Mobile Health School Screening and Telemedicine Referral to Improve Access to Specialty Care in Rural Alaska: Integrating Mixed Methods Data to Contextualize Trial Outcomes.
Samantha Kleindienst Robler, Meade Inglis-Jenson, Joseph J Gallo and 4 others
PMID 37594255WHAT IT FOUND
Telemedicine referral got 68.5% of children seen within nine months of a failed school hearing screen, against 32.1% with a letter home.
Where it worked, clinics had staff to spare, one person owned the follow-up, school and clinic talked, and families knew why it mattered.
Key findings
01In the trial, 68.5% of referred children in telemedicine communities (268 of 391) were seen within nine months of screening, compared with 32.1% (128 of 399) where families got the standard letter recommending they take their child to the local clinic. Averaged by community, the rates were 75.26% and 37.9%.
02Four things lined up with how well each community did: clinic capacity, personnel ownership and engagement, communication, and awareness of the need for follow-up. Interviewees described each of the four as a help where follow-up was high, a barrier where it was low, and a mix in communities in between. Two other themes, scheduling and telemedicine equipment and processes, did not follow that pattern.
03In communities with poor follow-up, staff described clinics with too few people to fit screening appointments around acute and emergency care, no one clearly responsible for the follow-up, information not reaching parents, and families not seeing why a child who was not sick needed to be seen.
STILL TO COME
How it was doneWhat they foundWhat it means for SLPs
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What it does not show
Only 101 people were interviewed, about 1% of the region's population. The authors sampled across all 15 communities and all six stakeholder groups until no new themes appeared, but the numbers per community and per group are small. Interviewees were recalling events from different lengths of time in the past, so some memories were fresher than others. The authors name their own potential bias in designing the trial and analysing the interviews, and describe the steps taken to limit it: local stakeholders helped write the interview guides, and coding involved a range of team members plus an off-site qualitative expert. The link between the four factors and follow-up is an association, not a test. The team averaged each community's two years of follow-up and sorted them into low, moderate and high using cut-offs they chose themselves, then read the interview accounts alongside. No community was given a programme to change any of these factors, and no statistical test of the association is reported. The mixing of the two data sets used only the eight communities assigned to telemedicine, so the paper says little about what helped or hindered follow-up where families received the standard letter. The trial's headline result is taken from the earlier publication of the quantitative outcomes rather than re-analysed here.
Declared interests
The work was funded by the Patient-Centered Outcomes Research Institute (PCORI-AD-1602-34571), a non-profit research funder. The declaration supplied describes who did what on the paper and names this funding source; it contains no commercial sponsor and no stated financial interests for the authors.
The easy way to misread this
Do not read the four factors as a proven way to improve follow-up. They were identified by setting interview accounts next to each community's follow-up rate; no community was given a programme to change them, and no test is reported showing that fixing clinic staffing, ownership, communication or awareness would raise follow-up.
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