Table 2.

Evaluation characteristics of included studies

Reference (author, date)	Study aims	Design	Outcome measures	Participants no (N) Age	Main findings
AIHW, 201825	Evaluate Hearing Health Programme ear and hearing health outreach services between July 2012 and December 2017	Repeat cross-sectionalandpre–post study	Service delivery, rates of ear disease, hearing status, demand for earandhearing health servicesandother follow-up services, outcome of children after exiting the programme, regional analysis, progress against benchmarks	N: not stated Age: under 21 years	Service delivery targets met, but numbers fell in 2017. Young people with ≥1 ear disease decreased from 66% to 61%, with hearing loss decreased from 55% to 45%. Over 3000 young people were still waiting for hearing health services at end 2017
Durham, 201826	Examine the alignment between Deadly Ears efforts and core concepts of system thinking. Identify potential strategies and levels of intervention to facilitate systems changes to better support ear health	Qualitative	Framework evaluated according to the 5 levels of intervention as outlined by the Intervention Level Framework: paradigm, goals, system structure, feedback and delays, and structural elements	Steering Committee members; Deadly Ears Programme staff; Community members	Three key areas where further work is needed to drive sustained improvements: (1) build the governance structures needed for paradigm shift to achieve a multi-sectoral approach; (2) develop shared system level goals; (3) develop system-wide feedback processes
Elliott, 201027	Determine feasibility of integrating a mobile telehealth-enabled ear, hearingandvision-screening service with existing community-based health services	Quantitative non-randomised	Community acceptance, integration with existing community-based services, the technical/practical feasibility of presenting diagnostic information for telemedicine consultations	N: 760 Age: 0–16 years	59% of children screened during the first 6 months, 41% failed ≥1 components of the ear-screening assessment and were all referred to community health services for management and/or follow-up review, 12% had signs of hearing impairment. 157 referrals made to ENT specialist for online review, 3 teleotology clinics were conducted and 59 cases were reviewed
Nguyen, 201531	Assess cost-effectiveness of supplemental MTESS service, compared with the existing outreach screening and surgical service alone	Retrospective costing study	Cost, outcomes of screening and treatment, and incremental cost-effectiveness ratio	Deadly Kids N:~350. MTESS N: 780 Age: 3–18 years	Compared with the Deadly Ears Programme, the probability of an acceptable cost-utility ratio at a willingness-to-pay threshold of $A50 000/QALY was 98% for the MTESS service. This cost effectiveness arises from preventing hearing loss & subsequent reduction in associated costs.
Smith, 201530	Examine whether there were changes in screening activity, fail and referral rates over the 6 years of service delivery in the study area	Retrospective review of service activity	Total number of completed assessments, total number of patients failing at least one screening test, overall proportion of failed screening assessments per year	N: 3105 Age: not stated	The service provided 5539 screening assessments. Mean screening failure rate for children outside of postcode 4605 (Cherbourg/Murgon area) was 22% (range 17%–29%) and 38% for children living inside postcode 4605 (range 34%–41%). While screening activity increased by over 50% since 2009, there was a slight reduction in the proportion of children failing assessment reduced from 33% in 2009 to 26% in 2014.
Smith, 201329	Examine whether the introduction of the telemedicine service led to changes in hospital referral trends at Royal Children’s Hospital in Brisbane and Cherbourg hospitals	Retrospective review of service activity	No of ENT outpatient appointment and failure-to-attend, no of surgical procedures completed	N: 329 (2006–8); 105 (2009–11) Age: not stated	At baseline (2006–08), there were 329 ENT outpatient appointments. Of these, 166 (51%) were failure-to-attends (FTAs). Between 2009 and 2011, there were 105 appointments, of which 40 (38%) were FTAs. At baseline, 100 children received surgical procedures at RCH; between 2009 and 2011 there were 43. In 2009–2011, 136 children were booked to receive surgical procedures at Cherbourg hospital, and 117 (86%) were completed
Smith, 201228	Examine the outcomes of the first 3 years of operation of MTESS	Retrospective review of service activity	Screening service activity, screening assessments results, referral and review by ENT surgeon, waiting times from referral to specialist assessment	N: 1053 Age: 0–18 years	2111 screening assessments were carried out at 21 schools, average screening rate was 85%. Over 50% of assessments resulted in a referral to the ENT specialist (for online assessment) or local doctor (for treatment). 20 specialist ENT online clinics were conducted during which 415 patients were reviewed. 55% of online review cases resulted in appointments at the next ENT outreach clinic for further review and/or surgery
Fernee, 200235	Demonstrate improvement in meanandindividual hearing thresholds following three different middle-ear surgical procedures. Investigate the effect of each procedure on hearing thresholds	Retrospective case–control study	Improvement in mean & individual hearing thresholds following middle-ear surgery. Effect of each surgical procedure on hearing thresholds	N: 38 Age: 5–24 years	Lower, non-statistically significant post-operative air conduction thresholds at 5–7 months for combined surgical procedures. Most significant improvement in hearing thresholds occurred at 2000 Hz. Tympanoplastyandadenoidectomy, combined with myringotomy, led to the greatest improvements in hearing thresholds. A large proportion of subjects had incomplete postoperative results.
Gruen, 200112	Identify barriers to accessing specialist care in the remote NT, describe the SOS Pilot Project, and evaluate the effectiveness of this model in improving access to specialist services	Mixed methods	Numbers of consultations with specialists, average cost per consultation, perceived barriers to accessing hospital-based outpatient care, and perceived impact of specialist outreach on these barriers	N: 25 remote health practitioners, patientsandspecialists Age: N/A	Perceived barriers included geographic remoteness, poor doctor–patient communication, poverty, cultural differences, and the structure of the health service. Between 1993 and 1999, there were 5134 SOS and non-SOS outreach consultations in surgical specialties. Intensive outreach practice increased total consultations by up to 441%andsignificantly reduced the number of transfers to hospital outpatient clinics (p<0.001)
Gruen, 200632	Assess the effects of outreach clinics on access, referral patterns, and care outcomes in remote communities in Australia.	Population-based observational study	Access, referral patterns, care outcomes	N: 2368 Age: all (median=19)	ENT outreach was not regular, being of no or low intensity (<6 months between visits). 246 new ENT problems were seen, with 151 referrals made. Of all problems, 18.3% had emergency referral, 30.9% elective referral, 12% opportunistic referral. Relative risk of regular outreach for timely completion of referrals was 1.25 (0.66–1.76, 96% CI) for ENT surgeons. Availability of regular outreach not associated with significant overall increase in referrals
Jacups, 201714	Review service provision model as a quality assurance process to inform the development of improved regional ENT services	Case series	Collaboration process, clinical and hearing outcomes, cost savings	16: (two non-indigenous) Age: 4–17 years	Surgeries successfully completed for 16 children, mean waitlist time of 1.2 years. Presurgery pure-tone average hearing thresholds were reported at left: 30.9 dB, right: 38.2 dB. Most presentations for bilateral OM with effusion (69%). Postsurgical follow-up indicated successful clinical outcomes in 80% of patients & successful hearing outcomes in 88% of patients. Telehealth for post-operative review enabled a minimum cost saving of $A21 664 for these 16 children.
Jacups, 201813	Identify the least costly model of ENT surgical access for remote living children	Retrospective costing evaluation	Incremental cost difference between base case (model 1) and two alternative approaches (model 2, 3) measured from health system perspective, and the patient and family perspective	16: (two non-indigenous) Age: 4–17 years	The least costly model offered low-risk ENT surgery from a remote setting hospital, with high use videoconference technology: TeleHealth (Model 3) could save $A3626-$5067/patient, compared with patients travelling to a regional public hospital (Model 1). A direct flight charter transfer to a regional private hospital (Model 2) reduced the cost by $A2178–$A2711/patient when compared with standard care (model 1).
Mak, 200033	Assess the outcome of operations performed in Kimberley hospitals for middle-ear disease	Descriptive study	Otoscopic and audiometric outcomes review (intact tympanic membrane and air-bone gap ≤25 dB at review ≥6 m postoperation)	N: 273 Age: 3.9 years-67.2 years (74% <20 years)	53% success rate; increasing age predicted success. Only 83 patients had postoperative follow-up records.
Mak, 200434	Assess the outcomes of myringoplasties to identify factors associated with a successful outcome	Prospective case series	Success (intact tympanic membrane and normal hearing 6 months +postoperative), closure of the perforation, postoperative hearing improvement	N: 58 Age: 5–15 years	49% were successful, 72% resulted in closure or reduction in size of the perforation, 51% resulted in hearing improvement. No association observed between success or hearing improvementandperforation size, or the presence of serous aural discharge at time of surgery.
Reeve, 201436	Reduce long waiting lists for ENT specialist review and improve primary ear healthcare	Retrospective evaluation	Access no of children screened for ear disease, effectiveness-referral letter completeness (history, otoscopy, tympanometry, audiometry), patient management and waiting time until first ENT contact	N: 710 Age: 0–18 years	Screened increased from 148/18 months to 710. Nearly twofold increase in patients referred to ENT (32, 66). Reduced median waiting time from 141 daysto22 days for ENT review using telehealth. Increased essential information—otoscopy, audiometry and tympanometry. Primary care management in accordance with guidelines improved.

ENT, ear, nose and throat; MTESS, mobile telemedicine-enabled ear health screening and surveillance; QALY, auality-adjusted life-year; SOS, Specialist Outreach Service.