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

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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.