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Computerized clinical support triples developmental delay screening

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Recommendations not always put into practice

Dr. Carroll and his colleagues’ randomized study, initiated 4 years after a 2006 guideline algorithm recommending developmental screening for all children at 9, 18, and 30 months, demonstrates that just because a recommendation is made does not mean it is being put into practice. Only a quarter of the 180 children in the control practices were screened, yet even in the intervention practices – which had the advantage of a unique technology, scanning machine, and novel office flow to assure compliance with guidelines – some 15% of children still were not screened.

Dr. Barbara Howard

Rates of positive screen results and referral rates did not differ significantly between the two groups, suggesting that the populations and offices were comparable. Furthermore, the 10-month time difference to “developmental diagnosis” between the study groups underscores the importance of timely screening, as earlier detection could result in earlier intervention, even though that was not assessed in this study.

While it is clear that screening must use evidence-based tools, this study adds to the data that shows that we also must find ways to put these tools in patients’ (or, in this case, parents’) hands, and results in the doctors’ laps. This ideally is done by means of a system that will make it a seamless part of the clinical work flow. Without methods to streamline work flow, rates of screening will remain suboptimal.

Dr. Barbara Howard is assistant professor of pediatrics at the Johns Hopkins University, Baltimore, and is president of Total Child Health, the company that licenses CHADIS, a web-based pediatric screening and clinical decision-making support system similar in principle to the CHICA system used in Dr. Carroll and his colleagues’ study.


 

References

Adding developmental surveillance and screening to a computerized clinical decision support system led to a more than threefold greater proportion of children being screened for developmental disabilities, according to results from a randomized trial.

The American Academy of Pediatrics has recommended since 2006 that all children be screened for developmental delays at 9, 18, and 30 months. This study, led by Dr. Aaron E. Carroll of the Indiana University in Indianapolis, and published in JAMA Pediatrics (2014 [doi:10.1001/jamapediatrics.2014.464]), randomized 360 children at their 9-, 18- or 30-month check-ups to screening under the Child Health Improvement through Computer Automation (CHICA) system, which prompts clinicians toward diagnostic and management strategies based on guidelines and patient records.

The study was conducted in four linked primary care clinics in Indianapolis, with the vast majority of patients covered by Medicaid. Patients in the control clinics (n = 180) were assessed using standard CHICA, while those in the intervention clinics (n = 180) were assessed with CHICA modified to include a developmental surveillance and screening component, which automatically printed a questionnaire aimed at parents. If a parent indicated any area of concern, a standardized screening tool for developmental delay was then printed for use by the physician.

The group randomized to CHICA with the developmental module saw 85% of children screened for developmental delays during the target visits, compared with 24% in the standard care group (P < .001).

Among children screened, the rate of a positive result was 19.6% for the intervention group and 18.2% for controls; this did not reach statistical significance. “This finding implies that the number of children at risk for developmental delay was similar between groups, but that more children were picked up in the intervention group because of higher screening rates,” Dr. Carroll and his colleagues wrote in their analysis.

Diagnoses of developmental delay following a target visit were shown to occur markedly earlier in the intervention group (mean age at diagnosis, 17.2 vs. 27.9 months; P < .001). “Because optimal outcomes of developmental delay depend on early detection, this finding is a critically important finding, although our study was not designed to detect changes in clinical outcomes,” the researchers wrote.

Dr. Carroll and his colleagues also looked at an additional 60 patient records in both the control and intervention clinics to determine developmental surveillance rates outside target visits. They found that the intervention led to a significant increase in the percentage of parents who were asked about concerns regarding their children’s development during those nontarget visits (71.7% vs. 41.7%, P = .04).

The researchers cited as a weakness of their study its use of the clinic as the basis of randomization, creating the potential for preexisting practice differences to affect results.

The study was funded by the Agency for Healthcare Research and Quality. None of the authors reported conflicts of interest.

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