A system dynamics model of clinical decision thresholds for the detection of developmental-behavioral disorders

Sheldrick, R. Christopher; Breuer, Dominic J.; Hassan, Razan; Chan, Kee; Polk, Deborah E.; Benneyan, James C.

doi:10.1186/s13012-016-0517-0

Cited by 21 publications

(22 citation statements)

References 74 publications

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“…4 Among these studies, referral rates ranged from 10% to 86%. 5 Whereas results such as these are widely interpreted as failures to implement evidence-based screening protocols with fidelity, we suggest an alternative explanation on the basis of at least 2 limitations in the logic underlying many screening recommendations. First, pediatricians make clinical decisions about patients as individuals, one at a time—they do not make decisions for groups of patients.…”

mentioning

confidence: 76%

“…For example, models that conceptualize screening as but one element in a larger system of care 5 might motivate research on ways to reduce burden in connecting patients with local treatment resources (eg, Help Me Grow), 46 research to advance models of collaborative, colocated mental health care (eg, Healthy Steps), 47 and research to reduce the burden of follow-up assessments to improve diagnostic validity (eg, Modified Checklist for Autism in Toddlers Follow-Up Interview). 34 Together, interventions such as these have the potential to improve identification far beyond what the use of screening instruments can accomplish alone.…”

Section: Researchmentioning

confidence: 99%

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Is a Positive Developmental-Behavioral Screening Score Sufficient to Justify Referral? A Review of Evidence and Theory

Sheldrick

Garfinkel

2017

Academic Pediatrics

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In their recommendations on screening for autism and developmental disabilities, the American Academy of Pediatrics recommends referral subsequent to a positive screening result. In this article, we argue that positive screening results are not always sufficient to justify a referral. We show that although positive predictive values are often low, they actually overstate the probability of having a disorder for many children who screen positive. Moreover, recommended screening thresholds are seldom set to ensure that the benefits of referral will equal or exceed the costs and risk of harm, which is a necessary condition for an optimal threshold in decision analysis. Drawing on recent recommendations for the Institute of Medicine/National Academy of Medicine, we discuss the implications of this argument for pediatric policy, education, and practice. In particular, we recommend that screening policies be revised to ensure that the costs and benefits of actions recommended in the event of a positive screen are appropriate to the screening threshold. We recommend greater focus on clinical decision-making in the education of physicians, including shared decision-making with patients and their families. Finally, we recommend broadening the scope of screening research to encompass not only the accuracy of specific screening instruments, but also their ability to improve decision-making in the context of systems of care.

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confidence: 76%

Section: Researchmentioning

confidence: 99%

Is a Positive Developmental-Behavioral Screening Score Sufficient to Justify Referral? A Review of Evidence and Theory

Sheldrick

Garfinkel

2017

Academic Pediatrics

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“…In addition, though there was no change in EI eligibility rates during of the intervention, less than half of children referred to EI were eligible throughout the study. As Sheldrick and colleagues (2016) have noted, the relationship between the rate of positive screening tests, rates of PCP referral to EI, and EI eligibility rates may be complex. Providers may disregard a positive screening test if it is inconsistent with their overall clinical impression.…”

Section: Discussionmentioning

confidence: 99%

Improving autism and developmental screening and referral in US primary care practices serving Latinos

Zuckerman

Chavez

Wilson

et al. 2020

Autism

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Improving autism spectrum disorder screening and referral in primary care may reduce autism spectrum disorder disparities for Latino children. The REAL-START intervention aimed to increase primary care provider adherence to autism spectrum disorder and developmental screening guidelines, and to increase Early Intervention referral for children at developmental risk in primary care clinics serving Latinos. This quasi-experimental study enrolled six Oregon primary care clinics. Clinic staff attended one initial and three follow-up trainings. Trainings addressed screening, billing, referral, and follow-up issues specific to Latinos. Clinic leaders met with a quality improvement facilitator to review performance. Medical record review measured screening and referral at 18- and 24-month well-child visits at baseline and 3, 6, 9, and 12 months. State Early Intervention database queries assessed Early Intervention eligibility. Overall, 2224 well-child visits were assessed (39% Latino). Clinics improved rates of autism spectrum disorder screening from 70% to 94% and general developmental screening from 62% to 95%. Adherence to screening guidelines increased from 46% to 91%. Proportion of children referred to Early Intervention for unchanged, but total referrals increased and age range of referred children broadened. Time to Early Intervention evaluation was slightly shorter among screening-age children. REAL-START may improve screening and referral for autism spectrum disorder and developmental delay in Latino communities. 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.

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“…Qualitative studies may shed light on the process of pediatrician decision-making about ASD screening and referral. Other authors have made the case that not all children with positive screens need to be referred [34,35], but if demographic factors are affecting referral decisions, disparities in ASD identification and intervention may perpetuate.…”

Section: Plos Onementioning

confidence: 99%

Adherence to screening and referral guidelines for autism spectrum disorder in toddlers in pediatric primary care

et al. 2020

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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,

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A system dynamics model of clinical decision thresholds for the detection of developmental-behavioral disorders

Cited by 21 publications

References 74 publications

Is a Positive Developmental-Behavioral Screening Score Sufficient to Justify Referral? A Review of Evidence and Theory

Is a Positive Developmental-Behavioral Screening Score Sufficient to Justify Referral? A Review of Evidence and Theory

Improving autism and developmental screening and referral in US primary care practices serving Latinos

Adherence to screening and referral guidelines for autism spectrum disorder in toddlers in pediatric primary care

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