Telemedicine Referral to Improve Access to Specialty Care for Preschool Children in Rural Alaska: A Cluster-Randomized Controlled Trial.

Small: 71 referred children across 14 communities, and the time-to-follow-up estimate is imprecise, with a confidence interval running from 1.8 to 11.4. Masking the community assignment was not possible because the communities had already been randomised in the main trial the year before, so people in the comparison communities may have known which pathway they were on. The trial relied on a telemedicine network already built into routine tribal health care with one regional hospital and one tertiary referral centre; the authors say this limits how far the result travels to settings with several organisations and different insurance coverage. Making it work depended on school and clinic staff coordinating, and the authors report influenza outbreaks, urgent care demands and staff shortages meant the intervention ran differently in different communities. The secondary outcome, whether any follow-up happened at all, was added after the trial was registered. The results split by previous hearing management are exploratory, and the sample was too small to test those differences with adequate precision. The groups were not identical at the start: 30.8% of referred children in telemedicine communities had hearing loss at screening versus 10% in standard care communities.

Funded by the Patient-Centered Outcomes Research Institute (PCORI), with an additional T32 training grant supporting one author. The authors report no conflicts of interest. The two principal investigators had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the analysis.

Do not read this as proof that a telemedicine appointment itself fixes a child's hearing. The trial could not separate the telemedicine consultation from the school-and-clinic coordination that arranged it, and half the children in the standard care group were still followed up. Do not assume it will transfer unchanged to a service without an established telemedicine network already wired into routine care.