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.
To compare the effectiveness of an expedited telehealth referral to specialty care versus a standard referral to primary care on improving time to diagnosis following school-based hearing screening for students in rural Alaska
|Design||Cluster randomized controlled trial|
|Population||790 students ages 4–21 attending school in 15 communities in northwestern Alaska|
Primary: time to diagnosis of ear or hearing conditions
Secondary: hearing loss prevalence, hearing-related quality of life, school performance
|Timeframe||9-month follow-up for primary outcome|
Childhood hearing loss is more prevalent in rural Alaska than in other U.S. communities. School-based health programs frequently include basic hearing and vision screening, but children in rural areas often do not receive the necessary follow-up care.
This cluster randomized controlled trial examined whether an expedited telemedicine specialty referral process improved time to diagnosis among students with hearing loss compared with a standard referral process. Researchers randomized 15 rural communities in northwestern Alaska to one of two groups:
- Expedited telemedicine specialty referral. For students requiring further screening following their initial school-based screening, schools and local health clinics collaborated to bring students to the clinic for a telemedicine consultation with a specialty care provider. Community health aides at the clinic assessed hearing, took pictures and measurements of students' ears, and sent this information to the specialist to support the consultation.
- Standard primary care referral. Schools sent parents of students who needed further screening a letter. The letter included a request for the parents to bring the child to the local health clinic for evaluation. When children arrived at the clinic, treatment options included scheduling a field visit with a specialist, receiving a telemedicine consultation, or receiving a referral to a primary care provider.
Schools and health systems used the referral process assigned to their communities. The study included 790 students requiring follow up from among 1,481 students who received an initial screening for hearing loss in schools. The median age was 10, and 60% were male. All participants were receiving care from a tribal healthcare organization.
The research team reviewed electronic medical records to determine time to diagnosis and assessed hearing loss prevalence using school screening data. Students completed surveys to assess hearing-related quality of life and school performance.
Community members and representatives from schools and health systems in the study region provided input on the study.
Compared with students receiving standard primary care referrals, students receiving expedited telemedicine specialty referrals were more likely to receive a diagnosis of an ear or hearing condition within nine months (69% versus 32%; adjusted risk ratio=2.32; 95% confidence interval [CI]: 1.4, 3.8). Of the students who received a diagnosis, students receiving expedited referrals received a diagnosis faster than those who received standard referrals (16 days versus 82 days; adjusted event time ratio=17.6; 95% CI: 7.6, 40.5).
The two groups did not differ significantly in prevalence of hearing loss, hearing-related quality of life, or school performance.
The study took place in communities that receive care through tribal health programs. Results may differ in other healthcare settings.
Conclusions and Relevance
Schools and health systems can use these results when looking for ways to improve the referral process following school hearing screening in rural areas.
Future Research Needs
Future studies could examine study outcomes in other healthcare settings.
Final Research Report
View this project's final research report.
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.
Results of This Project
Related Journal Citations
Stories and Videos
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 https://creativecommons.org/licenses/by-nc-nd/4.0/.
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
Study Registration Information
^Philip Hofstetter, AuD, MA, was the original principal investigator on this project.
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