North STAR Trial: Specialty Telemedicine Access for Referrals in Rural Alaska

摘要 阿拉斯加农村原住民儿童经历可预防的儿童听力损失的高患病率。校本 项目为许多服务不足的农村和少数民族儿童提供了获得预防服务的唯一途径， 从学校听力筛查中失访是常见的，农村地区缺乏专家 护理障碍。阿拉斯加部落卫生系统通过远程医疗解决了医疗保健的地理障碍 该网络不用于学校听力筛查，仅在部落地区可用。这 一项提案将一种新颖的远程保健模式直接引入学校，以覆盖服务不足的农村和少数民族儿童 阿拉斯加州，包括非部落地区。总体目标是前瞻性地实施 并评估阿拉斯加学校的一种新的虚拟专业护理模式，以减少学校后续护理的损失 听力筛查和改善农村地区获得专业护理的机会。这项工作建立在 该团队最近的PCORI资助的集群随机试验， 在村卫生室开展听力筛查转介预防模式。随机分配到诊所的儿童- 基于远程医疗专科转诊的患者接受耳/听力检查的可能性是其他患者的2.3倍（95% CI 1.4，3.8）。 诊断比那些接受标准转诊的一封家书。基于诊所的干预措施的成功 社区之间差异很大;与利益攸关方的访谈揭示了执行方面的挑战， 通过直接在学校提供远程保健来解决。目前的建议将建立一个独特的模式， 在整个国家的部落和非部落地区的护理，使虚拟专业护理直接进入学校。三 完成和互补的多个PI，他们合作进行PCRI和NIDCD资助的农村研究， 阿拉斯加，将领导一个跨学科的团队，和阿拉斯加利益相关者团队，其中包括阿拉斯加专员 教育、卫生和社会服务部将指导研究发展。在目标1中，团队将开发和 透过焦点小组，试行校本听觉损失虚拟专科护理的实施方案 与社区利益相关者的访谈。在目标2中，他们将进行一个阶梯式楔形， 在三个有代表性的地区（n=31所学校; 2 008名儿童）实施虚拟专业护理试验。的 主要结果是在筛查后两个月内进行专业随访的听力转介比例 约会基于PCRI试验数据的保守假设是，虚拟专科护理将改善随访- 上升了100%在目标3中，该团队将通过一项研究评估阿拉斯加学校虚拟专业护理的可持续性。 进行政策分析，以评估卫生和教育部门之间的一致性，查明政策和实践障碍 和加速器，并确定未来计划融资的支付模式。这种基于学校的远程医疗 解决可预防的儿童听力损失的模式可以转化为其他服务不足的农村和少数民族 在农村学校提供高价值的服务，以改变全国范围内的预防模式。

ABSTRACT Rural Alaska Native children experience a high prevalence of preventable childhood hearing loss. School-based programs provide the only access to preventive services for many underserved rural and minority children, yet loss to follow-up from school hearing screening is common and scarcity of specialists in rural areas compound barriers to care. The Alaska Tribal Health System addresses geographic barriers to care with a telehealth network, but the network is not used for school hearing screening and is only available in Tribal regions. This proposal brings a novel telehealth model directly into schools to reach underserved rural and minority children across the state of Alaska, including non-Tribal regions. The overall objective is to prospectively implement and evaluate a new virtual specialty care model in Alaska schools to reduce loss to follow-up from school hearing screening and improve access to specialty care in rural environments. This work builds on the team’s recent PCORI-funded cluster-randomized trial that translated Alaska’s existing Tribal telehealth network in village clinics to a prevention model for school hearing screening referrals. Children randomized to clinic- based telemedicine specialty referral were 2.3 (95% CI 1.4, 3.8) times more likely to receive an ear/hearing diagnosis than those receiving the standard referral of a letter home. Success of the clinic-based intervention varied substantially between communities; stakeholder interviews revealed implementation challenges that could be addressed by delivering telehealth directly in schools. The current proposal will establish a unique model of care in Tribal and non-Tribal regions across the state, bringing virtual specialty care directly into schools. Three accomplished and complementary multi-PIs, who collaborated on PCORI- and NIDCD-funded studies in rural Alaska, will lead an interdisciplinary team, and an Alaska Stakeholder Team that includes Alaska Commissioners for Education and Health and Social Services will guide study development. In Aim 1, the team will develop and pilot an implementation protocol for school-based virtual specialty care for hearing loss through focus groups and interviews with community stakeholders. In Aim 2, they will conduct a stepped wedge, cluster-randomized implementation trial of virtual specialty care in three representative regions (n=31 schools; 2,008 children). The primary outcome is proportion of hearing referrals resulting in specialty follow-up within two months of screening date. The conservative hypothesis, based on PCORI trial data, is that virtual specialty care will improve follow- up by 100%. In Aim 3, the team will evaluate sustainability of virtual specialty care in Alaska schools through a policy analysis to assess alignment between health and education sectors, identify policy and practice barriers and accelerators, and ascertain payment models for future programmatic financing. This school-based telehealth model to address preventable childhood hearing loss could be translated to other underserved rural and minority groups, bringing high-value services into rural schools to alter the paradigm of prevention nationwide.