目的:在一项整群随机对照试验中了解与结果相关的因素,该试验评估了15个阿拉斯加农村社区的学校听力筛查的远程医疗专业转诊干预措施。
方法:HearingNortonSound是一项混合方法的整群随机对照试验,将远程医疗专业转诊路径(干预)与标准初级保健转诊路径(对照)进行学校听力筛查。作为一项混合方法试验,收集了定量和定性数据,分析,和综合。主要试验结果发表在别处,但尚未报道社区特定定量结果和定性结果的整合。持续比较方法用于分析来自所有15个社区的六个利益相关者团体的半结构化访谈的定性数据。描述性统计数据用于描述两个试验年中社区特定的随访比例。整合了定性和定量结果,以揭示社区中环境因素与后续结果之间的关系。
结果:听力NortonSound试验于2017年10月至2019年3月招募了1481名儿童,共有790名儿童需要转诊。在远程医疗专业转诊路径社区(干预)中转诊的儿童中,68.5%接受随访(268/391),初级保健转诊社区(对照)为32.1%(128/399)(先前报告).当按社区划分时,远程医疗专业转诊社区和初级保健转诊社区接受随访的平均比例为75.26%(SD22.5)和37.9%(SD11.4),分别。对于定性数据收集,我们在2018年12月至2019年8月期间对101人进行了半结构化访谈.六个利益相关者团体参加:长者(n=14),父母(n=25),儿童(n=11),教师/学校工作人员(n=18),校长(n=6),和医疗保健提供者/诊所工作人员(n=27)。在分析过程中出现了与远程医疗专科转诊路径结果相关的六个总体因素:临床能力,人员所有权和参与度,调度,远程医疗设备/过程,通信,以及对后续行动必要性的认识。我们将这些因素与社区特定的随访百分比进行了整合,并发现了六个定性因素中的四个:临床能力,人员所有权和参与度,通信,和意识。没有看到调度和远程医疗设备/过程的关联,与随访结果存在可变关系。
结论:HearingNortonSound试验表明,远程医疗专业转诊途径可以缩小在学校听力筛查后失去随访的儿童的差距。作为一个整体,干预措施大大提高了接受随访的儿童比例,但是社区内部和社区之间的结果存在差异。为了理解这种可变性,我们分析了社区特定干预结果以及社区成员对干预相关因素的反馈.我们确定了促成干预成功的四个关键因素。注意这些因素对于在阿拉斯加农村及其他地区的未来工作中成功适应和实施这种远程医疗专业转诊干预措施和其他类似干预措施至关重要。
To understand factors associated with outcomes in a cluster-randomized controlled
trial that evaluated a telemedicine specialty referral intervention for school hearing screenings in 15 rural Alaskan communities.
Hearing Norton Sound was a mixed methods cluster-randomized controlled
trial that compared a telemedicine specialty referral pathway (intervention) to a standard primary care referral pathway (control) for school hearing screenings. As a mixed methods
trial, both quantitative and qualitative data were collected, analyzed, and integrated. Main
trial results are published elsewhere, but integration of community-specific quantitative outcomes and qualitative results have not yet been reported. The constant comparative method was used to analyze qualitative data from semistructured interviews with six stakeholder groups across all 15 communities. Descriptive statistics were used to describe community-specific proportions of follow-up in both
trial years. Qualitative and quantitative results were integrated to reveal relationships between contextual factors and follow-up outcomes across communities.
The Hearing Norton Sound trial enrolled 1481 children from October 2017 to March 2019, with a total of 790 children requiring referral. Of the children who referred in the telemedicine specialty referral pathway communities (intervention), 68.5% received follow-up (268/391), compared to 32.1% (128/399) in primary care referral communities (control)(previously reported). When broken down by community, the mean proportion receiving follow-up was 75.26% (SD 22.5) and 37.9% (SD 11.4) for the telemedicine specialty referral communities and primary care referral communities, respectively. For qualitative data collection, semistructured interviews were conducted with 101 individuals between December 2018 and August 2019. Six stakeholder groups participated: elders (n = 14), parents (n = 25), children (n = 11), teachers/school staff (n = 18), principals (n = 6), and healthcare providers/clinic staff (n = 27). Six overall factors related to the outcomes of the telemedicine specialty referral pathway emerged during analysis: clinic capacity, personnel ownership and engagement, scheduling, telemedicine equipment/processes, communication, and awareness of the need for follow-up. We integrated these factors with the community-specific follow-up percentages and found associations for four of the six qualitative factors: clinic capacity, personnel ownership and engagement, communication, and awareness. An association was not seen for scheduling and telemedicine equipment/processes, which had variable relationships with the follow-up outcome.
The Hearing Norton Sound trial demonstrated that a telemedicine specialty referral pathway can close the gap on children lost to follow up after school hearing screening. As a whole, the intervention profoundly increased the proportion of children receiving follow-up, but there was variability in outcomes within and between communities. To understand this variability, we analyzed community-specific intervention outcomes alongside community member feedback on factors related to the intervention. We identified four key factors that contributed to the success of the intervention. Attention to these factors will be essential to successful adaptation and implementation of this telemedicine specialty referral intervention and other similar interventions in future work in rural Alaska and beyond.