK, USA.

Abstract

Background: School-based programmes, including hearing screening, provide essential preventive services for rural children. However, minimal evidence on screening methodologies, loss to follow-up, and scarcity of specialists for subsequent care compound rural health disparities. We hypothesised telemedicine specialty referral would improve time to follow-up for school hearing screening compared with standard primary care referral.

Methods: In this cluster-randomised controlled trial conducted in 15 rural Alaskan communities, USA, we randomised communities to telemedicine specialty referral (intervention) or standard primary care referral (control) for school hearing screening. All children (K-12; aged 4-21 years) enrolled in Bering Straight School District were eligible. Community randomisation occurred within four strata using location and school size. Participants were masked to group allocation until screening day, and assessors were masked throughout data collection. Screening occurred annually, and children who screened positive for possible hearing loss or ear disease were monitored for 9 months from the screening date for follow-up. Primary outcome was the time to follow-up after a positive hearing screen; analysis was by intention to treat. The trial was registered with ClinicalTrials.gov, NCT03309553.

Findings: We recruited participants between Oct 10, 2017, and March 28, 2019. 15 communities were randomised: eight (750 children) to telemedicine referral and seven (731 children) to primary care referral. 790 (53·3%) of 1481 children screened positive in at least one study year: 391 (52∤1%) in the telemedicine referral communities and 399 (50∤4%) in the primary care referral communities. Of children referred, 268 (68·5%) in the telemedicine referral communities and 128 (32·1%) in primary care referral communities received follow-up within 9 months. Among children who received follow-up, mean time to follow-up was 41·5 days (SD 55·7) in the telemedicine referral communities and 92·0 days (75·8) in the primary care referral communities (adjusted event-time ratio 17·6 [95% CI 6·8-45·3] for all referred children). There were no adverse events.

Interpretation: Telemedicine specialty referral significantly improved the time to follow-up after hearing screening in Alaska. Telemedicine might apply to other preventive school-based services to improve access to specialty care for rural children.

Funding: Patient-Centered Outcomes Research Institute.

Publication types

Randomized Controlled Trial
Research Support, Non-U.S. Gov't

MeSH terms

Alaska
Child
Humans
Referral and Consultation
Rural Population
Schools
Telemedicine*

Associated data

ClinicalTrials.gov/NCT03309553

Grants and funding

AD-1602-34571/PCORI/Patient-Centered Outcomes Research Institute/United States