Tuesday, February 17, 2009

Setting Reasonable Expectations: Screening in the Literature

Alison Schonwald and her colleagues at Harvard made a useful contribution to the literature this month in Pediatrics, the journal of the AAP, with an article titled "Routine Developmental Screening Implemented in Urban Primary Care Settings"-  the abstract is available for free, but my academy has not yet opened its contents to the world without a subscription.  They describe the process of integrating the PEDS into two pediatric practices in the Harvard system, and spent time looking at the impact of that transition on the systems in which they practice.  To me, two things rang out loudly, that should inform our discussions:
1)  What do we call success?:  In academic practices, with the option of EASY access to a second level screening at no extra cost,  they were able to increase the rate of screening from 15% to 61%.  It will take more than a mandate to get kids screened-  it would be interesting to know why kids in this setting were not screened, and we shouldn't expect it to be much better quickly in non-academic settings with less facile access to second level screening.
2)  What are we likely to find?:  In young children, the RATE of identifying behavioral concerns increased, whereas the providers we pretty good at finding developmental problems before screening was implemented.  Overall, we are still talking about a small number of children, and NONE of the ones that they found rose to the level of SED.  These data suggest that behavioral screening under age 2 is UNLIKELY to find much SED.  Should we really be screening them 9 times over 2 years to find so little?
In kids over 2,  the providers were already pretty good at finding the behavioral problems-  the benefit was in the identification of more developmental problems.  And the rate at which they were positive is about 10%.  MOST OF WHICH DID NOT REQUIRE REFERRAL.  This is not too different from the early MassHealth data; we are finding problems, but not overwhelming the system more than we had done already.
Alison is to be congratulated for her perseverence at getting this important work into the literature.  With Karen Hacker's work on older children, it gives us a firm grounding on which to base our policy recommendations.

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