Appalachian STAR Trial: Specialty Telemedicine Access for Referrals in Rural Kentucky

ABSTRACT Health disparities in rural America begin early in life. These inequalities primarily arise from social determinants of health, with policies, community-level factors such as access to care, and organizational factors at the school and health system levels shaping health across the life course. In many areas, school-based health programs often provide the only access to preventive services for underserved rural and socioeconomically disadvantaged children. However, school screening programs are notoriously plagued by loss to follow-up, and limited numbers of specialists in rural areas for treatment compound barriers to care. We propose to prospectively implement a novel, multilevel mHealth screening and virtual specialty care referral intervention, “Appalachian STAR,” (AppSTAR) in eastern Kentucky schools to address social determinants at the policy, school, and health system level that hinder identification and treatment of preventable health disparities for two NIH-designated disparity populations: underserved rural and socioeconomically disadvantaged children. We will use school hearing screening as the prototype for this initiative due to the disproportionately high burden of preventable, infection- related hearing loss in underserved populations and the profound lifelong implications of childhood hearing loss for language development, school achievement, and future employment opportunities. We seek to accomplish this objective through the following aims: 1) Using the ADAPT-ITT framework and guided by key stakeholders, to systematically adapt the evidence-based telemedicine hearing screening program to form the AppSTAR intervention to meet the unique needs of rural communities, 2) Test effectiveness of AppSTAR through a stepped wedge, cluster-randomized hybrid type 1 trial in rural Kentucky to increase hearing screening within elementary schools and to increase specialty referral adherence, 3) Based on the Consolidated Framework of Implementation Research, to identify within the domains of hearing screener characteristics, outer setting, intervention characteristics, and implementation process influencing implementation of implementation factors of AppSTAR in each school, as well as preliminary implementation outcomes. We will conduct a mixed methods implementation analysis including acceptability, adoption, retention, and costs to evaluate sustainability of Appalachian STAR and inform future scale-up efforts. Our innovative AppSTAR intervention is the first study to apply telehealth for preventive school health programs. We will integrate lay-friendly mHealth screening technology with school-based virtual specialty care referral to ameliorate the longstanding national problem of loss to follow-up from screening and reduce barriers to specialty care in rural America. Following hearing loss, the Appalachian STAR model could be applied to numerous preventable health disparities, such as vision loss, obesity, and behavioral health, and could be scaled to other rural environments, applying policy change and digital innovations to radically expand access to care for underserved rural and socioeconomically disadvantaged children nationwide.