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Translating Evidencebased Developmental Screening into Pediatric Primary Care

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Title: Translating Evidencebased Developmental Screening into Pediatric Primary Care


1
Translating Evidence-based Developmental
Screening into Pediatric Primary Care
  • James Guevara, MD, MPH
  • Center for Pediatric Clinical Effectiveness
  • Seminar Series
  • October 3, 2008

2
Educational Aims
  • To review current knowledge of developmental
    problems and interventions in early childhood
  • To update participants on current screening
    recommendations
  • To understand barriers to implementation of
    developmental screening
  • To disseminate information on TEDS Study

3
Declarations
  • Current study is funded by a grant from CDC
  • R18 DD000345
  • No conflicts of interest to declare

4
Relevant Definitions
  • Developmental delay (DD) when a child does not
    meet developmental milestones within an expected
    period of time in one or more domains (motor,
    speech language, social behavioral,
    cognitive)
  • Presumptive Condition health condition that is
    strongly associated with DD, presumptive
    eligibility for early intervention
  • At Risk Condition health condition that is
    associated with DD, may require close monitoring

5
High Prevalence of DD
  • Prevalence estimated at 16.8 in U.S., _at_2 have
    severe disability
  • Strong association with certain medical and
    genetic conditions, eg. HIV or Downs Syndrome
  • Greater prevalence among lower SES children

6
Risk Factors for Developmental Delay
  • Very Low birthweight or prematurity
  • Known genetic disorders or syndromes (presumptive
    conditions), eg. Downs Syndrome
  • Known chronic medical conditions (presumptive
    conditions), eg. HIV
  • Family history of DD eg. Autism in sibling
  • Psychosocial factors eg. poverty, child abuse
    and neglect, failure to thrive, maternal
    depression, parent substance abuse, plumbism

7
Poor Prognosis for DD
Boyle et al, Pediatrics 1994 93399-403
8
Treatment of DD Parallel Tracks
  • Medical Management ancillary services and
    multidisciplinary specialty services
    (diagnosis-specific)
  • Individuals with Disabilities Act (IDEA) federal
    mandate for EI (diagnosis-independent)
  • Part C (Birth to Three)
  • Part B (Early childhood special education)
  • 3-5 years old (in some states, the age is birth
    to 5)

9
Varying Eligibility for EI
  • States must provide services to
  • Children experiencing developmental delays
  • Children with established presumptive conditions
    (eg, HIV, Downs Syndrome)
  • States may provide services to
  • Children at risk of experiencing a developmental
    delay (eg VLBW, prematurity, plumbism,
    abuse/neglect, parent SA)
  • Each state is required to establish a definition
    of eligibility for services for 5 developmental
    domains
  • Motor
  • Communication
  • Cognitive
  • Daily living
  • Socio-emotional

(Definitions of eligibility differ significantly
from state to state)
10
Evidence for Effectiveness for EI?
  • EI has beneficial effects on cognitive
    functioning greater school achievement, less
    grade retention, less use of special education
  • EI has beneficial effects on social functioning
    lower teenage pregnancy, less delinquency
  • Only _at_30 of children with DD are detected before
    school entry

11
A WASI (HLBW) B PPVT-III (HLBW C WJTA-Reading
(HLBW) D WJTA-Math (HLBW) E WASI (LLBW) F
PPVT-III (LLBW) G WJTA-Reading (LLBW) H
WJTA-Math (LLBW)
McCormick et al, Pediatrics 2006 117771-80
12
Surveillance vs. Screening
  • Surveillance ongoing process of recognizing
    children who may be at risk of DD
  • Screening use of standardized tools to identify
    DD and refine risk
  • Evaluation a complex assessment process of
    identifying specific developmental disorders and
    needs

13
AAP Policy Statement
Pediatrics 2006 118 405-20
14
Summary of AAP Policy Statements
  • Surveillance at all well child visits
  • Developmental screening at the 9-, 18-, and
    30-month visits
  • Autism screening at the 18- or 24-month visits
  • Developmental screening at any well child visit
    in which DD risk is identified
  • Referral for diagnostic evaluation and services
    for children who fail screen
  • Schedule early return visits for those at risk
    who pass screens

15
Screening Increases Referrals
Hix-Small et al, Pediatrics 2007 120381-9
16
Barriers to Developmental Screening
  • Limited time and lack of reimbursement
  • Lack of knowledge and training in screening
  • Concerns about over-identification
  • Difficulty making referrals

Pinto-Martin et al, AJPH 2005 951928
17
North Carolina ABCD Project effort to overcome
screening barriers
Earls et al, Pediatrics 2006 118e183-8
18
Knowledge Gaps
  • Unclear whether feasible to implement
    developmental screening in high risk urban
    population without statewide support
  • Unclear whether urban physicians and families
    accept developmental screening
  • Unclear whether screening results in increased
    identification of DD

19
Translating Evidence-based Developmental
Screening (TEDS) Study
  • Randomized controlled trial of developmental
    screening in four urban pediatric practices
  • Assesses implementation of AAP policy statements
    on screening
  • Funded by CDC (PI Guevara) and Commonwealth Fund
    (PI Pati)

20
TEDS Study Aims
  • To identify barriers and facilitators to the use
    of standardized developmental screening in urban
    primary care practice.
  • To assess the feasibility of implementation of
    the AAPs developmental screening policy compared
    with usual care
  • To determine the relative effectiveness of the
    AAPs developmental screening policy compared
    with usual care

21
FrameworkTheory of Planned Behavior
22
TEDS Study Design
  • Mixed methods design combining qualitative and
    quantitative components
  • Year 1 conduct focus groups with parents,
    clinicians, and office staff to identify barriers
    and facilitators to screening and map office
    workflow
  • Year 2-3 Randomized intervention with 3 arms
  • Usual care (surveillance)
  • Developmental screening by SRS at 9, 18, 24, 30
    months
  • Developmental screening by PCP at 9, 18, 24, 30
    months

23
Focus Groups Parents
  • Prioritize development
  • Recognition that screening is difficult due to
    competing demands
  • Preference for developmentally focused visits
  • Screening tools would be acceptable
  • serve to stimulate conversation with
    pediatrician on development
  • identify developmental weaknesses in their child
    that could be targeted

24
Focus Groups Pediatricians
  • Prioritize time management
  • Perception that parents prefer complete well
    child exams
  • Development important but preference for
    maintaining all elements of well child exam
  • Mixed receptivity to use of screening tools
  • Favorable if other office staff complete screens
  • Unfavorable if they have to take additional time
    to complete screens

25
Study Considerations
  • Allow PCPs to prioritize developmental domains
    and assist in selection of screening tools
  • Conduct provider training in use of screening
    tools
  • Map office flow procedures
  • Integrate developmental screening with usual well
    child care
  • Collaborate with EI provider to acquire referral
    outcomes

26
Selection of Screening Tools
27
Ages and Stages Questionnaire (ASQ)
  • Visits 9, 18, and 30 month visits
  • Accuracy Sensitivity 0.75, specificity 0.86
  • Logistics 10-15 min, 30 questions, age-specific
    forms, EHR compatible
  • Domains general parent report of milestones
  • Family family-friendly, concrete, 4-6 grade
    literacy
  • Training teaches milestones
  • Community accepted by Childlink, supported by
    PA DPW

28
Modified Checklist for Autism in Toddlers (M-CHAT)
  • Visits 18 and 24 month visits
  • Accuracy sensitivity .85, specificity .93
  • Logistics 23 questions yes/no, EHR compatible, 2
    minutes
  • Domains autism only
  • Family easy to complete and score, only hard
    for families with some
    concern
  • Training intro to autism
  • Community screener used by Childlink

29
Provider Training Materials
  • Developed training video and educational
    materials for ASQ and MCHAT
  • Allowed for group or individual training at
    provider discretion
  • Provided CME credits for attendings
  • Incorporated resident training into overall
    residency curriculum

After a crumb or cheerio is dropped into a
bottle, does your child purposely turn the bottle
over to dump it out?
30
Office Flow Procedures
31
Integration of Screening into Well Child Care
  • Facilitate recruitment with electronic prompt
  • Place screening tools (or at least scoring grids)
    into EHR with automated scoring
  • Assist PCPs and schedulers with identifying study
    participants and their allocation assignment in
    EHR
  • Dual schedule SRS with PCP
  • Generate screening reminder alerts for 9-, 18-,
    24-, and 30-month intervention arm visits
  • Use of 96110 CPT code for provider RVUs

32
Electronic recruitment prompt
33
Collaboration with EI
  • Memorandum of agreement to share data and fax EI
    health appraisals/prescriptions
  • Monthly Tracking spreadsheet generated and
    maintained by each PCC and updated by Childlink
  • Agreement by Childlink to accept ASQ and MCHAT
    results as part of their intake

34
Childlink Referral Spreadsheet
35
Study Procedures
  • Eligibility all children ages 0-30 months
    without DD or presumptive conditions or
    prematurity
  • 2100 eligible children recruited across all PCC
    sites using EPIC prompts at visits or by direct
    referral from PCPs to SRS
  • Families consented and followed for 18 months by
    RA and SRS
  • Randomization will occur following consent visit

36
Study Outcomes
  • identified with DD
  • with DD referred to EI
  • referred who complete MDE
  • Rates of eligibility for EI services (IFSP)
    eligible vs. ineligible (discharged or at risk)
  • Family satisfaction with screening/surveillance
    process

37
Conclusions
  • Developmental delays are prevalent in urban high
    risk populations
  • Use of validated screening tools can increase the
    identification of developmental delay
  • Barriers exist to the implementation of
    developmental screening tools
  • Decisions regarding developmental screening tools
    involve tradeoffs

38
Conclusions
  • Important to address provider buy-in and
    facilitate their participation
  • Map office flow to ensure smooth operation of
    procedures
  • Integrate developmental screening into current
    practices
  • To be most effective, developmental screening
    requires collaboration with early intervention
    programs

39
TEDS Study Personnel
  • Jim Guevara, MD, MPH
  • Marsha Gerdes, PhD
  • Susmita Pati, MD, MPH
  • Jennifer Pinto-Martin, PhD
  • Russ Localio, PhD
  • 4 SRS--Lynnette DeShields, Lara Kyriakou, Sofia
    Baglivo, Casey Morris
  • Ankur Rustgi and Jane Cavenaugh, RA
  • Trude Haecker, MD
  • Beth Rezet, MD
  • Nate Blum, MD

40
Role of Developmental Screening
  • Pediatricians under-identify DD in their patients
  • Pediatricians are better at identifying DD in
    patients with phenotypic features or certain
    domains of development
  • Developmental screening tools can enhance the
    rate of identification but require additional
    time to administer and score
  • Only 23 of pediatricians nationwide routinely
    use developmental screening instruments

41
Philadelphia County EI
  • Referrals made to Childlink (PHMC) birth to 34
    months or Elwyn Inc 34 months to 60 months
  • Initial phone assessment demographics and ASQ
  • In home (alternatively at Childlink) visits
    completion of MDE within 45 days of assessment
  • MDE outcome eligible (25 delay in one or more
    areas) with development of IFSP vs. ineligible
  • Ineligible discharged or placed in at risk
    program with follow-up Q2 months
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