Surveillance and Screening

1
Surveillance and Screening
American Academy of Pediatrics Family
Voices Maternal and Child Health Bureau National
Association of Childrens Hospitals and Related
Institutions and Shriners Hospitals for Children
2
Section One Introduction
3
How common are disabilities?

• 16 of children have developmental disabilities
• 20 - 30 are detected prior to school entrance
• 4th most common disability vision disorders
• gt 21 of preschoolers receive vision screening
• Bilateral hearing loss is present in every 1-3
  per 1000 newborn infants
• Early detection Early Intervention involvement

4
Why is the early detection of developmental
problems so critical?
Children involved in Early Intervention programs
are more likely

• To live independently
• Graduate from high school
• Save society 30,000-100,000 per child

5
Benefits of Early Detection

• Leads to early treatment improved health
  outcomes for children
• Positive benefit on later school performance
• Opportunity to avert secondary problems
• Addresses Healthy People 2010, Bright Futures,
  IDEA, AAP Periodicity Schedule, EPSDT, etc.

6
The key to early detection of disabilities is
quality surveillance and screening
7
Learning Objectives

• Understand the importance of ongoing
  surveillance.
• Understand what constitutes surveillance, proper
  methods of screening, and their importance in a
  medical home.
• Describe the barriers to surveillance and
  screening.
• Identify recommended tools and resources.
• Identify proper follow-up strategies after
  screening tests are performed.

8
Section Two Early Detection through Surveillance
and Screening
9
What is Surveillance?

• A flexible, continuous process, in which
  knowledgeable professionals perform skilled
  observations of children during child health care
  (in consultation w/families, specialists, child
  care providers, etc).
•  
• SM Dworkin, A Shannon, and P Dworkin. ChildServ
  Curriculum. Center for Childrens Health and
  Development, St Francis Hospital and Medical
• Center 1999 Hartford, CT.

10
Types of surveillance

• Typical children for changes in their mental
  health, developmental and/or health status
• All children who have or are at increased risk
  for a chronic physical, developmental,
  behavioral, or emotional condition
• CSHCN to assess primary diagnosis and care plan,
  early identification of secondary conditions and
  monitoring of treatment

11
What Resources are Available on Surveillance?

• Bright Futures Guidelines
• AAP Periodicity Schedule
• Other AAP Policy Statements

12
Surveillance techniques

• LISTEN

Think
Talk
13
Components of Effective Surveillance

• Elicit and/or attend to parents' concerns
• Obtain a relevant history
• Skillful observation of the child
• Share opinions with other professionals

14
Surveillance and Screening

• Surveillance is a continuous process
• Screening tools used to enhance the surveillance
  process.

15
What is screening?

• Brief, objective, and validated test
• Goal to differentiate children that are "probably
  ok" vs. "needing additional investigation
• Performed at a set point in time

16
Importance of Being Objective

• TOUCH OR TAKE TEMP?

17
Benefits of Screening

• Sorts children into 3 categories
• Needs additional evaluation - Did not pass
  screening test
• Needs close monitoring- Passed screening test but
  has risk factors
• Needs ongoing monitoring in the context of
  well-child care - Passed screening test and has
  no known risk factors

18
Two Main Categories of Screening Tests

• Population-based (Public Health)
• Medical Home-based

19
Section Three Integrating Surveillance and
Screening in the Medical Home
20
Barriers to implementation of surveillance and
screening

• Lack of infrastructure
• Parents
• Physicians
• Other controversies

21
Screenings Role

• Primary care physicians have good surveillance
  skills
• Screening compliments continuous surveillance
• Research indicates good screening is not always
  being done

22
How to incorporate Screening into Surveillance

• Regular use of professionally administered tool
  for all children
• Periodic use at office visits
• When concern arises

23
Developmental Screening - Data

• Periodic Survey of AAP Fellows 53 (2002)
• 7 out of 10 pediatricians always identify
  potential problems via clinical assessment
  (without use of a screening instrument or
  checklist)
• 48 of pediatricians indicated that they "always"
  or "sometimes" used a formal developmental
  screening instrument
• Majority of these use the Denver II which is
  known to have modest sensitivity and specificity
  depending on the interpretation of questionable
  results.
• MOST PEDIATRICIANS RELY ON CLINICAL JUDGMENT

24
Accuracy of Clinical Judgment

• Clinical judgment detects fewer than 30 of
  children who have developmental disabilities
• Glascoe FP. Pediatrics in Review.
  200021272-280.
• Palfrey et al. J Peds. 1994111651-655.

25
Accuracy of Screening Tests

• 70-80 of children with developmental
  disabilities are correctly identified
• Squires et al JDBP, 199617420-427
• Most over-referrals on standardized screens are
  children with below average development and
  psychosocial risk factors Glascoe, APAM,
  200115554-59

26
Developmental Screening - Recommendations

• Infants and young children should be screened for
  developmental delays using reliable and valid
  screening techniques
• Use of standardized developmental screening tools
  at periodic intervals will increase accuracy
• Parent-report questionnaires were by far the
  least costly in the short-term

27
Developmental Screening - Tools

• PEDS (Parents' Evaluation of Developmental
  Status)
• Relies on information from parents
• Screens for both developmental and behavioral
  problems
• Can be used in patients birth to 8 years
• Involves 10 questions to parents (4th-5th grade
  reading level)
• Available in English, Spanish, and Vietnamese
• Parents can complete in waiting room or can be
  administered in interview format in 2 minutes
• Standardized scoring procedures
• Total cost (including materials and
  administration) is 1.19 per patient
• A copy of this tool can be found in the
  appendices.

28
Developmental Screening - Tools

• Ages Stages Questionnaires (ASQ)
• Relies on information from parents
• Screens for developmental problems
  personal/social
• Takes 10-15 minutes to complete
• Can be used in patients 4 months to 5 years
• Separate 3-4 page form for each well-child visit
  (age-specific)
• Available in English, Spanish, Korean and French
• Standardized scoring procedures
• Can be photocopied
• A copy of this tool can be found in the
  appendices.

29
Developmental Screening - Tools

• Brigance Screens
• Relies primarily on observation and elicitation
  of skills (0-2 year age range can be administered
  by parent report)
• Can be used in patients 0-90 months
• 9 separate forms based on age
• Takes 10-15 minutes to administer
• Total cost is 10.68 per patient
• A copy of this tool can be found in the
  appendices.

30
Developmental Screening - Coding

• Procedure CPT Codes
• 96110 Developmental testing limited, with
  interpretation and report
• 99420 Administration and interpretation of
  health risk
• assessment instrument (eg, health
  hazard appraisal)
• 96115 Neurobehavioral status exam with
  interpretation and report, per hour

31
Mental Health Screening Data          80 of
children with mental health problems are not
identified   Lavigne et al.
Pediatrics. 199391649-655.
32
Accuracy of Mental Health Screening
Tests   80-90 of children with mental health
problems are correctly identified  
Sturner, JDBP. 19911251-64.
33
Mental Health Screening - Recommendations

• Screening tools can
• Increase the identification of psychosocial
  problems and mental disorders in primary care
• Provide a framework for discussing psychosocial
  issues with families
• Classified into three categories
• Broad psychosocial tools
• General screening tools
• Problem, symptom or disorder-specific tools

34
Mental Health Screening Broad Psychosocial
Tools

• Pediatric Intake Form (or Family Psychosocial
  Screen)
• Relies primarily on parent report
• Can be administered by office staff
• Addresses parental depression, substance use,
  domestic violence, parental history of abuse, and
  social supports
• Takes 5-10 minutes to administer
• No cost associated with tool
• A copy of this tool can be found in the
  appendices.

35
Mental Health Screening General Screening Tools

• Pediatric Symptom Checklist (PSC)
• Relies primarily on parent report of childrens
  behavioral/ emotional problems
• Designed to evaluate the psychosocial functioning
  of children ages 3-16
• Can be administered by office staff, parents or
  others
• Takes 5-10 minutes
• Translations into Spanish, Creole, Mandarin,
  Chinese, and Swahili
• There is a youth self-report version of the PSC
• Standardized scoring procedures
• No cost associated with the tool
•   A copy of this tool can be found in the
  appendices.

36
Mental Health Screening Problem, Symptom or
Disorder Specific Tools

• Children Depression Inventory (CDI)
• Relies primarily on self-report of childs
  feelings for the past two weeks
• Designed to screen children and adolescents ages
  6-17 for possible depression
• Can be used in a variety of settings
• Takes 10-15 minutes to administer
• Can be administered individually or to groups
• A 27-item questionnaire
• Standardized scoring procedures
• Total cost is 1.64 per patient

37
Mental Health Screening
Procedure (CPT) Coding

• 96100 - Psychological testing with interpretation
  and report, per hour
• 96105 - Assessment of aphasia with
  interpretation and report, per hour
• 96110 - Developmental testing limited with
  interpretation and report
• 96111 - Developmental testing extended with
  interpretation and report, per hour

38
Mental Health Screening (Contd.)
Procedure (CPT) Coding

• 96115 - Neurobehavioral status exam with
  interpretation and report, per hour
• 96117 - Neuropsychological testing battery with
  interpretation and report, per hour
• 99420 - Administration and interpretation of
  health risk assessment instrument

39
Preschool Vision Screening - Data

• gt 25 of children receive good vision screening
  in preschool age range
• Age-sensitive
• Many tests, no uniform acceptance
• Limited validation

40
Preschool Vision Screening Task Force (1998)

• Convened by National Eye Institute and the US
  Maternal and Child Health Bureau
• Examined scientific evidence for preschool vision
  screening
• Looked at the 11 sets of preschool vision
  screening guidelines in existence

41
Preschool Vision Screening - Recommendations

• Assessment for eye problems in newborn period
  and all subsequent routine health supervision
  visits
• Vision screening starting at age 3 including
•      - Distance visual acuity
• - Ocular alignment (including stereopsis
• testing)
• - Ocular media clarity (red reflex check)

42
Special Considerations

• Vision screening is for children that appear
  "normal
• CSHCN should be referred for a comprehensive eye
  examination
• Children who already have corrective lenses
  should be screened with their glasses on

43
Preschool Vision Screening - Distance Visual
Acuity

• Lea Symbols
• Picture chart designed for young children
  unfamiliar with letters
• Involves four symbols apple, house, square,
  circle
• Studies have shown high testability rate (92 at
  age 3 and 98 at age 5)
• www.lea-test.fi

44
Preschool Vision Screening - Distance Visual
Acuity

• HOTV Test
• Letter chart involving four letters H, O, T, and
  V
• Most 4 year olds testable 3 year olds have a bit
  more difficulty
• Can be used as a "matching game

45
Distance Acuity Screening - Special
Considerations

• Testing distance of 10 feet
• Consider use of disposable adhesive eye patches
• Ensure proper set-up of testing space

46
Preschool Vision Screening - Ocular Alignment

• Stereopsis Screening Random Dot E
• Helps determine the presence of binocular vision
• Child wears polarized glasses to determine
  whether they can visualize a stereogram in 1 of 2
  cards presented
• Cards held 16 inches away
• Passing 4 correct responses (out of 6)

47
Preschool Vision Screening - Ocular Media Clarity

• Red Reflex Examination
• Direct examination of child's eyes in a darkened
  room, using an ophthalmoscope
• Eyes viewed separately at a distance of 12-18
  inches
• A red reflex should be seen in both eyes
• Refer child with white pupil, dark spots, or
  absent red reflex

48
Preschool Vision Screening Issues to Consider

• Can be performed in community-based settings
  medical home keeps a record of results
• Ongoing training of screeners
• Promising technologies that may be useful in the
  primary care setting

49
Preschool Vision Screening
Procedure (CPT) Coding

• 99173 Screening test of visual acuity,
  quantitative, bilateral
•  

50
Hearing Screening - Data

• "Failure to detect children with congenital or
  acquired hearing loss may result in lifelong
  deficits in speech and language acquisition, poor
  academic performance, person-social
  maladjustments, and emotional difficulties."
  Yoshinaga-Itano et al, 1998

51
Hearing Screening - Recommendations for Newborns

• Acceptable methodologies include Automated
  Auditory Brainstem Response (AABR) and Evoked
  Otoacoustic Emission (EOAE)
• Should detect infants with hearing loss gt 35
  decibels in the better ear
• Referral rate for formal audiologic testing not lt
  4

52
Hearing Screening - Recommendations Beyond
Newborns

• Some congenital hearing loss does not become
  evident until later in childhood
• Some hearing loss is acquired
• Periodic objective assessment should be performed
  in accordance with AAP Periodicity Schedule
• Use age-appropriate technology

53
Hearing Screening - Tools

• Otoacoustic Emissions
• Applicable to all ages
• Remain still during the 10 minute test
• Small probe containing microphone is placed in
  the ear
• Not a true test of hearing
• (It does not assess cortical processing of
  sound)

54
Hearing Screening - Tools

• Behavioral Pure-Tone Audiometry
• Hearing cannot be definitively considered normal
  until a child is mature enough for a reliable
  behavioral audiogram
• Determines hearing thresholds at specific
  frequencies
• Pure tone audiometry should be considered solely
  a screening test (As most offices are not sound
  proof)

55
Hearing Screening
Procedure (CPT) Coding

• 92551 - Screening test, pure tone, air only
• 92552 - Pure tone audiometry (threshold) air
  only
• 92586 - Auditory evoked potentials for evoked
  response audiometry and/or testing of the central
  nervous system limited

56
Hearing Screening - Other Issues

• Children who need further evaluation should be
  referred to an audiologist that is capable of
  evaluating children

57
Oral Health Screening Significance

• Fewer children visit a dentist before entering
  kindergarten today than 10 years ago
• Tooth decay starts before 2 years of age
• U.S. Department of Health and Human Services.
• National Center for Health Statistics. 1997.
• Healthy People 2000 Review 1997.

58
Oral Health Screening Recommendations

• An oral health risk assessment can increase the
  identification of dental problems
•  
• A risk assessment can provide
• Framework for discussing dietary practices
• Fluoride exposure
• Oral hygiene
• Establishment of a consistent oral health care
  provider to families

59
Oral Health Screening Tools

• AAPD Caries Risk Assessment Tool (CAT)
• Relies on observation and parent report
• Must be administered by a trained physician,
  dentist or other health care professional
• Addresses dietary practices, fluoride exposure,
  oral hygiene, utilization of dental services, and
  the mothers risk of dental caries
• Takes 5-10 minutes to administer

60
Oral Health Screening Tools

• Kids Get Care Oral Health Assessment
• Relies on parent/caregiver report.
• Can be administered by physicians, dentists, or
  other health care professionals.
• Not a standardized tool.
• Addresses dietary practices, feeding practices,
  and oral hygiene.
• Takes less than 5 minutes to administer.
• No cost is associated with the tool.
• A copy of this tool can be found in the
  appendices.

61
Oral Health Screening Procedure (CDT)Coding

• Current Dental Terminology (CDT)
• D1310 Nutritional counseling for control of
  dental disease
• D1320 Tobacco counseling for the control and
  prevention of oral disease
• D1330 Oral hygiene instructions

62
Section Four Next Steps- Beyond Surveillance and
Screening
63
Case Study Overview

• Frequent ear infections and parental concern
• Routine surveillance suggests the need for more
  in-depth screening
• Hearing screening passed
• Be aware of Child Find services
• Indications from screening outcomes
• Plan to re-screen in 3 - 4 months

64
How to Explain Screening Test Results

• Use language that encourages follow-up
• Avoid negative and meaningless words
• Be sensitive to cultural meanings of words

65
Maintain a Central Record

• Appropriately document all screening results
• Results from screening tests performed outside
  the medical home should be reviewed and included
  in the patient chart

66
Strategies to Help Maintain a Central Record

• Establish a tracking system within the practice 
• - Utilize a systematic approach with assigned
  responsibilities
• -  Develop bi-directional communication
• Establishing a tracking system for referrals
• - Tickler system

67
Making Appropriate Referrals IDEA

• Part C Early Intervention
• Provides services to children (ages 0-3) who
  have, or are at risk for, developmental
  disabilities
• Offered through a state agency- state to state
  variability
• Individual Family Service Plan (IFSP) developed
• State to state variations
• Primary care physician can refer patients
  directly to the state agency
• Agency evaluates to determine whether he/she
  qualifies for services

68
Making Appropriate Referrals IDEA

• Section 619 of Part B Preschool Special
  Education Program
• Provides services to children ages 3-5
• State to state variations
• Offered through the school system
• Primary care physicians cannot refer directly
• Encourage parents to request an IEP evaluation
  from the local school
• IEP developed if necessary
• Services may include special instruction,
  assistive technology, counseling, audiology,
  therapies, etc.

69
Strategies to Ensure Appropriate Referrals and
Comprehensive Follow-up

• Ensure appropriate referrals for diagnostic
  testing, management, and psychosocial support
• Educate office staff and parents about referral
  sources

70
Evaluating Your Surveillance and Screening System

• Continuous quality improvement
• Involve entire practice staff in evaluation
  process (front desk, nurses, etc.)
• Establish a set time line for evaluation process

71
Sample Quality Improvement Strategies

• Critically evaluate the screening tools
• Are they validated?
• Do they have good sensitivity and specificity?
• Are they easily administered and well accepted?
• Review how surveillance notes are organized and
  updated
• Conduct chart reviews
• Evaluate the training methods used to acclimate
  staff to tools

72
Sustaining Your Medical Home Screening System

• Screening and Follow-up Takes Time!
• Advocate for adequate reimbursement
• Increase EPSDT reporting and billing
• Utilize CPT codes regardless of reimbursement

73
Sustaining Your Medical Home Screening System

• Most screening tests can be completed by trained
  office staff
• Physician can spend majority of time
• - Reviewing screening results already completed
• - Perform surveillance
• - Discuss care plan with parents

74
Sustaining Your Medical Home Screening System
(Contd.)

• Utilize validated screening tools that can be
  completed by parents in the waiting room
• Purchase software that includes a tracking
  mechanism for screening tests
• Implement the use of surveillance/screening
  checklists inside the patients chart

75
Section Five Wrap-Up
76
Learning Objectives and Barriers Addressed

• Acknowledge the importance of continuous
  screening.
• Uncertainty around the relationship between
  surveillance and screening.
• Limited awareness of quality screening tools.
• Not having a system in place to handle children
  with positive screenings.
• Communication of test results and treatment.
• Time and reimbursement.