Appalachian STAR Trial

美国农村的健康差距在生命早期就开始了，原因是健康的社会决定因素始于 童年。学校保健方案往往是农村儿童获得预防性服务的唯一途径。 然而，学校筛查的实施情况多种多样，受到追踪损失的困扰，农村的专家有限。 地区加剧了医疗保健的障碍。我们建议在阿巴拉契亚地区前瞻性地实施一种新的护理模式 肯塔基州农村学校，以解决学校、卫生系统和政策层面的社会决定因素 妨碍确定和治疗NIH指定的两个差异人群中可预防的健康差异： 服务不足的农村和社会经济上处于不利地位的儿童。我们的目标是建立一部小说， 可推广的以学校为基础的远程医疗驱动的预防保健模式 美国农村地区服务不足的人口。我们将调整和评估我们的循证方法， “STAR”(转诊的特殊远程医疗接入)，我们发现这在农村的部落环境中很有效 阿拉斯加。阿巴拉契亚有一些美国最贫穷的县，这使得这个地区成为适应 美国乡村。这项创新的“阿巴拉契亚STAR试验”将是首个将远程医疗应用于学校的研究 对于预防性服务，可直接求助于专家。听力筛查将成为STAR DUE的原型 对于缺乏服务的儿童中可预防的、与感染相关的听力损失的沉重负担以及深远的终身 儿童听力损失的影响。我们的跨学科团队与服务不足的人 肯塔基州社区以及与社区咨询委员会和利益攸关方咨询委员会的伙伴关系 提供州政府最高层的支持(见肯塔基州州长信)。我们将从 调整明星护理模式，通过社区满足农村社区和学校的需求- 和利益相关者驱动的方法。我们将通过以下方式评估肯塔基州农村66所学校的星级关怀模式 阶梯式楔形群-随机混合型1型有效性--对幼儿园儿童的实施试验 在14个县(n=~3600/年)。明星干预包括县级学校筛查政策的变化 增强了mHealth学校的听力筛查，随后进行了虚拟专科护理转介。阶梯形楔子 设计允许评估政策/筛查和转诊部分以及与通常护理的比较 与完全干预(第2年与第5年)，同时满足社区的意见，即干预对所有人都可用。主要 结果是1)儿童接受筛查和2)转诊在两个月内得到特殊护理的百分比 放映。我们保守地假设筛查的百分比将提高20%，后续将 提高40%。在试验期间，我们将评估多层次的实施因素和结果，以向Scale- 进入其他农村地区。我们的明星模式既可以在美国农村推广，也可以应用于其他 可预防的健康差距，将学校卫生政策变化与数字创新相结合，从根本上 在全国范围内扩大对服务不足的农村儿童和社会经济困难儿童的关爱。

Health disparities in rural America begin early in life, arising from social determinants of health that start in childhood. School health programs often provide the only access to preventive services for rural children. However, school screening is variably implemented, plagued by loss to follow-up, and limited specialists in rural areas compound barriers to care. We propose to prospectively implement a novel model of care in Appalachian schools of rural Kentucky to address social determinants at the school, health system, and policy levels that hinder identification and treatment of preventable health disparities for two NIH-designated disparity populations: underserved rural and socioeconomically disadvantaged children. Our goal is to establish a novel, generalizable model of school-based, telehealth-driven preventive care that can be disseminated in underserved populations across rural America. We will adapt and evaluate our evidence-based approach, “STAR” (Specialty Telemedicine Access for Referrals), that we have found effective in a Tribal setting in rural Alaska. Appalachia has some of the poorest counties in the US, making this region ideal for adapting across rural America. The innovative “Appalachian STAR trial” will be the first study to apply school-based telehealth for preventive services, with direct access to specialists. Hearing screening will be the prototype for STAR due to the high burden of preventable, infection-related hearing loss in underserved children and the profound lifelong implications of childhood hearing loss. Our interdisciplinary team has relationships with underserved communities in Kentucky and partnership with a Community Advisory Board and Stakeholder Advisory Board providing support from the highest levels of state government (See KY Governor Letter). We will begin by adapting the STAR model of care to meet the needs of rural communities and schools through a community- and stakeholder-driven approach. We will evaluate the STAR care model in 66 schools in rural Kentucky through a stepped wedge cluster-randomized hybrid type 1 effectiveness-implementation trial with kindergarten children in 14 counties (n=~3600/year). The STAR intervention includes county-level school screening policy change with enhanced mHealth school hearing screening, followed by virtual specialty care referral. The stepped-wedge design allows evaluation of the policy/screening and referral components as well as comparison of usual care vs. full intervention (years 2 vs.5), while meeting community input that the intervention be available to all. Primary outcomes are the percentage of 1) children screened and 2) referrals resulting in specialty care within two months of screening. We conservatively hypothesize the percentage screened will improve by 20% and follow-up will improve by 40%. During the trial, we will assess multi-level implementation factors and outcomes to inform scale- up into other rural areas. Our STAR model could be both scaled across rural America and applied to other preventable health disparities, combining policy change on school health with digital innovations to radically expand access to care for underserved rural and socioeconomically disadvantaged children nationwide.