Results Summary

What was the research about?

Childhood hearing loss is more common in rural Alaska than in other U.S. communities. Students with hearing loss may have speech and language delays, or they may have trouble in school and drop out early. In Alaska, students receive screening for hearing loss at school, but many don’t get follow-up care.

In this study, the research team compared two referral processes to help students with hearing loss in rural Alaska receive the follow-up care they need:

  • New telehealth referral. For students who needed follow-up care, schools and local health clinics worked together to bring students to the clinic. At the clinic, students had a telehealth visit with a specialist. Telehealth provides care to patients remotely. Community health aides at the clinic sent information about students’ hearing to specialists for review.
  • Standard referral. Schools sent parents a letter if their child needed follow-up care. The letter asked the parent to bring the child to the local health clinic for more testing.

The research team looked at how long it took students to receive an ear or hearing condition diagnosis. The team also looked at hearing loss, hearing-related quality of life, and school performance.

What were the results?

Of the 1,481 students who received screening for hearing loss in schools, 790 needed a referral for follow-up.

After nine months, students using the new process were more likely to get a diagnosis—and to get it faster—than students using the standard process:

  • 68 percent of students who used the new process had a diagnosis within nine months compared with 32 percent of students who used the standard process.
  • Of students who got a diagnosis, students who used the new process had a diagnosis within 16 days on average compared with 82 days for those who used the standard process.

After nine months, students who used the two referral processes didn’t differ in hearing loss, hearing-related quality of life, or school performance.

Who was in the study?

The study included 790 students ages 4–21 living in one of 15 rural communities in northwestern Alaska. The median age was 10, and 60 percent were boys. Students were receiving care from a tribal health program.

What did the research team do?

The research team assigned the 15 communities by chance to one of the two referral processes. Schools and health systems used the process assigned to their communities.

The research team reviewed health records to learn about diagnoses. Students completed surveys about other outcomes.

Community members and staff from schools and health systems in the study region helped plan and conduct the study.

What were the limits of the study?

The study took place in communities that receive care through tribal health programs, which offer health care to Alaska Native people. Results may differ in other healthcare settings.

Future studies could look at study outcomes in other healthcare settings.

How can people use the results?

Communities receiving care through tribal health programs can use the results when considering ways to improve follow-up care for children with hearing loss.

Final Research Report

View this project's final research report.

Journal Citations

Article Highlight: Children in school-based hearing screening programs who received telehealth-based specialist referrals experienced follow-up care up to 17.6 times faster, compared with children who received standard primary care referrals, according to results from this study, which appear in the July 2022 edition of Lancet Global Health.

The study, which was conducted in 15 rural Alaskan communities between 2017 and 2020, is considered to be the first to demonstrate that telemedicine can reduce a key rural health disparity in access to care. The researchers also suggest that the benefits of telemedicine could translate to other preventive school-based services to improve specialty health care for children in rural areas.

 Enlarge results infographic
 (Credit: Susan D. Emmett)

Stories and Videos

Media Mentions

This Simple Test Can Help Kids Hear Better (Susan Emmett | TEDGlobal 2017)

NOTE: This talk was presented at an official TED conference. View the video and more on the TED website.

The video above is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International (CC BY-NC-ND 4.0) License. It is attributed to TED Talks. To view a copy of this license, visit

Peer-Review Summary

Peer review of PCORI-funded research helps make sure the report presents complete, balanced, and useful information about the research. It also assesses how the project addressed PCORI’s Methodology Standards. During peer review, experts read a draft report of the research and provide comments about the report. These experts may include a scientist focused on the research topic, a specialist in research methods, a patient or caregiver, and a healthcare professional. These reviewers cannot have conflicts of interest with the study.

The peer reviewers point out where the draft report may need revision. For example, they may suggest ways to improve descriptions of the conduct of the study or to clarify the connection between results and conclusions. Sometimes, awardees revise their draft reports twice or more to address all of the reviewers’ comments. 

Peer reviewers commented and the researchers made changes or provided responses. Those comments and responses included the following:

  • The reviewers praised the researchers on this well-written final report of an important research project.  There were few substantive comments.
  • One reviewer noted that the researchers asserted their study had limited generalizability because of its unique Tribal healthcare context and asked the researchers to provide some details about how the unique context could affect generalizability. The researchers explained that this telemedicine-focused study would require the community having an existing telehealth infrastructure like the one the researchers utilized in the Tribal health system.
  • The reviewer asked how the generalizability of the study could be improved in future studies. The researchers responded by suggesting that in non-Tribal areas the intervention could be moved into the school to address the need for a telehealth infrastructure and some of the other limitations of this study.

Conflict of Interest Disclosures

Project Information

Samantha Kleindienst Robler, AuD, PhD
Norton Sound Health Corporation
Addressing Childhood Hearing Loss Disparities in an Alaska Native Population: A Community Randomized Trial

Key Dates

December 2016
May 2022

Study Registration Information

^Philip Hofstetter, AuD, MA, was the original principal investigator on this project.


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Last updated: April 15, 2024