Probably the most challenging aspect of adopting quality approaches to screening/surveillance is figuring out how to make it work in our practices. There are many considerations but there are also many effective models.
The 5 approaches to implementation described below are from a study (Glascoe, 2014) of 79 clinics serving 20, 941 families with a wide-range of backgrounds –from affluent parents to low-income, and from English-speaking to non-English speaking. Although the focus is on use of PEDS Online, the same processes are applicable when using tools in print, i.e., just add scoring and report writing into the clinic workflow.
Most children, 66% (N = 13,859), were screened at ages coinciding with the AAP’s periodicity schedule (+ 1 month), i.e., at ~ 2 , 4, 6, 9, 12, 15, 18, 24, 36, 48, 60, 72, and 84 months. Nevertheless, 34% (N = 7,082) were screened between well-visit ages, indicating substantial use of opportunistic screening/surveillance. Interestingly, children screened outside the well-visit schedule were 1 ½ times more likely to perform poorly on one or more screening tests [OR = 1.6, 95%CI (1.50 – 1.67), p < .0001].This finding should elevate “the index of suspicion” when children arrive between the usually scheduled visits.
The figure below shows the percentage of children with high/moderate risk scores on PEDS, two or more milestones unmet on the PEDS:DM, and failing scores on the M-CHAT. Visible is the known and predictable increase in delays as children’s age increases (Newachek, Strickland, Shonkoff et al, 1998). Children 3 years and older were twice as likely to perform poorly on screens than were children in the birth through 2 year age range [OR = 2.3, 95%CI (2.12 – 2.43), p < .0001]. Thus, we really need to work hard to ensure that children return for well visits, most especially after 2 years of age where attendance drops substantially.
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