Improving autism and developmental screening and referral in US primary care practices serving Latinos.
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ABSTRACT: Lay abstract
Latino children experience delays in access to diagnosis and treatment of autism spectrum disorder. Primary care-based screening of all children for autism spectrum disorder and referring them for services may reduce racial/ethnic differences and improve care. REAL-START, a yearlong screening intervention, was effective in increasing screening for autism spectrum disorder and general developmental delays, increasing therapy referrals, and shortening time for developmental assessment in primary care clinics with Latino patients.
SUBMITTER: Zuckerman KE
PROVIDER: S-EPMC7854844 | biostudies-literature |
REPOSITORIES: biostudies-literature
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Project description:OBJECTIVES:Although the American Academy of Pediatrics recommends screening for autism spectrum disorder (ASD) for all young children, disparities in ASD diagnosis and intervention in minority children persist. One potential contributor to disparities could be whether physicians take different actions after an initial positive screen based on patient demographics. This study estimated factors associated with physicians completing the follow-up interview for the Modified Checklist for Autism in Toddlers with Follow-up (M-CHAT-F), and referring children to diagnostic services, audiology, and Early Intervention (EI) immediately after a positive screen. METHODS:Children seen in a large primary care network that has implemented universal ASD screening were included if they screened positive on the M-CHAT parent questionnaire during a 16-30 month well child visit (N = 2882). Demographics, screening results, and referrals were extracted from the electronic health record. RESULTS:Children from lower-income families or on public insurance were more likely to have been administered the follow-up interview. Among children who screened positive, 26% were already in EI, 31% were newly referred to EI, 11% were referred each to audiology and for comprehensive ASD evaluation. 40.2% received at least one recommended referral; 3.7% received all recommended referrals. In adjusted multivariable models, male sex, white versus black race, living in an English-speaking household, and having public insurance were associated with new EI referral. Male sex, black versus white race, and lower household income were associated with referral to audiology. Being from an English-speaking family, white versus Asian race, and lower household income were associated with referral for ASD evaluation. A concurrent positive screen for general developmental concerns was associated with each referral. CONCLUSIONS:We found low rates of follow-up interview completion and referral after positive ASD screen, with variations in referral by sex, language, socio-economic status, and race. Understanding pediatrician decision-making about ASD screening is critical to improving care and reducing disparities.
| S-EPMC7205236 | biostudies-literature
Project description:PurposeThe American Academy of Pediatrics recommends screening adolescents for substance use at all well-child and appropriate acute-care visits. However, many pediatric practices aim for such screenings annually at well-child visits.MethodsAs part of a larger study, 7 urban Federally Qualified Health Center clinics implemented universal screening for risky alcohol and drug use using the Car, Relax, Alone, Forget, Friends, Trouble (CRAFFT) screening tool. The present study compared uptake of screening and screening results at well-child versus acute-care visits.ResultsOver a period of 13 months for which encounter-level electronic medical records data were available, there were 6,346 clinic visits by 3,475 unique patients aged 12-17 years, at which 76.6% (n = 4,865) of visits had a screening for problematic substance use conducted. Rates of screening were 95.1% (2,750/2,891 involving 2,629 unique adolescents) for well-child visits and 61.2% (2,115/3,455 involving 1,535 unique adolescents) for acute-care visits. Rates of positive screening results were 9.0% (248/2,750 involving 245 unique adolescents) for well-child visits and 7.8% (164/2,115 involving 126 unique adolescents) for acute-care visits. Of the 469 unique adolescents screened only during an acute-care visit during that same period, 40 unique adolescents had positive screening results for a positive screening rate of 8.5%.ConclusionsNearly 10% of adolescent patients screened only at acute-care visits would not have been screened if screening was implemented solely at well-child visits, and 40 adolescents reporting substance use would have been missed. The findings highlight the benefits of screening adolescents at every primary care visit to better detect and intervene in adolescents' substance use.
| S-EPMC6589381 | biostudies-literature
Project description:INTRODUCTION:Intensive behavioral counseling is effective in preventing type 2 diabetes, and insurance coverage for such interventions is increasing. Although primary care provider referrals are not required for entry to the Centers for Disease Control and Prevention (CDC)-recognized National Diabetes Prevention Program lifestyle change program, referral rates remain suboptimal. This study aims to assess the association between primary care provider behaviors regarding prediabetes screening, testing, and referral and awareness of the CDC-recognized lifestyle change program and the Prevent Diabetes STAT: Screen, Test, and Act Today™ toolkit. Awareness of the lifestyle change program and the STAT toolkit, use of electronic health records, and the ratio of lifestyle change program classes to primary care physicians were hypothesized to be positively associated with primary care provider prediabetes screening, testing, and referral behaviors. METHODS:Responses from primary care providers (n=1,256) who completed the 2016 DocStyles cross-sectional web-based survey were analyzed in 2017 to measure self-reported prediabetes screening, testing, and referral behaviors. Multivariate logistic regression was used to estimate the effects of primary care provider awareness and practice characteristics on these behaviors, controlling for provider characteristics. RESULTS:Overall, 38% of primary care providers were aware of the CDC-recognized lifestyle change program, and 19% were aware of the STAT toolkit; 27% screened patients for prediabetes using a risk test; 97% ordered recommended blood tests; and 23% made referrals. Awareness of the lifestyle change program and the STAT toolkit was positively associated with screening and referring patients. Primary care providers who used electronic health records were more likely to screen, test, and refer. Referring was more likely in areas with more lifestyle change program classes. CONCLUSIONS:This study highlights the importance of increasing primary care provider awareness of and referrals to the CDC-recognized lifestyle change program.
| S-EPMC6241213 | biostudies-literature
Project description:PurposeWe undertook a study to assess whether implementing 7 evidence-based strategies to build improvement capacity within smaller primary care practices was associated with changes in performance on clinical quality measures (CQMs) for cardiovascular disease.MethodsA total of 209 practices across Washington, Oregon, and Idaho participated in a pragmatic clinical trial that focused on building quality improvement capacity as measured by a validated questionnaire, the 12-point Quality Improvement Capacity Assessment (QICA). Clinics reported performance on 3 cardiovascular CQMs-appropriate aspirin use, blood pressure (BP) control (<140/90 mm Hg), and smoking screening/cessation counseling-at baseline (2015) and follow-up (2017). Regression analyses with change in CQM as the dependent variable allowed for clustering by practice facilitator and adjusted for baseline CQM performance.ResultsPractices improved QICA scores by 1.44 points (95% CI, 1.20-1.68; P <.001) from an average baseline of 6.45. All 3 CQMs also improved: aspirin use by 3.98% (average baseline = 66.8%; 95% CI for change, 1.17%-6.79%; P = .006); BP control by 3.36% (average baseline = 61.5%; 95% CI for change, 1.44%-5.27%; P = .001); and tobacco screening/cessation counseling by 7.49% (average baseline = 73.8%; 95% CI for change, 4.21%-10.77%; P <.001). Each 1-point increase in QICA score was associated with a 1.25% (95% CI, 0.41%-2.09%, P = .003) improvement in BP control; the estimated likelihood of reaching a 70% BP control performance goal was 1.24 times higher (95% CI, 1.09-1.40; P <.001) for each 1-point increase in QICA.ConclusionImprovements in clinic-level performance on BP control may be attributed to implementation of 7 evidence-based strategies to build quality improvement capacity. These strategies were feasible to implement in small practices over 15 months.
| S-EPMC8575517 | biostudies-literature
Project description:The past decade has seen growing concern about research practices in cognitive neuroscience, and psychology more broadly, that shake our confidence in many inferences in these fields. We consider how these issues affect developmental cognitive neuroscience, with the goal of progressing our field to support strong and defensible inferences from our neurobiological data. This manuscript focuses on the importance of distinguishing between confirmatory versus exploratory data analysis approaches in developmental cognitive neuroscience. Regarding confirmatory research, we discuss problems with analytic flexibility, appropriately instantiating hypotheses, and controlling the error rate given how we threshold data and correct for multiple comparisons. To counterbalance these concerns with confirmatory analyses, we present two complementary strategies. First, we discuss the advantages of working within an exploratory analysis framework, including estimating and reporting effect sizes, using parcellations, and conducting specification curve analyses. Second, we summarize defensible approaches for null hypothesis significance testing in confirmatory analyses, focusing on transparent and reproducible practices in our field. Specific recommendations are given, and templates, scripts, or other resources are hyperlinked, whenever possible.
| S-EPMC7403881 | biostudies-literature
Project description:BACKGROUND: The European Practice Assessment program provides feedback and outreach visits to primary care practices to facilitate quality improvement in five domains (infrastructure, people, information, finance, and quality and safety). We examined the effectiveness of this program in improving management in primary care practices in Germany, with a focus on the domain of quality and safety. METHODS: In a before-after study, 102 primary care practices completed a practice assessment using the European Practice Assessment instrument at baseline and three years later (intervention group). A comparative group of 102 practices was included that completed their first assessment using this instrument at the time of the intervention group's second assessment. Mean scores were based on the proportion of indicators for which a positive response was achieved by all of the practices, on a scale of 0 to 100. RESULTS: We found significant improvements in all domains between the first and second assessments in the intervention group. In the domain of quality and safety, improvements in scores (mean scores were based on the proportion of indicators for which a positive response was achieved by all of the practices, on a scale of 0 to 100) were observed in the following dimensions: complaint management (from a mean score of 51.2 at first assessment to 80.7 at second assessment); analysis of critical incidents (from 79.1 to 89.6); and quality development, quality policy (from 40.7 to 55.6). Overall scores at the time of the second assessment were significantly higher in the intervention group than in the comparative group. INTERPRETATION: Primary care practices that completed the European Practice Assessment instrument twice over a three-year period showed improvements in practice management. Our findings show the value of the quality-improvement cycle in the context of practice assessment and the use of established organizational standards for practice management with the Europeaen Practice Assessment.
| S-EPMC3255110 | biostudies-literature
Project description:Asthma is the most commonly encountered chronic disease in children. Periodic assessment of asthma severity and control is an integral part of asthma management, but patients with uncontrolled asthma don't always schedule routine asthma care visits. The aim of this project was to improve asthma control and severity screening in a primary care setting by using a validated tool for all visits for patients with a diagnosis of asthma aged 4-21 years. Our QI team developed a protocol to administer the Asthma Control Test (TM), a validated questionnaire to assess asthma control. The stakeholders involved were the physicians, nursing staff, and the Health Information Team (HIT). All patients who had a prior diagnosis of asthma or with an asthma medication in their chart, who presented for any clinical visit including asthma were administered ACT. The staff scored the ACT and included the form in the encounter sheet so that the physicians can review the scores, address the asthma control, severity, and document in the chart. The number of patients whose asthma control was assessed improved from 10% per year to 85% after the three PDSA cycles. Administration of the tool did not impact the flow of the patients in a busy primary care practice. Screening asthma severity and control for patients diagnosed with asthma with a validated questionnaire when presenting for any chief complaint including asthma will help the provider address the severity and control of asthma symptoms in a timely manner and would potentially help prevent unwanted emergency department or urgent care usage.
| S-EPMC4935809 | biostudies-literature
Project description:BACKGROUND/AIM:Early diagnosis of chronic illnesses and cancers mainly occurs at primary health care centers (PHCs) by primary health care physicians (PHPs). The incidence of colorectal cancer (CRC) in the Kingdom of Saudi Arabia (KSA) is rising and this has been attributed to many factors. The increasing incidence of CRC is compounded by nonadherence to screening recommendations. Therefore, evaluating PHPs knowledge, attitudes, and practices of screening for CRC is clinically important. We aimed to evaluate the knowledge, attitudes, and practices of PHPs regarding CRC screening and to identify the factors associated with nonadherence of PHPs to screening recommendations. MATERIALS AND METHODS:PHPs working at three tertiary care centers and PHCs across the city of Jeddah were randomly recruited. Participants were surveyed using a comprehensive questionnaire that recorded data on demographics, qualifications, and knowledge of various modalities and guidelines related to CRC screening. Perspectives about effectiveness of, or adherence to, factors that influence physicians' perspectives or recommendations for CRC screening were also assessed. Logistic regression analysis was used to identify physician characteristics associated with PHPs perspectives and nonadherence to CRC screening. RESULTS:A total of 127 PHPs were recruited. The average age of participants was 34 (±8.4) years, 86.6% were native Saudi's and 56.7% were females. The majority of surveys (66.9%) were completed at 24 PHCs and the remaining at hospital-based family medicine clinics. Most of the PHPs (55%) had a bachelor's degree and 31.5% were board-certified or carried a PhD in family medicine; 95% of participants believed that CRC screening in general was effective, but as much as 55% reported that they did not practice screening. The male physicians [odds ratio (OR) = 0.44, 95% confidence interval (CI) = 0.19-0.99, P = 0.048)] and PHPs with only a bachelor degree or less (OR = 0.72, 95% CI = 0.55-0.93, P = 0.011) were less likely to recommend screening for CRC. CONCLUSIONS:A considerable proportion of PHPs do not adhere to CRC screening recommendations despite a wide belief that screening is effective. Male PHPs with lower qualifications appear to be less likely to recommend screening.
| S-EPMC5738794 | biostudies-literature
Project description:OBJECTIVES:Chronic kidney disease (CKD) is common; therefore, coordination of care between primary care and nephrology is important. Ontario Renal Network's KidneyWise toolkit was developed to provide guidance on the detection and management of people with CKD in primary care (www.kidneywise.ca). The aim of this study was to evaluate the impact of the April 2015 KidneyWise toolkit release on the characteristics of primary care referrals to nephrology. DESIGN AND SETTING:The study was a prospective pre-post design conducted at two nephrology sites (community site: Trillium Health Partners in Mississauga, Ontario, Canada, and academic site: St Joseph's Healthcare in Hamilton, Ontario, Canada). Referrals were compared during the 3-month time period immediately prior to, and during a 3-month period 1?year after, the toolkit release. PRIMARY AND SECONDARY OUTCOME MEASURES:The primary outcome was the change in proportion of referrals for CKD that met the KidneyWise criteria. Additional secondary referral and quality of care outcomes were also evaluated. Multivariable logistic regression was used to evaluate preselected variables for their independent association with referrals that met the KidneyWise criteria. RESULTS:The proportion of referrals for CKD among people who met the KidneyWise referral criteria did not significantly change from pre-KidneyWise to post-KidneyWise implementation (44.7% vs 45.8%, respectively, adjusted OR 1.16, 95% CI 0.85 to 1.59, p=0.36). The proportion of referrals for CKD that provided a urine albumin-creatinine ratio significantly increased post-KidneyWise (25.8% vs 43.8%, adjusted OR 1.45, 95% CI 1.06 to 1.97, p=0.02). The significant independent predictors of meeting the KidneyWise referral criteria were academic site, increased age and use of the KidneyWise referral form. CONCLUSIONS:We did not observe any change in the proportion of appropriate referrals for CKD at two large nephrology centres 1?year after implementation of the KidneyWise toolkit.
| S-EPMC7044871 | biostudies-literature
Project description:Data on liver and non-liver co-morbidities in chronic hepatitis B (CHB) patients are limited. This study analyzes the prevalence of co-morbidities in a multicenter CHB cohort evaluated over 15 years.This study included 2734 consecutive adult American CHB patients from a university medical center and several community primary care clinics. Data were analyzed by time periods (patients in each time period were unique without overlapping): 2000-2005 (n?=?885), 2006-2010 (n?=?888), and 2011-2015 (n?=?961). Patients were identified via electronic query using diagnosis code with data confirmed and extracted via individual chart review. Most patients were male (57.9%) and Asian (89.6%).Mean age increased significantly from 43.3?±?13.4 years during 2000-2005 to 49.1?±?14.4 during 2011-2015 (p?<?0.001). Between 2000-2005 and 2011-2015, fatty liver disease among new CHB patients increased from 1.6 to 6.8% (p?<?0.001). Advanced liver diseases also increased (p?<?0.001): cirrhosis (12.6-24.6%), hepatic decompensation (1.1-7.9%), and hepatocellular carcinoma (HCC) (4.9-9.1%). Similar trends were observed for non-liver co-morbidities (p?<?0.001). Specifically, diabetes increased almost fivefold (4.9-22.9%), hypertension increased threefold (12.3-36.1%) and chronic kidney disease increased 4.5-fold (4.4-19.7%). Prevalence of osteopenia and osteoporosis also increased in CHB patients: 5.4-13.4% (p?<?0.001) and 2.9-8.7% (p?<?0.001), respectively. These trends were observed in both liver clinics and primary care clinics (except for advanced liver disease), treated and untreated patients, and for both sexes.The CHB patient population is aging and now presents with significantly more co-morbidities. Early diagnosis and linkage to care is needed to prevent and mitigate liver as well as non-liver co-morbidities.
| S-EPMC5862154 | biostudies-other