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Quality Improvement/Patient Safety: Primary & Subspecialty Outpatient Quality Improvement

QI 2: Screening in Primary Care

684 - Improving Early Detection of Autism Spectrum Disorder in a Community Pediatric Clinic: A Resident-Led Longitudinal Quality Improvement Project

Friday, April 28, 2023

5:15 PM – 7:15 PM ET

Poster Number: 684
Publication Number: 684.152

Katherine Aschheim, NewYork-Presbyterian Morgan Stanley Children's Hospital, New YorK, NY, United States; Connie Kostacos, Columbia University Vagelos College of Physicians and Surgeons, Cos Cob, CT, United States; Mariellen M. Lane, Columbia University Vagelos College of Physicians and Surgeons, New York, NY, United States

Presenting Author(s)

Katherine Aschheim, MD, MSc (she/her/hers)

Resident Physician
NewYork-Presbyterian Morgan Stanley Children's Hospital
New YorK, New York, United States

Background: Children with Autism Spectrum Disorder (ASD) greatly benefit from early diagnosis and referral for related services. Early Intervention (EI) has been associated with improved cognitive performance, language, and adaptive behavior skills for children with ASD. The AAP recommends screening all children for ASD at the 18 and 24 month visits, and the Modified Checklist for Autism in Toddlers (MCHAT) is a validated screening tool. Primary care pediatricians have an opportunity to make a significant impact in the lives of patients with ASD by improving rates of screening and referrals.

Objective: From October 2021 to April 2022 we aimed to: 1) Increase the rates of MCHAT screening at the 18 or 24 month visits from a baseline of 34% to >60%; 2) Increase rates of referrals to EI and audiology for positive screens to from a baseline of 37% to >60%.

Design/Methods: The current process for MCHAT screening was assessed in a hospital-affiliated, joint resident-faculty practice in an urban, predominantly Hispanic community. A provider barriers survey revealed lack of knowledge of screening guidelines, inconsistent MCHAT administration, and non-standard EI referral processes. Based on these barriers, a key driver diagram was created (Figure 1). The following Plan-Do-Study-Act cycles were performed: didactic sessions for providers, physical reminders in exam rooms, use of electronic tablets that for pre-exam completion of bilingual MCHAT screener, bilingual paper MCHAT and scoring workflow guidance in exam rooms, and a standard workflow for EI referrals. Rates of MCHAT screening and referrals to EI and audiology were assessed monthly.

Results: The rate of MCHAT screening at the 18 or 24 month well child visit improved from a baseline of 34% to 80% by April 2022 (Figure 2). Referrals to EI for patients who screened positive increased from a baseline of 47% to a high of 100% in January 2022, and then dropped to 50% in April 2022 (Figure 3). The rate for audiology referrals generally mirrored that of EI referrals, but was 100% in April 2022.

Conclusion(s): This resident-led QI project demonstrated that screening for ASD and referrals to EI and audiology can be improved by educating providers and caregivers, posting physical reminders, prescreening patients using tablets, and creating a standard EI referral process. The low referral rate seen in April 2022 is hard to interpret given the low numbers of positive screens that month (n=2). Future work should focus on collaboration with Information Technologies to optimize pre-visit and pre-exam bilingual screening, and to simplify electronic referrals to EI agencies.