1、Translating Evidence-based Developmental Screening into Pediatric Primary Care,James Guevara, MD, MPH Center for Pediatric Clinical Effectiveness Seminar Series October 3, 2008,Educational Aims,To review current knowledge of developmental problems and interventions in early childhood To update parti

2、cipants on current screening recommendations To understand barriers to implementation of developmental screening To disseminate information on TEDS Study,Declarations,Current study is funded by a grant from CDC R18 DD000345 No conflicts of interest to declare,Relevant Definitions,Developmental delay

3、 (DD): when a child does not meet developmental milestones within an expected period of time in one or more domains (motor, speech 93:399-403,Treatment of DD: Parallel Tracks,Medical Management: ancillary services and multidisciplinary specialty services (diagnosis-specific) Individuals with Disabil

4、ities 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),Varying Eligibility for EI,States must provide services to: Children experiencing developmental delays Children wi

5、th 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 develop

6、mental domains: Motor Communication Cognitive Daily living Socio-emotional,(Definitions of eligibility differ significantly from state to state),Evidence for Effectiveness for EI?,EI has beneficial effects on cognitive functioning: greater school achievement, less grade retention, less use of specia

7、l education EI has beneficial effects on social functioning: lower teenage pregnancy, less delinquency Only 30% of children with DD are detected before school entry,McCormick et al, Pediatrics 2006; 117:771-80,A: WASI (HLBW) B: PPVT-III (HLBW C: WJTA-Reading (HLBW) D: WJTA-Math (HLBW) E: WASI (LLBW)

8、 F: PPVT-III (LLBW) G: WJTA-Reading (LLBW) H: WJTA-Math (LLBW),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 specifi

9、c developmental disorders and needs,Pediatrics 2006; 118: 405-20,AAP Policy Statement,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

10、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,Screening Increases Referrals,Hix-Small et al, Pediatrics 2007; 120:381-9,Barriers to Developmental Screening,Limite

11、d 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; 95:1928,North Carolina ABCD Project: effort to overcome screening barriers,Earls et al, Pediatrics 2006; 118:e183-8,Knowledge Gap

12、s,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,Translating Evidence-based Developm

13、ental 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),TEDS Study Aims,To identify barriers and facilitators to the

14、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,Fram

15、ework:Theory of Planned Behavior,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 interventi

16、on 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,Focus Groups: Parents,Prioritize development Recognition that screening is difficult due to competing demands Preference for developmentally focused

17、 visits Screening tools would be acceptable: serve to stimulate conversation with pediatrician on development identify developmental weaknesses in their child that could be targeted,Focus Groups: Pediatricians,Prioritize time management Perception that parents prefer complete well child exams Develo

18、pment 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,Study Considerations,Allow PCPs to prioritize developmental

19、 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,Selection of Screening Tools,Ages and Stages Quest

20、ionnaire (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 Communi

21、ty: accepted by Childlink, supported by PA DPW,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 fa

22、milies with some concern Training:intro to autism Community:screener used by Childlink,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 res

23、ident 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?”,Office Flow Procedures,Integration of Screening into Well Child Care,Facilitate recruitment with electronic prompt Place screening tool

24、s (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 co

25、de for provider RVUs,Electronic recruitment prompt,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

26、as part of their intake,Childlink Referral Spreadsheet,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 co

27、nsented and followed for 18 months by RA and SRS Randomization will occur following consent visit,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

28、with screening/surveillance process,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 developm

29、ental screening tools involve tradeoffs,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,TEDS Study Personnel,Jim Guevara, MD, MPH Marsha Gerdes, PhD Susmita Pati, MD, MPH Jennifer Pinto-Martin, PhD Russ Localio,