EPSDT: Routine Screening for Autism and Developmental Delay

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EPSDT Routine Screening for Autism and
Developmental Delay
Mary S. Applegate, MD, FAAP, FACP OHIO Medicaid
Medical Director Applem_at_jfs.ohio.gov NASMD,
November 13, 2008
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Disease Lifecycle
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3 Levels of Prevention
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EPSDT

• Primary Secondary Prevention EP
• Most Secondary some Tertiary Prevention SD
• Some Secondary all Tertiary Prevention T

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Rationale for Routine Screening

• 16 of children have a developmental /or
  behavioral disorder
• Newacheck, PW, Strickland, B, Shonkoff, JP, et
  al. An epidemiologic profile of children with
  special health care needs. Pediatrics 1998
  102117.
• Only 30 are identified prior to school entry,
  signifying missed opportunities for Early
  Intervention
• Palfrey, JS, Singer, JD, Walker, DK, Butler, JA.
  Early identification of children's special needs
  a study in five metropolitan communities. J
  Pediatr 1987 111651.

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Benefits of Routine Screening

• Early detection, diagnosis and treatment
• Parents become more engaged supported in
  childs health care
• Parents can match the childs abilities to
  developmentally appropriate activities
• Early Intervention leads to better health
  outcomes, improved school performance and may
  prevent secondary problems

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Downside of Routine Screening

• What if the child has a false positive test?
• Studies have shown that many have other needs
  that are identified and can be addressed through
  Early Intervention
• What if the child has a false negative test?
• A repeat screen can be done.

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The Scientific Evidence Behind Screening

• 3 criteria are important in deciding what
  conditions to include in a periodic health
  examination screen (USPTF)
• 1). Burden of suffering
• 2). Quality of the screening test
• 3). Quality (effectiveness, safety cost) of
  intervention for primary or secondary prevention.
• NOTE The prevalence and incidence of the
  condition is important in screening

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Yield of Repeat Screening
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Biases in Screening

• Lead time (Time of detection by screening vs.
  usual method)
• Length time (Time from screen to symptoms)
• Compliance bias

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Lead Time Bias
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Length Time Bias
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Compliance Bias
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Characteristics of the Ideal Screen

• Valid
• Reliable
• Sensitive
• Specific
• Requires little time or preparation
• Inexpensive
• Accessible

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Definitions

• Positive Predictive Value (PPV) A/AB
• Negative Predictive Value (NPV) D/CD
• Accuracy AD/ABCD
• Sensitivity A/AC
• Specificity D/BD

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Current Conditions A Snapshot of Care
ESchor, Rethinking Well-child Care, Pediatrics
114, 2004
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Current Conditions

• 20 of all visits to the pediatrician are
  developmental or behavioral in nature.
• 80 of parental concerns are accurate
  (Olson, AC, 2003)
• American Academy of Pediatrics (AAP) Policy 2006
  recommends routine surveillance and standardized
  developmental and behavioral screening
• Effective screening is not done routinely by most
  practitioners (15)
• Practitioners, agencies and states have struggled
  with how to operationalize the recommendation

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Current conditions Surveillance vs. Screening

• Surveillance A flexible, continuous process in
  which knowledgeable professionals perform skilled
  observations of children during child health care
  (in consultation with families, specialists,
  child care providers, etc)
• a mile wide, an inch deep

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Surveillance vs. Screening

• Screening A brief, objective, validated test
  performed at specific points in time or if there
  is a concern to differentiate children that are
  probably OK vs. those who need additional
  investigation
• a mile deep, an inch wide
• Objectivity matters e.g. Temperature taking
• Screening compliments continuous surveillance

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Pediatrician Recognition ofDevelopmental
Behavioral Problems
JV Lavigne et.al. Pediatrics. Mar.1993
91(3)649-55
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Detection Rates
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Screening Benefits

• Screening works (better than surveillance
  alone)
• Facilitates access to services
• Encourages communication
• Cost effectiveness possible? (based on Early
  Intervention studies)
• Improved family satisfaction

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Barriers to Routine Screening

• Expense related to tools, training, office flow
  etc
• Time, time, time
• Culture of trusting own tools vs. new tools, wait
  see
• Knowledge access to tools methods
• What to do with falsely or - tests
• Coding and billing issues lack of uniform
  reimbursement
• Limited referral resources complex processes
  involved

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Other Considerations

• What happens after a positive screen?
• What therapies are accessible?
• What therapies have evidence to suggest outcomes
  are improved?
• What outcomes are meaningful as a medical
  benefit?
• Who has responsibility for which aspects of care?
  Medical care providers, teachers, parents, mental
  health personnel, public health?

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Other Considerations

• Several different subspecialist types may assist
  in highly variable ways with the definitive
  diagnosis and/or treatment. How could we help
  clinicians establish best practice?
• If States adopt the AAP/Bright Futures
  periodicity schedule of screening, how do we
  resolve the fact that it will still take years to
  obtain widespread adoption by the health care
  workforce?
• Recognize that routine mental health and drug
  and alcohol screens will likely follow. Are
  there additional implications for those
  populations?

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Other Considerations

• How does the emphasis on Autism screening
  compare to other pediatric conditions for which
  we screen? Is it more important than vision,
  hearing dental conditions?
• (all of which have convincing clinical outcomes
  cost- effectiveness data)
• How would the anticipated fiscal impact of such
  screening affect other services?

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Other Considerations

• Voices for Children Focus Group Study noted that
  parents did not feel developmental screening
  should be mandated, citing fear of labeling a
  child for life.

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Special Thanks

• TN AAP/TEIS
• OhioHealth/Riverside Methodist Hospitals Library
• OHP
• MMD Colleagues
• AHRQ
• NASMD